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®“°°“√ª√–™ÿ¡2004 Consensus for Clinical Practice Guideline
for the management of Upper GI Bleeding
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Uppe r G I b l e e d i n g ○ ○ ○
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1 Hematemesis / Melena
2 Initial Assessment and Resuscitation
3 Risk Stratification
3 A Low Risk 3 B High Risk
Supportive Treatmentand Monitoring
Endoscopy AvailableElective Endoscopy
Yes No
Ulcer bleeding Variceal Bleeding Others Refer
High risk Low risk Pharmacologic Therapy(Somatostatin or analogue)
Endoscopic Hemostasisfor Major Stigmata
Hemorrhage
PPI for SuspectedNon-variceal
Bleeding
Samotostain forSuspected Variceal
Bleeding4
5
6 7
8
TherapeuticEndoscopy Feasible
Antisecretorytherapy
TherapeuticEndoscopy Feasible
Yes No Yes No Continue PharmacologicTherapy
EndoscopicHemostasis
Consult Surgeonor Refer
EVL/EIS SB 24-48 hrs Fail Success
Bleeding Stop Ongoing Bleed
Success Fail Success Fail
OR
OR
Re-endoscopyand Hemostasis
Rebleed SB 24-48 hrs TIPS or Surgeryor Refer
Fail
Success Rebleed
Re-endoscopyEVL/EISRebleed OR
PharmacologicTherapy andMonitoring
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9 10 16
11 15 11
1317 19
22
12
20 21
23
14
18
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1
He
mat
emes
is / M
elena
2
Init
ial A
sses
smen
t and
Res
uscit
ation
3
Risk
Stra
tifica
tion
3 A
Lo
w Ri
sk3
B
High
Risk
Supp
ortiv
e Tre
atm
ent
and
Mon
itorin
g
Endo
scop
y Av
ailab
le
Elec
tive
Endo
scop
y
Yes
No
PPI f
or S
uspe
cted
Non-
varic
eal
Blee
ding
Sam
otos
tain
for
Susp
ecte
d Va
ricea
lBl
eedi
ng4 5
67
8
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Uppe r G I b l e e d i n g ○ ○ ○
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Ulce
r blee
ding
Varic
eal
Blee
ding
Othe
rsRe
fer
High
risk
Low
risk
Phar
mac
ologic
The
rapy
(Som
atos
tatin
or a
nalog
ue)
Endo
scop
ic He
mos
tasis
for M
ajor S
tigm
ata
Hem
orrh
age
Ther
apeu
ticEn
dosc
opy
Feas
ible
Antis
ecre
tory
ther
apy
Ther
apeu
ticEn
dosc
opy
Feas
ible
Yes
NoYe
sNo
Cont
inue
Phar
mac
ologic
Ther
apy
Endo
scop
icHe
mos
tasis
Cons
ult S
urge
onor
Ref
erEV
L/EI
SSB
24-
48 h
rsFa
ilSu
cces
s
910
16
1115
11
13
1719
12
18
Yes
No8
8
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Blee
ding
Sto
pOn
going
Blee
d
Succ
ess
Fail
Succ
ess
Fail
OR OR
Re-e
ndos
copy
and
Hem
osta
sisRe
blee
dSB
24-
48 h
rsTI
PS o
r Sur
gery
or R
efer
Fail
Succ
ess
Rebl
eed
Re-e
ndos
copy
EVL/
EIS
Rebl
eed
ORPh
arm
acolo
gicTh
erap
y an
dM
onito
ring
22
2021
23
14
Endo
scop
icHe
mos
tasis
Cons
ult S
urge
onor
Ref
er
13
12EV
L/EI
SSB
24-
48 h
rsFa
il17
19Su
cces
s
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Uppe r G I b l e e d i n g ○ ○ ○
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§”Õ∏‘∫“¬‡æ‘Ë¡‡µ‘¡µ“¡·ºπ¿Ÿ¡‘
1. ·ºπ¿Ÿ¡‘π’È„™â‡©æ“– ”À√—∫ºŸâªÉ«¬∑’Ë¡“¥â«¬¿“«–‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√ à«πµâπ‡©’¬∫æ≈—π ∑’ˇ°‘¥¢÷Èπ¿“¬„π 48 ™—Ë«‚¡ß‡∑à“π—Èπ ‚¥¬ºŸâªÉ«¬Õ“®¡“¥â«¬Õ“°“√Õ“‡®’¬π‡ªìπ‡≈◊Õ¥ À√◊Õ∂à“¬ melena
2. Initial Assessment and Resuscitationë Supportive Treatmenta. Maintain airwayb. History and physical examination for assessment of severity
and causesc. NG irrigationd. Fluid resuscitatione. Blood for CBC, cross-match blood group for blood transfusion
À¡“¬‡Àµÿ : √“¬≈–‡Õ’¬¥°“√¥Ÿ·≈√—°…“„Àâª√—∫µ“¡§«“¡‡À¡“– ¡¢ÕߺŸâªÉ«¬·µà≈–√“¬·≈–µ“¡ ¿“槫“¡æ√âÕ¡¢Õß ∂“π欓∫“≈
3. Risk Stratification3A Low clinical risk factors3B High clinical risk factors include
ë Host factors- Age > 60 years- Co-morbid conditions e.g. renal failure, cirrhosis, cardio-
vascular disease, COPD- Hemodynamic instability e.g. orthostatic hypotension,
pulse >100 /min, systolic BP < 100 mmHg- Coagulopathy including drug-related
ë Bleeding character- Continuous red blood from NG after irrigation
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- Red blood per rectumë Patient course
- Need blood transfusion- Rebleeding- Hemodynamic instability
Note: In special circumstances, patientsû referral may be considered if- The patient has rare blood group (group AB, Rh negative)- Taking more than 1 hr to the nearest referral hospital- Blood transfusion is not available
4. Supportive Treatment and Monitoringë Supportive treatment as 2ë Oral PPI double dose until endoscopy
5. Elective Endoscopyë Every patient should have endoscopy done if availableë If endoscopy is not available, consider patientûs referral
6. Suspected non-variceal bleedingë Continuous IV infusion or bolus PPI or oral PPI double doseë If endoscopy is available with in 8 hr, PPI may not be needed
