Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
Definitions of GI bleeding
GI Bleeding include Upper and Lower of GIB
Causes of GI bleeding
Pathogenesis of GI bleeding
Diagnosis of GI bleeding
Clinical of GI bleeding
Management of GI bleeding
Recommendation of GI bleeding
Clinical guideline of GI bleeding
G I bleeding with radiological interventions(ACR Appropriateness Criteria).Tc-99m RBC scintigraphy,Catheter-directed Angiography,Pharmacological control,Embolization,Arterial interventions,Endoscopy,CT Angiography
SMALL BOWEL OBSTRUCTION- GENERALISED ABDOMINAL PAIN
#surgicaleducator #epigastricabdominalpain #pepticulcerdisease #usmle #babysurgeon #surgicaltutor
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Small Bowel Obstruction- a didactic lecture.
• It is one of the common surgical problems you see in surgical wards.
• I have discussed the various causes for Generalised Abdominal Pain, epidemiology, etiology,pathology, clinical features, investigations, and treatment of Small Bowel Obstruction.
• I have also included a mind map, diagnostic algorithm and a treatment algorithm for Small Bowel Obstruction.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.
Seminar present the Upper Gastrointestinal Bleeding problems
Edited by : Dr. Inzar Yassen & Dr. Ammar L. Aldwaf
in Hawler Medical Uni. collage of medicine in 14/01/2014
Iraq - Kurdistan - Erbil
Definitions of GI bleeding
GI Bleeding include Upper and Lower of GIB
Causes of GI bleeding
Pathogenesis of GI bleeding
Diagnosis of GI bleeding
Clinical of GI bleeding
Management of GI bleeding
Recommendation of GI bleeding
Clinical guideline of GI bleeding
G I bleeding with radiological interventions(ACR Appropriateness Criteria).Tc-99m RBC scintigraphy,Catheter-directed Angiography,Pharmacological control,Embolization,Arterial interventions,Endoscopy,CT Angiography
SMALL BOWEL OBSTRUCTION- GENERALISED ABDOMINAL PAIN
#surgicaleducator #epigastricabdominalpain #pepticulcerdisease #usmle #babysurgeon #surgicaltutor
• Dear Viewers,
• Greetings from “Surgical Educator”
• Today I have uploaded a video on Small Bowel Obstruction- a didactic lecture.
• It is one of the common surgical problems you see in surgical wards.
• I have discussed the various causes for Generalised Abdominal Pain, epidemiology, etiology,pathology, clinical features, investigations, and treatment of Small Bowel Obstruction.
• I have also included a mind map, diagnostic algorithm and a treatment algorithm for Small Bowel Obstruction.
• I hope the video will be very useful and you will enjoy it.
• You can watch all my surgical teaching videos in the following link:
• youtube.com/c/surgicaleducator
• Thank you for watching the video.
Seminar present the Upper Gastrointestinal Bleeding problems
Edited by : Dr. Inzar Yassen & Dr. Ammar L. Aldwaf
in Hawler Medical Uni. collage of medicine in 14/01/2014
Iraq - Kurdistan - Erbil
This powerpoint was for a subject i did in 2008, based around how to identify children crying out for help after they have been abused in a number of different ways.
Upper Gastrointestinal Bleeding (UGIB) - General ApproachMohamed Badheeb
What does the science & evidence say about UGIB ?
Introduction & Background on Upper GI Bleeding.
- Incidence and Epidemiology
- Etiologies
2. Guidelines on UGIB
- Resuscitation, Risk assessment
- Diagnostic Modalities
- Treatment Options
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
Anti ulcer drugs and their Advance pharmacology ||
Anti-ulcer drugs are medications used to prevent and treat ulcers in the stomach and upper part of the small intestine (duodenal ulcers). These ulcers are often caused by an imbalance between stomach acid and the mucosal lining, which protects the stomach lining.
||Scope: Overview of various classes of anti-ulcer drugs, their mechanisms of action, indications, side effects, and clinical considerations.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
4. Nonvariceal bleeding
Approximately 80% of ulcers stop
bleeding.
