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2004 Consensus for Clinical Practice Guideline
for the management of Upper GI Bleeding
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5. ○
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Upper GI bleeding
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1 Hematemesis / Melena
2 Initial Assessment and Resuscitation
3
Risk Stratification
3 A Low Risk
6
4 Supportive Treatment
and Monitoring
3 B High Risk
PPI for Suspected
Samotostain for
Non-variceal
Suspected Variceal
Bleeding
Bleeding
Endoscopy Available
7
5 Elective Endoscopy
No 8
Yes
Ulcer bleeding
9 High risk
Variceal Bleeding
Others
10 Low risk 16 Pharmacologic Therapy
(Somatostatin or analogue)
Refer
Endoscopic Hemostasis
for Major Stigmata
Hemorrhage
Therapeutic
Therapeutic
11 Endoscopy Feasible 15 Antisecretory 11 Endoscopy Feasible
therapy
Yes
No
12 Endoscopic
Hemostasis
13
Consult Surgeon
or Refer
Fail
Re-endoscopy
and Hemostasis
19 SB 24-48 hrs
17 EVL/EIS
18
Continue Pharmacologic
Therapy
Fail
Success
Bleeding Stop
21
Fail
OR
Ongoing Bleed 22
20
Success
Rebleed
SB 24-48 hrs
TIPS or Surgery 23
or Refer
OR
Fail
Rebleed
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5
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Success
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Re-endoscopy
EVL/EIS
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Rebleed OR
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14
Pharmacologic
Therapy and
Monitoring
No
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Success
Yes

6. ○
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Supportive Treatment
and Monitoring
Elective Endoscopy
4
3 A Low Risk
2
3
1
Hematemesis / Melena
5
6
3 B High Risk
Samotostain for
Suspected Variceal
Bleeding
Yes
Endoscopy Available
PPI for Suspected
Non-variceal
Bleeding
Risk Stratification
8
7
No
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Initial Assessment and Resuscitation
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6
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12
11
Endoscopic
Hemostasis
Consult Surgeon
or Refer
13
16
17
No
Low risk
Yes
10
15 Antisecretory 11
therapy
High risk
Therapeutic
Endoscopy Feasible
9
Ulcer bleeding
EVL/EIS
Yes
No
19 SB 24-48 hrs
Therapeutic
Endoscopy Feasible
Pharmacologic Therapy
(Somatostatin or analogue)
Variceal Bleeding
Yes
Refer
Fail
8
Success
18
Continue Pharmacologic
Therapy
Endoscopic Hemostasis
for Major Stigmata
Hemorrhage
Others
No
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7
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Upper GI bleeding

8. ○
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12
EVL/EIS
19 SB 24-48 hrs
21
Fail
17
Fail
Success
Pharmacologic
Therapy and
Monitoring
14
Rebleed
OR
Re-endoscopy
and Hemostasis
Fail
Success
Re-endoscopy
EVL/EIS
OR
Success
Fail
SB 24-48 hrs
Rebleed
OR
20
Success
Bleeding Stop
Rebleed
TIPS or Surgery 23
or Refer
Ongoing Bleed 22
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Consult Surgeon
or Refer
Endoscopic
Hemostasis
13
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8
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9. ○
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Upper GI bleeding
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§”Õ∏‘∫“¬‡æ‘Ë¡‡µ‘¡µ“¡·ºπ¿Ÿ¡‘
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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 Resuscitation
ë Supportive Treatment
a. Maintain airway
b. History and physical examination for assessment of severity
and causes
c. NG irrigation
d. Fluid resuscitation
e. 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 Stratification
3A Low clinical risk factors
3B High clinical risk factors include
ë Host factors
- Age > 60 years
- Co-morbid conditions e.g. renal failure, cirrhosis, cardiovascular 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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9

