Acute Gastrointestinal Bleeding: Part II
ABSTRACT
Objective:
To review the management of acute gastrointestinal bleeding in the critically ill patient in a two part presentation.
Data sources:
Articles and a review of studies reported from 1991 to 2001 and identified through a MEDLINE search of the English language literature on acute gastrointestinal bleeding.
Summary of review:
Oesophageal varices are a common source of upper gastrointestinal bleeding in patients who have portal hypertension. Management requires resuscitation and treatment of associated coagulation disturbances along with intravenous octreotide (50 ug followed by 50 ug/hr for 48 hr) before endoscopy is performed. Octreotide is more effective than vasopressin in controlling acute variceal haemmorhage and has fewer side effects compared with glypressin.
To provide haemostasis, endoscopic variceal scerosis has largely been replaced by variceal ligation using an overtube and small elastic 'o' rings to band the bleeding variceal channels. If bleeding continues then balloon tamponade and intravenous fibrinolytic inhibitors (e.g. tranexamic acid 3 - 6 g i.v. daily) are used for 24 hr before endoscopy (with variceal ligation) is repeated. If the variceal bleeding is resistant to repeated banding, portal decompression using transjugular intrahepatic portosystemic shunt or surgical shunt should be considered. While beta adrenergic blockers (e.g. propranalol) are indicated to reduce the incidence of rebleeding, they are contraindicated in a patient with actively bleeding oesophageal varices.
Conclusions:
Acute oesophageal variceal bleeding can often be managed successfully using octreotide and variceal ligation. If bleeding continues then transjugular intrahepatic portosystemic shunt or surgical shunt should be considered. (Critical Care and Resuscitation 2001; 3: 117-124)
Key Words:
Acute gastrointestinal bleeding, oesophageal and gastric varices, somatostatin analogs and derivatives, transjugular intrahepatic portosystemic shunt, liver cirrhosis