Note: - Continuous IV infusion PPI: Omeprazole or Pantoprazole 80mg v bolus then infusion drip 8 mg/hr
- Bolus PPI: Omeprazole or Pantoprazole 40 mg v twice daily7. Suspected variceal bleeding
ë Clinical signs include- Previous documented of esophageal varices or gastric
varicesor - Signs of portal HT e.g. splenomegaly, ascites, hepatic en-
cephalopathy, dilated superficial vein
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Uppe r G I b l e e d i n g ○ ○ ○
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or - Clinical cirrhosis with thrombocytopenia and/or spleno-megaly
ë Medication: Somatostatin 250 microgram bolus followed withsomatostatin 250 microgram/hour IV or Octreotide 50 micro-gram bolus followed with octreotide 50 microgram/hour IV
ë If endoscopy can be performed urgently, somatostatin or itsanalogue may not be needed
8. Patient should be referred ifë High risk of bleeding including recurrent bleeding and no endo-
scopic treatment or no surgical treatment availableë Rare blood groupë No blood transfusion available
9. High endoscopic risksë Arterial bleeding; spurting, oozingë Non-bleeding visible vesselë Adherent clot
10. Low endoscopic risksë Hematin spotë Clean-based ulcerë Gastritis
11. Therapeutic endoscopy feasibleë Defined as ability to do any of therapeutic modalities (even 1
modality)12. Endoscopic hemostasis
ë Spurting : injection with adrenaline and followed with thermalcoagulation or hemoclips
ë Clot adherent : injection with adrenaline then removal of clot,
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followed with thermal coagulation or hemoclipsë Non bleeding visible vessel : thermal coagulation, fibrin sealant
or hemoclips13. Consult surgeon as soon as possible or refer if no surgeon available14. Pharmacologic therapy
ë Drugs : oral or IV infusion PPI is either used depending onpatients severity and physicianûs judgement
15. Antisecretory therapyë Drugs : oral or IV infusion PPI is either used depending on
patients severity and physicianûs judgementë In NSAID user including low dose ASA
- PPI is recommended in ongoing NSAIDs use- H
2RA is as effective as PPI if NSAIDs are stopped
16. Pharmacologic therapy in variceal bleedingë Somatostatin 250 microgram bolus, followed with somatosta-
tin 250 microgram/hour IV or Octreotide 50 microgram bolus,followed with octreotide 50 microgram/hour IV
ë If the patient already received somatostatin or its analoguebefore endoscopy, bolus dose is not needed
17. Endoscopic variceal ligation (EVL) or Endoscopic injection sclero-therapy (EIS) depends on the experiences of the endoscopist
18. Continue pharmacologic therapy for 5 days19. Sengstaken Blakemore tube (SB) insertion20. Hemostatic success means bleeding stopped
ë May consider discharge somatostatin or its analogue if the EVLor EIS is completely performed
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Uppe r G I b l e e d i n g ○ ○ ○
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21. If hemostasis failë Somatostatin or its analogue should be continuedë Consider options according to healthcare resources, experi-
ences of the endoscopist and the patientûs conditions- Consult for surgery or Transcutaneous intrahepatic porto-
systemic shunt (TIPS) with or without temporary tampon-ade with Sengstaken Blakemore tube
- Temporary tamponade with Sengstaken Blakemore tube andre-endoscopy after 24-48 hr
22. If bleeding is still ongoing more than 24-48 hour surgery or TIPS isneeded
23. The surgeon should be capable for shunt surgery otherwise referto the center that has more equipped facilities
À¡“¬‡Àµÿ: °≈ÿà¡«‘®—¬‚√§°√–‡æ“–Õ“À“√ ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬ ‰¥â®—¥∑” Statement ‡√◊ËÕß·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬∑’Ë¡“¥â«¬¿“«–‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√ à«πµâπ ´÷Ëß®–¡’√“¬≈–‡Õ’¬¥√«¡∑—Èß¡’‡Õ° “√Õâ“ßՑ߇æ◊ËÕ„™âª√–°Õ∫°—∫ guideline „πÀπ—ß ◊Õ‡≈à¡π’È·≈–‰¥â àßµàÕ‰ª¬—ß√“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààߪ√–‡∑»‰∑¬, °√–∑√«ß “∏“√≥ ÿ¢·≈– ∂“∫—πæ—≤π“·≈–√—∫√Õߧÿ≥¿“æ‚√ß欓∫“≈ (æ√æ) ‡æ◊ËÕ‡º¬·æ√àµàÕ‰ª ∑à“π “¡“√∂À“√“¬≈–‡Õ’¬¥‰¥â„π®ÿ≈ “√ ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘πÕ“À“√·Ààߪ√–‡∑»‰∑¬, “√√“™«‘∑¬“≈—¬Õ“¬ÿ√·æ∑¬å·Ààߪ√–‡∑»‰∑¬ ·≈– www.thaigastro.org
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Consensus for Clinical Practice Guidelinefor the management of Upper GI Bleeding
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