The overall mortality rate is approximately
10%
Elderly with significant comorbidity :
increase mortality.
5. Mortality/Morbidity
Retrospective chart review
73.2% of deaths occurred in patients older than
60 years.
One or more comorbid illnesses were noted in
98.3% of patients who died.
Yavorski RT, Wong RK, Maydonovitch C, Battin LS, Furnia A, Amundson
DE. Analysis of 3,294 cases of upper gastrointestinal bleeding in military
medical facilities. Am J Gastroenterol. Apr 1995;90(4):568-73.
7. Early resuscitation
Early intensive resuscitation of patients with
upper gastrointestinal bleeding decreases
mortality.
Aggressive hemodynamic resuscitation,
correction of hematocrit ( >28%)and
coagulopathy (INR>1.8)
Mortality significantly decrease in intensive
resuscitation group
No difference in rebleeding, surgical intervention
Baradarian R, Ramdhaney S, Chapalamadugu R, Skoczylas L, Wang K,
Rivilis S, et al. Am J Gastroenterol. Apr 2004;99(4):619-22.
13. Nasogastric lavage
Diagnosis
– confirm recent bleeding (coffee ground
appearance)
– possible active bleeding (red blood in the
aspirate that does not clear)
– a lack of blood in the stomach (not exclude an
upper gastrointestinal lesion).
Severity of the hemorrhage
– The characteristics of the nasogastric lavage
fluid (eg, red, coffee grounds, clear) and the
stool (eg, red, black, brown) can indicate the
severity of the hemorrhage.
14. Risk Factors
American Society for Gastrointestinal
Endoscopy (ASGE),
Risk factors associated with increased mortality,
recurrent bleeding, the need for endoscopic
hemostasis, or surgery
– age older than 60 years
– severe comorbidity
– active bleeding (eg, witnessed hematemesis, red
blood per nasogastric tube, fresh blood per rectum),
– Hemodynamic instability :hypotension
– red blood cell transfusion greater than or equal to 6
units
– severe coagulopathy.
Adler DG, Leighton JA, Davila RE, Hirota WK, Jacobson BC, Qureshi
WA, et al. ASGE guideline: The role of endoscopy in acute non-variceal
upper-GI hemorrhage. Gastrointest Endosc. Oct 2004;60(4):497-504.
16. High clinical risk factors
–Bleeding character
Continuous red blood from NG after
irrigation
Red blood per rectum
Need blood transfusion
Rebleeding
Inpatient hemodynamic instability
18. Very low risk criteria
No comorbid disease
Normal vital signs
Normal or trace positive stool guaiac
Negative gastric aspiration
Normal or near normal hematocrit
No problem home support
Proper understanding symptoms and signs of
significant bleeding
Follow up arrange within 24 hours
Rosen
21. Early endoscopy
Early endoscopy in upper gastrointestinal
hemorrhage: associations with recurrent
bleeding, surgery, and length of hospital stay.
Demonstrated a lower rate of rebleeding
and shorter length of stay when
endoscopy is performed within 24 hours of
admission
Cooper GS, Chak A, Way LE, Hammar PJ, Harper DL, Rosenthal
GE. Gastrointest Endosc. Feb 1999;49(2):145-52.
22. Early endoscopy
High risk patients
– Stop bleeding and save life
Low risk patients
– Discharge early from hospital
23. Stigmata of recent hemorrhage
SRH Prevalence Rebleeding Surgery Mortality
Clean
base
42% 5% 0.5% 2%
Flat spot 20% 10% 6% 3%
Adherent
clot
17% 22% 10% 7%
Visible
vessel
17% 43% 34% 11%
Active
bleeding
18% 70% 35% 11%
24. Endoscopic risk
High endoscopic risk : Need endoscopic
therapy and medication
– Arterial bleeding, spurting, oozing
– Non-bleeding visible vessel
– Adherent clot
Low endoscopic risk : Need medical
therapy
– Clean-base ulcer
– Flat spot
26. Predictive value of Rockall Score
Low risk defined as score of <=2
4.3% rebleeding
0.1% mortality
27. Intervention for diagnosis
Angiography : bleeding at least 0.5-1
mL/min
– Bleeding persists and endoscopy fails to
identify a bleeding site.
