CPG for upper GI bleeding , http://www.gastrothai.net/files/10.guideline%20Upper%20GI%20Bleeding.pdf

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2004 Consensus for Clinical Practice Guideline
for the management of Upper GI Bleeding
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3. 3
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5. 5
Upper GI bleeding ○ ○ ○
○ ○ ○ ○ ○ ○
○ ○ ○
1 Hematemesis / Melena
2 Initial Assessment and Resuscitation
3 Risk Stratification
3 A Low Risk 3 B High Risk
Supportive Treatment
and Monitoring
Endoscopy Available
Elective Endoscopy
Yes No
Ulcer bleeding Variceal Bleeding Others Refer
High risk Low risk Pharmacologic Therapy
(Somatostatin or analogue)
Endoscopic Hemostasis
for Major Stigmata
Hemorrhage
PPI for Suspected
Non-variceal
Bleeding
Samotostain for
Suspected Variceal
Bleeding4
5
6 7
8
Therapeutic
Endoscopy Feasible
Antisecretory
therapy
Therapeutic
Endoscopy Feasible
Yes No Yes No Continue Pharmacologic
Therapy
Endoscopic
Hemostasis
Consult Surgeon
or Refer
EVL/EIS SB 24-48 hrs Fail Success
Bleeding Stop Ongoing Bleed
Success Fail Success Fail
OR
OR
Re-endoscopy
and Hemostasis
Rebleed SB 24-48 hrs TIPS or Surgery
or Refer
Fail
Success Rebleed
Re-endoscopy
EVL/EISRebleed OR
Pharmacologic
Therapy and
Monitoring
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9 10 16
11 15 11
13
17 19
22
12
20 21
23
14
18

6. 6
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○ ○ ○ ○ ○ ○
○ ○ ○
1Hematemesis/Melena
2InitialAssessmentandResuscitation
3RiskStratification
3ALowRisk3BHighRisk
SupportiveTreatment
andMonitoring
EndoscopyAvailable
ElectiveEndoscopy
YesNo
PPIforSuspected
Non-variceal
Bleeding
Samotostainfor
SuspectedVariceal
Bleeding4
5
67
8

7. 7
Upper GI bleeding ○ ○ ○
○ ○ ○ ○ ○ ○
○ ○ ○
UlcerbleedingVaricealBleedingOthersRefer
HighriskLowriskPharmacologicTherapy
(Somatostatinoranalogue)
EndoscopicHemostasis
forMajorStigmata
Hemorrhage
Therapeutic
EndoscopyFeasible
Antisecretory
therapy
Therapeutic
EndoscopyFeasible
YesNoYesNoContinuePharmacologic
Therapy
Endoscopic
Hemostasis
ConsultSurgeon
orRefer
EVL/EISSB24-48hrsFailSuccess
910
16
111511
13
1719
12
18
YesNo8

8. 8
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○ ○ ○ ○ ○ ○
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BleedingStopOngoingBleed
SuccessFailSuccessFail
OR
OR
Re-endoscopy
andHemostasis
RebleedSB24-48hrsTIPSorSurgery
orRefer
Fail
SuccessRebleed
Re-endoscopy
EVL/EISRebleed
OR
Pharmacologic
Therapyand
Monitoring
22
2021
23
14
Endoscopic
Hemostasis
ConsultSurgeon
orRefer
13
12
EVL/EISSB24-48hrsFail1719Success

9. 9
Upper GI bleeding ○ ○ ○
○ ○ ○ ○ ○ ○
○ ○ ○
§”Õ∏‘∫“¬‡æ‘Ë¡‡µ‘¡µ“¡·ºπ¿Ÿ¡‘
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à«πµâπ‡©’¬∫æ≈—π ∑’ˇ°‘¥¢÷Èπ¿“¬„π 48 ™—Ë«‚¡ß‡∑à“π—Èπ ‚¥¬ºŸâªÉ«¬Õ“®¡“¥â«¬
Õ“°“√Õ“‡®’¬π‡ªìπ‡≈◊Õ¥ À√◊Õ∂à“¬ melena
2. Initial Assessment and Resuscitation
ë Supportive Treatment
a. Maintain airway
b. History and physical examination for assessment of severity
and causes
c. NG irrigation
d. Fluid resuscitation
e. Blood for CBC, cross-match blood group for blood transfusion
À¡“¬‡Àµÿ : √“¬≈–‡Õ’¬¥°“√¥Ÿ·≈√—°…“„Àâª√—∫µ“¡§«“¡‡À¡“– ¡¢ÕߺŸâªÉ«¬
·µà≈–√“¬·≈–µ“¡ ¿“槫“¡æ√âÕ¡¢Õß ∂“π欓∫“≈
3. Risk Stratification
3A Low clinical risk factors
3B High clinical risk factors include
ë Host factors
- Age > 60 years
- Co-morbid conditions e.g. renal failure, cirrhosis, cardio-
vascular disease, COPD
- Hemodynamic instability e.g. orthostatic hypotension,
pulse >100 /min, systolic BP < 100 mmHg
- Coagulopathy including drug-related
ë Bleeding character
- Continuous red blood from NG after irrigation
○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○

