الفهرس 
Etiology and pathophysiology of upperOnly 14 pages are availabe for public view
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Abstract
ummary
UGIB is a common problem in the ICU representing a
substantial economic and clinical burden. Despite the
introduction of endoscopic therapy that reduces the rate of
rebleeding, the mortality has decreased only minimally. This
has been attributed to increased incidence in the elderly who
have a worse prognosis because of their frequent use of
NSAIDs, antiplatelets or anticoagulants, and their frequent
comorbid conditions. The ICU provider plays an important role
in coordinating and managing the care of high-risk patients with
acute UGIB. These patients require intensive clinical and
hemodynamic monitoring, correction of coagulopathy,
appropriate pharmacologic intervention, and rapid diagnostic
and therapeutic intervention.
Clinical assessment of UGIB patients provides a rational
basis for key early decisions on their medical management. The
medical history, physical examination, and initial investigations
are important in assessing resuscitation requirements, triage,
endoscopy timing, consultation requirements and
prognostication.
Scoring tools have been developed to try to identify
patients with UGIB at greatest risk for mortality and rebleeding.
These tools could be used to triage patients to a higher level of
Summary
120
hospital care or more urgent endoscopy. Pre-endoscopy scoring
systems include the clinical Rockall score and the Glasgow-
Blatchford score. Whereas, the most commonly used postendoscopy
scoring system is the complete Rockall score.
The initial management of any UGIB patient is
resuscitation. This includes stabilizing the airway, breathing,
and circulation, ensuring stable hemodynamics. Early
aggressive resuscitation of UGIB patients significantly
decreases mortality and myocardial infarction rates.
Routine prophylactic endotracheal intubation in UGIB
patients does not significantly change the incidence of
cardiovascular events, aspiration pneumonia or mortality in
these patients. However, common sense supports that endotracheal
intubation should be performed before endoscopy in
patients with ongoing hematemesis, hemodynamic instability in
spite of volume loading, agitation with the absence of
cooperation, GCS < 8 or the patient that becomes agitated or
suffers from renewed hematemesis during endoscopy.
The choice of fluid for resuscitation is an area of ongoing
research, in patients with a tentative diagnosis of nonvariceal
bleeding crystalloids and/or colloids constitute a reasonable
initial approach. In patients with a strong suspicion of variceal
bleeding due to liver cirrhosis, albumin 5% is deemed to be the
preferred volume expander.
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121
Current guidelines support the use of a restrictive
transfusion strategy for the management of UGIB as it
improves the outcomes among these patients compared with a
liberal transfusion strategy. Recommending a hemoglobin
threshold for transfusion of 7 g//dL, with a target level of 7 to 9
g/dL. However, a higher target level of hemoglobin should be
pursued in patients who have low tolerance to anemia because
of comorbidities such as coronary artery disease, cardiac or
renal failure.
Coagulopathy should be corrected in an UGIB bleeding
patient for endoscopic hemostasis but should not delay
endoscopy. In hemorrhagic shock due to UGIB, early treatment
with fresh-frozen plasma is recommended when bleeding is
massive but is much debated in cirrhotic patients for fear of
overtransfusion and subsequent worsening of portal
hypertension.
Currently, the real benefit of nasogastric tube insertion and
gastric lavage has been challenged by modern endoscope with
good irrigation system. However, nasogastric tube insertion has
advantages as a diagnostic bedside maneuver to evaluate GI
Bleeding, help clear the gastric blood for better endoscopic
visualization and to minimize the risk of aspiration.
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122
Although the use of pre-endoscopy prokinetic agents may
improve diagnostic yield in selected patients with suspected
blood in the stomach and reduce the need for a repeat EGD,
they are not warranted for routine use in all UGIB patients.
However, they may be useful in patients who are suspected to
have substantial amounts of blood or clot in their UGI tract or
those who have recently eaten.
PPIs have become the dominant acid suppressive therapy
used in the treatment of nonvariceal UGIB. Pre-endoscopic PPI
administration significantly reduces high-risk stigmata at index
endoscopy and need for endoscopic intervention but should not
delay endoscopy. However, no effect on clinically important
outcome measures such as rebleeding, mortality and need for
surgery was seen.
Vasoactive agents improve clinical outcomes in acute
variceal bleeding patients as they can control bleeding in up to
80% of these patients and reduce the risk of rebleeding. They
are now considered as an integral part of the evidence-based
standard of care in cirrhotic patients presenting with acute
UGIB. Although it is beneficial in treating UGIB due to varices,
their benefit has not been confirmed in patients with
nonvariceal UGIB.
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123
Bacterial infections are more common in cirrhotic patients
with variceal bleeding than in noncirrhotic hospitalized patients.
Recent studies have shown that reduction in recurrent bleeding
rate can be facilitated by giving antimicrobial prophylaxis in
cirrhotic patients who presented with UGIB.
EGD is the prime diagnostic and therapeutic tool for
UGIB. Early endoscopy can dramatically reduce the risk of
rebleeding or continued bleeding, the need for surgery, the
transfusion requirements, and the length of hospital stay.
Post-endoscopic ICU admission is recommended in high
risk individual and high risk bleeding stigmata. PPI therapy,
administered following EGD, has been proven to be effective,
as well, leading to a decrease in recurrent PUD bleeding,
mortality rate, need for blood transfusion, need for surgery and
duration of hospital stay. PPIs are recommended for 6-8 weeks
following UGIH and/or endoscopic treatment of PUD to allow
for full mucosal healing.
It is recommended that ASA be resumed as soon as
possible in high cardiothrombotic risk patients after achieving
endoscopic hemostasis. PPIs should be administered for as long
as ASA is used.
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124
Patients admitted to ICU with kidney failure,
coagulopathy, receiving antiplatelet therapy, requiring
mechanical ventilation for more than 48h and for whom enteral
feeding is not possible should be considered to be at risk of
stress ulcer bleeding and they should be given ulcer
prophylaxis.