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- Red blood per rectum
ë 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 Monitoring
ë Supportive treatment as 2
ë Oral PPI double dose until endoscopy
5. Elective Endoscopy
ë Every patient should have endoscopy done if available
ë If endoscopy is not available, consider patientûs referral
6. Suspected non-variceal bleeding
ë Continuous IV infusion or bolus PPI or oral PPI double dose
ë If endoscopy is available with in 8 hr, PPI may not be needed
Note: - Continuous IV infusion PPI: Omeprazole or Pantoprazole 80
mg v bolus then infusion drip 8 mg/hr
- Bolus PPI: Omeprazole or Pantoprazole 40 mg v twice daily
7. Suspected variceal bleeding
ë Clinical signs include
- Previous documented of esophageal varices or gastric
varices
or - Signs of portal HT e.g. splenomegaly, ascites, hepatic encephalopathy, dilated superficial vein
10
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11. ○
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Upper GI bleeding
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or -
○
11
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12.
○
11.
○
10.
○
9.
○
8.
Clinical cirrhosis with thrombocytopenia and/or splenomegaly
ë Medication: Somatostatin 250 microgram bolus followed with
somatostatin 250 microgram/hour IV or Octreotide 50 microgram bolus followed with octreotide 50 microgram/hour IV
ë If endoscopy can be performed urgently, somatostatin or its
analogue may not be needed
Patient should be referred if
ë High risk of bleeding including recurrent bleeding and no endoscopic treatment or no surgical treatment available
ë Rare blood group
ë No blood transfusion available
High endoscopic risks
ë Arterial bleeding; spurting, oozing
ë Non-bleeding visible vessel
ë Adherent clot
Low endoscopic risks
ë Hematin spot
ë Clean-based ulcer
ë Gastritis
Therapeutic endoscopy feasible
ë Defined as ability to do any of therapeutic modalities (even 1
modality)
Endoscopic hemostasis
ë Spurting : injection with adrenaline and followed with thermal
coagulation or hemoclips
ë Clot adherent : injection with adrenaline then removal of clot,

12. ○
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16.
17.
18.
19.
20.
12
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15.
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13.
14.
○
·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬
followed with thermal coagulation or hemoclips
ë Non bleeding visible vessel : thermal coagulation, fibrin sealant
or hemoclips
Consult surgeon as soon as possible or refer if no surgeon available
Pharmacologic therapy
ë Drugs : oral or IV infusion PPI is either used depending on
patients severity and physicianûs judgement
Antisecretory therapy
ë Drugs : oral or IV infusion PPI is either used depending on
patients severity and physicianûs judgement
ë In NSAID user including low dose ASA
- PPI is recommended in ongoing NSAIDs use
- H2RA is as effective as PPI if NSAIDs are stopped
Pharmacologic therapy in variceal bleeding
ë Somatostatin 250 microgram bolus, followed with somatostatin 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 analogue
before endoscopy, bolus dose is not needed
Endoscopic variceal ligation (EVL) or Endoscopic injection sclerotherapy (EIS) depends on the experiences of the endoscopist
Continue pharmacologic therapy for 5 days
Sengstaken Blakemore tube (SB) insertion
Hemostatic success means bleeding stopped
ë May consider discharge somatostatin or its analogue if the EVL
or EIS is completely performed
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13. ○
○
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Upper GI bleeding
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21. If hemostasis fail
ë Somatostatin or its analogue should be continued
ë Consider options according to healthcare resources, experiences of the endoscopist and the patientûs conditions
- Consult for surgery or Transcutaneous intrahepatic portosystemic shunt (TIPS) with or without temporary tamponade with Sengstaken Blakemore tube
- Temporary tamponade with Sengstaken Blakemore tube and
re-endoscopy after 24-48 hr
22. If bleeding is still ongoing more than 24-48 hour surgery or TIPS is
needed
23. The surgeon should be capable for shunt surgery otherwise refer
to the center that has more equipped facilities
À¡“¬‡Àµÿ: °≈ÿà¡«‘®—¬‚√§°√–‡æ“–Õ“À“√ ¡“§¡·æ∑¬å√–∫∫∑“߇¥‘π
Õ“À“√·Ààߪ√–‡∑»‰∑¬ ‰¥â®—¥∑” Statement ‡√◊ËÕß·π«∑“ß°“√¥Ÿ·≈
√—°…“ºŸâªÉ«¬∑’Ë¡“¥â«¬¿“«–‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√ à«πµâπ ´÷Ëß®–¡’√“¬
≈–‡Õ’¬¥√«¡∑—ß¡’‡Õ° “√Õâ“ßՑ߇æ◊Õ„™âª√–°Õ∫°—∫ guideline „πÀπ—ß ◊Õ‡≈à¡π’È
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“∏“√≥ ÿ¢·≈– ∂“∫—πæ—≤π“·≈–√—∫√Õߧÿ≥¿“æ‚√ß欓∫“≈ (æ√æ) ‡æ◊Õ
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ª√–‡∑»‰∑¬ ·≈– www.thaigastro.org
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Consensus for Clinical Practice Guideline
for the management of Upper GI Bleeding
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