ENDOSCOPY Upper GI endoscopy is the most accurate technique for the identification of upper tract bleeding sites. It predicts morbidity, and, with the advent of therapeutic endoscopy, is associated with improved outcomes. Early therapeutic endoscopy, where available, should be considered the treatment of choice for significant upper GI bleeding. Thus, early consultation for potential endoscopy should be considered in patients with significant hemorrhage.

Esophageal varices can be endoscopically treated by either band ligation or injection sclerotherapy. Sclerotherapy, which controls acute hemorrhage in up to 90 percent of patients, may decrease the duration of hospitalization and amount of blood transfused when compared with portal-caval shunting. However, complications of sclerotherapy include perforation, sepsis, stricture formation, and portal and mesenteric venous thrombosis. Endoscopic band ligation appears to be as effective as sclerotherapy, but with a decreased incidence of complications, particularly rebleeding and esophageal stricture formation. 12 In addition, band ligation appears superior to sclerotherapy in the long-term management of varices.13

Endoscopic hemostasis (with injection sclerotherapy, electrocoagulation, heater probes, and lasers) has been used successfully in a variety of nonvariceal etiologies of upper GI bleeding, as well.

In lower GI bleeding, proctoscopy is often diagnostic in patients with anorectal sources of bleeding, such as hemorrhoids. If an anorectal source is suspected, the patient should be carefully evaluated for significant volume loss or more dangerous proximal sources of bleeding mimicking anorectal bleeding. Colonoscopy can be diagnostic in other forms of lower tract hemorrhage, such as diverticulosis or angiodysplasia, and may also allow ablation of bleeding sites by using the aforementioned technologies.

DRUG THERAPY Infusions of somatostatin and its synthetic, longer-acting derivative, octreotide, have been shown to be effective in reducing bleeding from both varices and peptic ulcer disease. Octreotide has been shown to be as effective as sclerotherapy in acute variceal bleeding. 14 Both agents, when used in addition to sclerotherapy, are more effective than sclerotherapy alone.1 l6 These agents possess the advantages of vasopressin, with considerably fewer side effects. They should be considered useful adjuncts, either before endoscopy or when endoscopy is unsuccessful, contraindicated, or unavailable. 17

Vasopressin has been used in the past to control GI bleeding, most commonly from varices. However, adverse reactions are common, including hypertension, dysrhythmias, myocardial and splanchnic ischemia, decreased cardiac output, and gangrene from local infiltration. Although the concomitant use of nitroglycerin has been shown to reduce the incidence of these side effects, the use of vasopressin has been largely supplanted by the use of somatostatin, octreotide, and therapeutic endoscopy.

Studies have also suggested that the proton-pump inhibitor omeprazole may be useful to reduce rebleeding, transfusion requirements, and the need for surgery in the treatment of bleeding peptic ulcers.18!9

Other drugs may be of benefit in patients with GI hemorrhage, but are of less concern in the initial emergency department management. For instance, b-blocker therapy has been shown to be beneficial in patients with varices, in preventing both initial variceal bleeds and rebleeding. —i2!.. Additionally, the treatment of Helicobacter pylori infection with antibiotics reduces the recurrence of peptic ulcer and rebleeding. 22 However, the use of H2 antagonists in acute upper GI hemorrhage remains of unproven benefit,23 with no conclusive evidence for reduction in the rates of rebleeding, surgery, or death.

BALLOON TAMPONADE Balloon tamponade with the Sengstaken-Blakemore tube or its variants can provide therapeutic benefit and presumptive diagnostic information. It can control documented variceal hemorrhage in 40 to 80 percent of patients. The device consists of gastric and esophageal balloons and, depending on the variation, may include gastric and/or esophageal aspiration ports. The gastric balloon should be inflated first. If bleeding does not cease, the esophageal balloon should then be inflated, using a manometer to ensure that the pressure does not exceed 40 to 50 mmHg. Radiologic confirmation of proper balloon placement is suggested. The device should be kept in place 24 h after bleeding has ceased. Some authors recommend deflating the esophageal balloon for 30 to 60 min every 8 h to prevent mucosal ulceration.

Like vasopressin therapy, balloon tamponade is frequently associated with adverse reactions, often severe. Mucosal ulceration, esophageal or gastric rupture, asphyxiation from dislodged balloons, tracheal compression secondary to balloon inflation, and aspiration pneumonia have all been reported. Many authors recommend routine prophylactic endotracheal intubation to prevent pulmonary complications. Because of the incidence of adverse reactions, the use of balloon tamponade has decreased considerably and should be considered an adjunctive or temporizing measure supplementing the more definitive modalities of band ligation or sclerotherapy.

SURGERY With patients who do not respond to medical therapy, and in whom endoscopic hemostasis, if available, fails, emergency surgical intervention is indicated. Surgical consultation on any patient admitted to the hospital for GI bleeding is prudent, in case uncontrollable rebleeding occurs.

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