10. 10
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○ ○ ○ ○ ○ ○
○ ○ ○
- Red blood per rectum
ë Patient course
- Need blood transfusion
- Rebleeding
- Hemodynamic instability
Note: In special circumstances, patientsû referral may be considered if
- The patient has rare blood group (group AB, Rh negative)
- Taking more than 1 hr to the nearest referral hospital
- Blood transfusion is not available
4. Supportive Treatment and Monitoring
ë Supportive treatment as 2
ë Oral PPI double dose until endoscopy
5. Elective Endoscopy
ë Every patient should have endoscopy done if available
ë If endoscopy is not available, consider patientûs referral
6. Suspected non-variceal bleeding
ë Continuous IV infusion or bolus PPI or oral PPI double dose
ë If endoscopy is available with in 8 hr, PPI may not be needed
Note: - Continuous IV infusion PPI: Omeprazole or Pantoprazole 80
mg v bolus then infusion drip 8 mg/hr
- Bolus PPI: Omeprazole or Pantoprazole 40 mg v twice daily
7. Suspected variceal bleeding
ë Clinical signs include
- Previous documented of esophageal varices or gastric
varices
or - Signs of portal HT e.g. splenomegaly, ascites, hepatic en-
cephalopathy, dilated superficial vein

11. 11
Upper GI bleeding ○ ○ ○
○ ○ ○ ○ ○ ○
○ ○ ○
or - Clinical cirrhosis with thrombocytopenia and/or spleno-
megaly
ë Medication: Somatostatin 250 microgram bolus followed with
somatostatin 250 microgram/hour IV or Octreotide 50 micro-
gram bolus followed with octreotide 50 microgram/hour IV
ë If endoscopy can be performed urgently, somatostatin or its
analogue may not be needed
8. Patient should be referred if
ë High risk of bleeding including recurrent bleeding and no endo-
scopic treatment or no surgical treatment available
ë Rare blood group
ë No blood transfusion available
9. High endoscopic risks
ë Arterial bleeding; spurting, oozing
ë Non-bleeding visible vessel
ë Adherent clot
10. Low endoscopic risks
ë Hematin spot
ë Clean-based ulcer
ë Gastritis
11. Therapeutic endoscopy feasible
ë Defined as ability to do any of therapeutic modalities (even 1
modality)
12. Endoscopic hemostasis
ë Spurting : injection with adrenaline and followed with thermal
coagulation or hemoclips
ë Clot adherent : injection with adrenaline then removal of clot,

12. 12
·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬○ ○ ○
○ ○ ○ ○ ○ ○
○ ○ ○
followed with thermal coagulation or hemoclips
ë Non bleeding visible vessel : thermal coagulation, fibrin sealant
or hemoclips
13. Consult surgeon as soon as possible or refer if no surgeon available
14. Pharmacologic therapy
ë Drugs : oral or IV infusion PPI is either used depending on
patients severity and physicianûs judgement
15. Antisecretory therapy
ë Drugs : oral or IV infusion PPI is either used depending on
patients severity and physicianûs judgement
ë In NSAID user including low dose ASA
- PPI is recommended in ongoing NSAIDs use
- H2
RA is as effective as PPI if NSAIDs are stopped
16. Pharmacologic therapy in variceal bleeding
ë Somatostatin 250 microgram bolus, followed with somatosta-
tin 250 microgram/hour IV or Octreotide 50 microgram bolus,
followed with octreotide 50 microgram/hour IV
ë If the patient already received somatostatin or its analogue
before endoscopy, bolus dose is not needed
17. Endoscopic variceal ligation (EVL) or Endoscopic injection sclero-
therapy (EIS) depends on the experiences of the endoscopist
18. Continue pharmacologic therapy for 5 days
19. Sengstaken Blakemore tube (SB) insertion
20. Hemostatic success means bleeding stopped
ë May consider discharge somatostatin or its analogue if the EVL
or EIS is completely performed

