Hepatic Failure/GI/Endocrine Emergencies

Transfusion

Current guidelines recommend a transfusion threshold of 7 g/dL for hospitalized hemodynamically

stable patients, including those in the ICU, and a threshold of 8 g/dL in patients with preexisting

cardiovascular disease. This recommendation does not extend to patients with acute coronary

syndrome.

A higher hemoglobin threshold may be appropriate in patients with hypotension or who are

bleeding rapidly.

Platelet transfusion, typically if the platelet count is less than 50,000/mm3, should be considered.

Endoscopy

Diagnostic endoscopy

Used to diagnose and assess the risk posed by the bleeding lesion(s). Therapeutic endoscopy

may also be used for the lesion(s) to reduce the risk of bleeding recurrence (discussed later in

the chapter).

ii.

Patients with UGIB should generally have a diagnostic endoscopy within 24 hours.

iii.

Patients who are hemodynamically unstable and those with a suspected variceal UGIB should

have a diagnostic endoscopy as soon as possible and no later than 12 hours after presentation.

iv.

Erythromycin or metoclopramide may be used when a large amount of blood in the stomach

would hinder an endoscopy; however, routine use is not recommended. Use reduces the need

for repeated endoscopy (OR 0.55; 95% CI, 0.32–0.94) but does not alter the need for blood

products, length of hospital stay, or need for surgery.

Endotracheal intubation before endoscopy may be indicated to prevent aspiration, but patient

selection is controversial.

vi.

Endoscopic findings predict the risk of rebleeding and guide further therapies.

further bleeding and guide management decisions (Table 6).

Risk of

Rebleeding

Stigmata of

Recent Hemorrhage

Forrest

Grade

Prevalence

Rebleeding Rate

High

Active spurting bleeding

IA

9.3% (spurting and oozing)

55% (spurting and oozing)

Active oozing bleeding

IB

Nonbleeding visible vessel

IIA

6.1%

43%

Adherent clot

IIB

6.5%

22%

Low

Flat pigmented spot

IIC

13.1%

10%

Clean base

III

52.6%

5%

Information from: Laine L, Peterson W. Bleeding peptic ulcer. N Engl J Med 1994;331:717-27; Enestvedt BK, Gralnek IM, Mattek N, et al. An evaluation of endoscopic

indication and findings related to nonvariceal upper-GI hemorrhage in a large multicenter consortium. Gastrointest Endosc 2008;67:422-9; and Laine L, Jensen DM.

therapy should be initiated.

Therapeutic endoscopy

Can be used in conjunction with a diagnostic endoscopy to treat the source of UGIB once it

has been identified

ii.

Non-variceal UGIB

a non-bleeding visible vessel.