Evidence-based, cost-effective management of upper gastrointestinal hemorrhage. An algorithm of the Journal of Trauma and Acute Care Surgery emergency general surgery algorithms work group

This algorithm, developed by the Journal of Trauma and Acute Care Surgery Emergency General Surgery algorithms work group, addresses the initial evaluation and management of upper gastrointestinal (UGI) hemorrhage in the acute setting (Fig. 1). The algorithm is intended to serve as a bedside reference for clinicians. The algorithm is annotated with letters linked to corresponding text, providing the rationale and evidence to support these recommendations. The algorithm is not a substitute for the clinical judgment and experience of bedside clinicians and should not be considered as the “standard of care.” We encourage institutions to utilize these recommendations to formulate local protocols, but recognize that there are patient-specific factors and institutional resource availability that may require deviation from this algorithm. UGI hemorrhage is typically defined as bleeding into the GI tract proximal to the ligament of Treitz. Emergency department visits for UGI hemorrhage are common, with an incidence of 130 visits per 100,000 persons.1 UGI hemorrhage has a mortality rate of up to 20% depending on etiology1–3 and can require high resource utilization in the form of massive transfusion, procedural intervention, and/or surgery. The emergency general surgeon’s expertise is frequently sought in cases of UGI bleeding due to their experience in managing critically ill patients with shock, as well as their ability to intervene surgically to achieve definitive bleeding control should the need arise.4 INITIAL PRESENTATION OF PATIENTS WITH UPPER GASTROINTESTINAL HEMORRHAGE Hematochezia While hematochezia is often associated with lower GI hemorrhage, between 10% and 25% of cases are due to UGI hemorrhage.5,6 For this reason, patients presenting with active bleeding per rectum should undergo evaluation for both upper and lower GI bleeding.7–9 Nasogastric tube lavage is no longer routinely recommended due to its low sensitivity and low negative predictive value for detecting UGI bleeding;4,7 however, patients with lower GI bleeding who undergo this diagnostic procedure may have a shorter time to upper endoscopy.10 The current recommendation for patients with bright red blood per rectum and hemodynamic instability is to proceed directly to upper endoscopy for earlier diagnosis and intervention.11 Hematemesis Hematemesis is a more overt sign of UGI hemorrhage, and patients presenting in this manner should undergo immediate airway assessment and resuscitation. Treatment should be directed at prompt intervention for hemorrhage control. Hospital Admission Versus Outpatient Management The Glasgow-Blatchford Score (Table 1) for pre-endoscopy risk stratification has been well validated to predict patients who are at risk of rebleeding, mortality within 30 days, and need for hospital-based intervention.4,8,12,13 Patients with a score of ≤1 should be considered for close outpatient follow-up, while patients with higher scores should be considered for hospital admission. TABLE 1 - Glasgow-Blatchford Score for UGI Bleeding Risk Parameter Score Hemoglobin, g/dL Male 12–13 1 10–11.9 3 7 with active bleeding at time of endoscopy, Child-Pugh C 10–13, or prior hepatic venous pressure gradient >20 mm Hg), pre-emptive transjugular TIPS should be considered within 72 hours and ideally within 24 hours of upper endoscopy.2,34–36 K. Urgent TIPS can also be used as rescue therapy for esophageal variceal bleeding that is refractory to combined medical and endoscopic management.34 For refractory bleeding of isolated gastric varices in patients with cirrhosis, balloon-occluded retrograde transvenous obliteration by IR has gained popularity in recent years.47 At the time of discharge, patients with acute EVUGIH should be scheduled for follow-up endoscopic band ligation to eradicate remaining/new esophageal varices at 1-4 week intervals, depending on risk2,37 (Fig. 1).Figure 1: Algorithm for management of upper GI hemorrhage in the acute setting. IV, intravenous.