13. 13
Upper GI bleeding ○ ○ ○
○ ○ ○ ○ ○ ○
○ ○ ○
21. If hemostasis fail
ë Somatostatin or its analogue should be continued
ë Consider options according to healthcare resources, experi-
ences of the endoscopist and the patientûs conditions
- Consult for surgery or Transcutaneous intrahepatic porto-
systemic shunt (TIPS) with or without temporary tampon-
ade with Sengstaken Blakemore tube
- Temporary tamponade with Sengstaken Blakemore tube and
re-endoscopy after 24-48 hr
22. If bleeding is still ongoing more than 24-48 hour surgery or TIPS is
needed
23. The surgeon should be capable for shunt surgery otherwise refer
to the center that has more equipped facilities
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≈–‡Õ’¬¥√«¡∑—Èß¡’‡Õ° “√Õâ“ßՑ߇æ◊ËÕ„™âª√–°Õ∫°—∫guideline„πÀπ—ß ◊Õ‡≈à¡π’È
·≈–‰¥â àßµàÕ‰ª¬—ß√“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààߪ√–‡∑»‰∑¬, °√–∑√«ß
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ª√–‡∑»‰∑¬ ·≈– www.thaigastro.org

14. 14
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Consensus for Clinical Practice Guideline
for the management of Upper GI Bleeding
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πæ.∏πæ≈ ‰À¡·æß √æ. ߢ≈“π§√‘π∑√å ߢ≈“
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15. 15
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πæ.√—∞°√ «‘‰≈™π¡å √æ.∏√√¡»“ µ√å ª∑ÿ¡∏“π’
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πæ.√“«‘π ‚´π’Ë √æ.»Ÿπ¬å≈”ª“ß ≈”ª“ß
πæ.«√æ®πå π√ ÿ™“ √æ. ¡‡¥Á®æ√–π“߇®â“ ‘√‘°‘µµ‘Ï ™≈∫ÿ√’
æµÕ.πæ.«√æ—π∏ÿå ‡ “«√ √æ.µ”√«® °√ÿ߇∑æœ
æ≠.«‚√™“ ¡À“™—¬ √æ.®ÿÓ≈ß°√≥å °√ÿ߇∑æœ
πæ.«—≤π“¬ÿ∑∏ √√æ“π‘™ √æ.§à“¬ ÿ√ ’Àå °“≠®π∫ÿ√’
πæ.«’√¬ÿ∑∏ ‚¶…‘µ °ÿ≈™—¬ √æ.π§√æ‘ß§å ‡™’¬ß„À¡à
πæ.»√—≥¬å «√√≥¿“ π’ √æ. √√æ ‘∑∏‘Ϫ√– ߧå Õÿ∫≈√“™∏“π’
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πæ.»ÿ¿™—¬ »√’»‘√‘√ÿàß √æ.æ≠“‰∑»√’√“™“ ™≈∫ÿ√’
πæ. ∂“æ√ ¡“π— ∂‘µ¬å √æ.»‘√‘√“™ °√ÿ߇∑æœ
πæ. ¡∫—µ‘ µ√’ª√–‡ √‘∞ ÿ¢ √æ.‡«™»“ µ√凢µ√âÕπ °√ÿ߇∑æœ
πæ. ¡Õ“® µ—È߇®√‘≠ √æ.°“à ‘π∏ÿå °“à ‘π∏ÿå
πæ. “«‘µ√ ‚¶…‘µ™—¬«—≤πå √æ.√“¡“∏‘∫¥’ °√ÿ߇∑æœ
πæ. ‘√‘«—≤πå Õπ—πµæ—π∏ÿåæß»å √æ.√“™«‘∂’ °√ÿ߇∑æœ
πæ. ÿ‡®µπå ‡≈‘»‡Õπ°«—≤π“ √æ.ÀπÕߧ“¬ ÀπÕߧ“¬
πæ. ÿπ∑√ µ√’ √“πÿ«—≤π“ √æ.‡´Áπ‡¡√’Ë π§√√“™ ’¡“
πæ. ÿπ∑√ ™‘πª√– “∑»—°¥‘Ï √æ.π§√√“™ ’¡“ π§√√“™ ’¡“
πæ. ÿæ®πå æß»åª√– ∫™—¬ √æ.»‘√‘√“™ °√ÿ߇∑æœ
πæ. ÿæ√™—¬ °“≠®π«“ ’ √æ.≈æ∫ÿ√’ ≈æ∫ÿ√’
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πæ.ÕßÕ“® ‰æ√ ≥±√“ß°Ÿ√ √æ.¡À“√“™π§√‡™’¬ß„À¡à ‡™’¬ß„À¡à
πæ.Õ”π“® ®‘µ√«√π—π∑å √æ.‡®√‘≠°√ÿߪ√–™“√—°…å °√ÿ߇∑æœ
πæ.Õÿ¥¡ §™‘π∑√ √æ.»‘√‘√“™ °√ÿ߇∑æœ
πæ.‚ÕÓ√ «‘«—≤π“™à“ß √æ.Õÿ¥√∏“π’ Õÿ¥√∏“π’
πæ.∏—≠‡¥™ π‘¡¡“π«ÿ≤‘æß…å √æ.»‘√‘√“™ °√ÿ߇∑æœ
πæ. ¡™“¬ ≈’≈“°ÿ»≈«ß»å √æ.»‘√‘√“™ °√ÿ߇∑æœ

16. 16
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