– As salvage therapy, embolization of the
bleeding vessel can be as successful as
emergent surgery in patients who have failed
a second attempt of endoscopic therapy
33. Meta-analysis: the efficacy of intravenous
H2-receptor antagonists in bleeding peptic
ulcer.
30 RCT,3786 bleeding GU and DU
The use of H2-receptor antagonists has not
been shown to be effective in altering the course
of UGIB.
Conclusion : There was a possible minor benefit
with intravenous H2 antagonists in bleeding
gastric ulcers but no benefit in duodenal ulcers
Levine JE, Leontiadis GI, Sharma VK, Howden
CW. Aliment Pharmacol Ther. Jun 2002;16(6):1137-42.
34. Proton pump inhibitor therapy for peptic ulcer
bleeding: Cochrane collaboration meta-analysis of
randomized controlled trials.
A meta-analysis of 24 randomized controlled
trials that evaluated PPIs for bleeding ulcers
(with or without endoscopic therapy)
Significant reduction in the risk of rebleeding, the
need for repeat endoscopic hemostasis, and
surgery.
Not effect overall mortality, but reduced mortality
in Asian trials and in patients with active
bleeding or nonbleeding visible vessels.
Leontiadis GI, Sharma VK, Howden CW. Mayo Clin
Proc. Mar 2007;82(3):286-96.
35. Comparison of intravenous pantoprazole with
intravenous ranitidine in prevention of
rebleeding from gastroduodenal ulcers
Result :
• During 72 hours rebled was
3.2% in Pantoprazole group
versus 12.9% in Ranitidine
group
Duvnjak M, et.al. Gut /Suppl. III 49 (2001): 2379
Conclusion: Intravenous Pantoprazole is significantly superior
to intravenous ranitidine in the prevention of rebleeding from
gastroduodenal ulcer after initial endoscopic haemostasis.
Rebleeding during 72h
12.9%
3.2%
0%
2%
4%
6%
8%
10%
12%
14%
Pantoprazole i.v. Ranitidine i.v
36. Effect of PPI on gastric pH
Increase intragastric pH
- pH>6.0 for 84-99% of day
No reported tolerance
Continuous infusion (CI) superior to intermittent bolus
administration
Clinical improvements in rebleeding and/or surgery with:
Bolus 80mg + CI 8mg/h
38. Median % time 24-hour intragastric pH above indicated value after
treatment with pantoprazole
Effect of pantoprazole i.v. on gastric pH –
intermittent bolus vs continuous infusion
Brunner et al; 1996
Median
%
Time
pH
Above
100%
80%
60%
40%
20%
0%
pH
3 4 5 6
80mg + 8mg/h
Placebo
40mg/h x 2 h
+ 8mg/h
40mg + 4mg/h
40mg q8h
• Loading dose of 80mg superior to 40mg
• CI dose of 8mg superior to 4mg Brunner et al; 1996
39. Pantoprazole i.v. in patients with UGIB after
endoscopic hemostasis (1)
van Rensburg et al; 1997
Dose : 80 mg bolus then 8mg/hour
Median
Intragastric
pH
8
6
4
2
0
Time (h)
0 8 16 24 32 40 48
Intragastric pH of >6 is achieved over prolonged period
40. Pantoprazole sodium
Particulate matter จากการผสมยาต้นตารับ
pantoprazole iv สูตรเดิม จึงต้องใช้ in-line filter
4 ปีต่อมาหลังการวางตลาดขาย ใน USA ได้มีการปรับสูตรผงยาฉีด
pantoprazole ใหม่ โดยผสม EDTA และ sodium
hydroxide
จนถึงปัจจุบัน USA ยังคงไม่พิจารณาให้ขึ้นทะเบียนยาสามัญของ
สูตรผงยาฉีด pantoprazole sodium
41. PPI after endoscopic therapy
An increasing amount of evidence in the
literature states that therapy with high-
dose PPIs (IV bolus followed by
continuous infusion) may decrease the rate
of rebleeding after endoscopic therapy. By
increasing the gastric pH above 6, the clot
is stabilized.
