Evaluation and initial management of patients with upper gastrointestinal bleeding

Evaluation and initial management of a patient with gastrointestinal (GI) bleeding progresses in stepwise fashion, beginning with assessment of the severity of bleeding. For this, the hematocrit must be considered in conjunction with factors reflecting vascular volume such as blood pressure and heart rate. Resuscitation to maintain tissue oxygenation should then be instituted with intravenous fluids and blood products in amounts appropriate to the severity of hemorrhage. Vital signs are monitored carefully. During resuscitation, attention is directed to determining whether bleeding comes from the upper or lower GI tract. If upper GI bleeding has been proven, gastric lavage is performed through a large-bore orogastric tube using copious quantities of fluid. Empiric therapy for upper GI bleeding, usually aimed at reducing gastric acidity, may be instituted as decisions regarding diagnostic techniques are considered. Endoscopy is a more accurate diagnostic tool than barium x-rays and can be performed in all but massively bleeding patients. There is overwhelming evidence, however, that, at least in patients who cease bleeding during resuscitation, endoscopy does not alter outcome. Since endoscopy is expensive, it should be reserved for selected patients in whom a specific diagnosis will dictate an important change in therapy.