Address etiology

Risk factors for rebleeding

• Clinical

   ○ Prolonged hypotension

   ○ Age > 65 years

   ○ Fresh blood in emesis, in nasogastric aspirate, or on rectal examination

   ○ Evidence of active bleeding

   ○ Large transfusion requirements

   ○ Low initial hemoglobin

   ○ Coagulopathy

   ○ Concomitant diseases (e.g., hepatic, renal, and neoplasm)

• Endoscopic

   ○ Ulcers > 1–2 cm in size

   ○ Site of bleeding

     ■ Posterior lesser gastric curvature or posterior duodenal wall

   ○ Evidence of stigmata of recent hemorrhage

     ■ Spurting vessel

     ■ Oozing vessel

     ■ Non-bleeding visible vessel (NBVV)

     ■ Ulcer with an adherent clot

Management

• Appropriate fluid resuscitation (note: do not over resuscitate)

• Placement of a nasogastric tube in the appropriate patient

   ○ Benefits may include

     ■ Potential reduction in risk of massive aspiration if placed initially in an awake patient

     ■ Facilitates endoscopic view

     ■ May help gauge activity and severity of bleeding

• Urgent endoscopy (within 24 h of presentation)

• Histamine₂-receptor antagonists are not recommended

• Pantoprazole IV

   ○ In patients with evidence of stigmata of recent hemorrhage

   ○ May be initiated prior to endoscopy

   ○ 80 mg IV over 2 min followed by 8 mg/h continuous IV infusion for up to 72 h

   ○ Step-down to oral/enteral proton pump inhibitor (high-dose) once stable (e.g., pantoprazole 40 mg bid or esomeprazole 40 mg bid)

   ○ Esomeprazole or lansoprazole may be utilized as alternative intravenous agents

• Oral/enteral proton pump inhibitor

   ○ In patients with a flat spot or clean ulcer base

• Octreotide 50 mcg IV bolus followed by 50 mcg/h continuous IV infusion for 3–5 days

   ○ In patients with evidence of a spurting or oozing vessel who are at the highest risk of rebleeding (author’s opinion)^b

• Helicobacter pylori testing and treatment where appropriate

Medications

• Antimicrobials (noninfectious)

• Sorbitol-containing solutions

   ○ Guaifenesin, theophylline, and valproic acid

• Prokinetic agents

   ○ Metoclopramide and erythromycin

• Histamine₂-receptor antagonists, proton pump inhibitors, magnesium-containing enteral products, and misoprostol

• Digoxin, procainamide, and quinidine

Enteral nutrition formulas (especially hyperosmotic formulas)

Infectious

• Clostridium difficile, Staphylococcus aureus, and Candida spp.

• Uncommon—Salmonella spp., Shigella spp., Campylobacter spp., Yersinia spp., and enteropathogenic Escherchia coli

Others

• Fecal impaction, ischemic bowel, pancreatic insufficiency, and intestinal fistulae

• Gastrointestinal neoplasm

   ○ Vasoactive intestinal polypeptide secreting tumors

Supportive measures

• Abstinence from alcohol

   ○ Alcohol withdrawal prophylaxis or treatment

• Nutrition support

   ○ Protein restriction should not be routinely utilized

• Corticosteroid therapy for patients with alcoholic hepatitis (steatonecrosis) with or without hepatic encephalopathy

   ○ Maddrey score or discriminant function = 4.6 (patient’s prothrombin time − prothrombin time control) + total bilirubin

     ■ If the score is ≥ 32 and/or the patient is encephalopathic, consider administering prednisone or prednisolone (the active form of prednisone) if there is no evidence of an upper gastrointestinal tract hemorrhage or an active infection