42. Pantoprazole infusion as adjuvant therapy to
endoscopic treatment in patients with peptic ulcer
bleeding: Prospective randomized controlled trial
Showkat AZ, et al.J Gastroenterol Hepatol 2006;21:716-721
43. Method
• Setting: double-blind, placebo-controlled, prospective trial
• Patients: above 18 years of age with peptic ulcer bleeding
and undertaken successful endoscopic therapy
Endoscopy to
confirm peptic ulcer
bleeding
Endoscopic Tx
(epinephrine inj
& heat probe
Pantoprazole
IV (n=102)
Placebo
IV (n=101)
Random IV 80mg + 8
mg/hr for 72
hrs
Pantoprazole
40 mg tab for
6 wks
• Efficacy measurement
- Primary: rate of rebleeding
- Secondary: need for rescue therapy, need for surgery,
mortality, duration of hospital stay, and
blood transfusion requirement
44. Result
Rebleeding, surgery, and mortality
– Pantoprazole therapy was associated with significant
reductions in rates of rebleeding
7 . 8 %
2 . 9 %
2 . 0 %
1 9 . 8 %
7 . 9 %
4 . 0 %
0 . 0 % 5 . 0 % 1 0 . 0 % 1 5 . 0 % 2 0 . 0 % 2 5 . 0 % 3 0 . 0 %
P a nt opr a z ole
P la c e bo
Not sig
46. High-dose intravenous proton pump inhibition
following endoscopic therapy in the acute
management of patients with bleeding peptic
ulcers in the USA and Canada: a cost-effectiveness
analysis.
The suggested dose of intravenous
pantoprazole is 80-mg bolus followed by 8-mg/h
infusion. The infusion is continued for 48-72
hours. This therapy has been shown to be cost-
effective
Barkun AN, Herba K, Adam V, Kennedy W, Fallone CA,
Bardou M. Aliment Pharmacol Ther. Mar 2004
50. Conclusion
High dose PPI before endoscopy
Reduced the need for endoscopic therapy
Accelerate resolution of signs of bleeding
in ulcers
No significant different in
–Amount of blood transfusion
–Recurrent bleeding (both groups
received PPI after endoscopic therapy)
–Underwent emergency surgery
–Mortality within 30 days
Lau JY, N Engl J Med 2007
52. Objective
To determine whether using PPI therapy
prior to the performance of endoscopy is
associated with improved clinical
outcomes in patients presenting with signs
of ANVUGIB.
58. Radiological intervention
Angiography with Injection vasopressin
Angiography with Embolic materials
Indication
– Endoscopic therapy failure
– Not stable enough to undergo surgery
59. Surgery
Indications
– Severe bleeding, not response to
resuscitation
– Endoscopic therapy failure
– Rebleeding after endoscopic therapy
– Surgical condition: perforation, obstruction,
malignancy
60. Surgery
Aim : Stop bleeding, not to reduce acid
secretion
Contraindications to emergency surgery
include impaired cardiopulmonary status
and bleeding diathesis
62. Hematemesis /Melena
Initial Assessment and Resuscitation and risk stratification
Supportive Treatment
and Elective
endoscopy
No
Yes
Consider Drug therapy
Somatostatin or analogues for suspected
Variceal bleeding
PPI for suspected non-variceal bleeding
High Risk
No
Refer
Endoscopy Available
Yes
Ulcer bleeding Variceal bleeding Others
63. Note
Suspect non variceal bleeding
– Continuous iv infusion or bolus PPI
Continuous iv infusion PPI: Pantoprazole or
Omeprazole 80 mg iv bolus then infusion drip 8
mg/hr
Bolus PPI: Pantoprazole or Omeprazole 40 mg iv
twice daily