Immediate resuscitative measures take priority. Patients with profuse upper GI hemorrhage may require definitive airway management to prevent aspiration of blood. Oxygen should be administered, and cardiac monitoring is indicated. Volume replacement should be initiated with crystalloids via large-bore intravenous lines. The decision to administer blood should be based on the clinical findings of volume depletion or continued bleeding, rather that on initial hematocrit values. General guidelines for initiation of blood transfusion are continued active bleeding and failure to improve perfusion and vital signs after the infusion of 2 L of crystalloid. The threshold for blood transfusion should be lower in the elderly. Coagulation factors should be replaced as needed. A urinary catheter is indicated in patients with hypotension.

A nasogastric (NG) tube should be placed in all patients with significant GI bleeding, regardless of the presumed source. Concerns that NG tube passage may provoke bleeding in patients with varices are unwarranted. Bright red or maroon blood per rectum unexpectedly originates from upper GI sources approximately 14 percent of the time.10 A negative gastric aspirate does not conclusively exclude an upper GI etiology and may result from intermittent bleeding or from pyloric spasm or edema preventing reflux of duodenal blood. If bright red blood or clots are found on NG aspiration, gentle gastric lavage should be performed. To be effective, a large-bore tube, usually oral, must be used. Room temperature water is the preferred irrigant, as iced solutions have no proven benefit and have theoretical disadvantages.11 The addition of levarterenol to the lavage solution is similarly of unproven benefit. Overvigorous suction should be avoided, because it may produce gastric erosions that can confuse findings on subsequent endoscopy.

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