Hepatic Failure/GI/Endocrine Emergencies

Bleeding ulcers may result in right upper quadrant pain. Mallory-Weiss tears may present as emesis,

retching, or coughing before hematemesis. Patients with symptoms associated with chronic liver disease

will likely have variceal bleeding.

Hemodynamic instability may be present in patients with significant hypovolemia. Initial care of these

patients should focus on patient stabilization.

Insertion of an NG tube is controversial because it has not been shown to improve clinical outcomes,

but inspection of the aspirate may be useful in patients without frank hematemesis.

If the aspirate contains bright red blood, urgent endoscopy is likely indicated.

A normal-appearing aspirate does not rule out UGIB because about 15% of patients with a normal

aspirate have high-risk lesions on endoscopy.

Insertion of an NG tube may be contraindicated in patients with a history of varices, particularly

those with recent endoscopic band ligation.

In patients with a variceal hemorrhage, a hepatic venous pressure gradient greater than 20 mm Hg is

a strong predictor of early rebleeding and death and can be used for risk stratification. Measuring this

gradient is not feasible at most centers, but more than 80% of patients with Child-Turcotte-Pugh class

C have a gradient greater than 20 mm Hg.

Scoring tools may help in patient risk stratification, which can aid in site of care and endoscopy timing

decisions.

The Blatchford scoring system uses clinical and laboratory parameters to predict the need for

clinical intervention.

The Rockall scoring system incorporates endoscopic findings and predicts a patient’s risk of

rebleeding and death.

The AIMS65 scoring system uses clinical and laboratory parameters to estimate in-hospital

mortality, hospital length of stay, and cost in patients with acute UGIB.

risk of rebleeding or mortality who may not require hospitalization or inpatient endoscopy. The

guidelines do not make a recommendation for or against using the Rockall score and recommend

against using the AIMS65 scoring system to identify patients at low risk of rebleeding or mortality.

General measures

Venous access with two large-caliber (at least 18 gauge; 16 gauge preferred if hemodynamically

unstable) peripheral intravenous catheters should be achieved. Access by peripheral intravenous

catheters is preferred to central venous catheterization because of their improved ability to deliver

intravenous fluids more quickly (because of the Poiseuille law).

Supplemental oxygen by nasal cannula should be administered to patients with an oxygen saturation

below 90%.

A blood type and cross-match should be sent immediately (in preparation for possible blood

transfusion).

(crystalloids) and blood transfusions (if indicated).

A study of patients with hemodynamic instability secondary to UGIB compared usual care with

intensive resuscitation focused on achieving hemodynamic stability, a hematocrit greater than

28%, and an INR less than 1.8. Intensive resuscitation was associated with a lower mortality rate

(2.8% vs. 11.1%, p=0.04) and a lower incidence of myocardial infarction (5.6% vs. 13.9%, p=0.04).

See the Shock Syndromes II: Hypovolemic, Critical Bleeding, and Obstructive chapter for further

discussion of hypovolemic shock secondary to hemorrhage.