1. Provide venous access with large bore IV (14-18 gauge); central venous line for major bleed and patients with cardiac disease; monitor vital signs, urine output. hematocrit. Gastric lavage is of unproven benefit but clears the stomach before endoscopy. Iced saline may lyse clots ; room temperature tap water may be preferable . Intubation may be required to protect airway.
2. Type and cross match blood (6 units may be needed for a major bleed).
3. Prepare the surgical team for standby when bleeding is massive.
4. Support blood pressure with isotonic fluids (normal saline); albumin and fresh frozen plasma in cirrhotics. Packed red blood cells when available (whole blood if massive bleeding) ; maintain Hct >25-30.
5. IV calcium (e.g upto 10-20 ml 10% calcium gluconate IV over 10 to 15 minutes) if serum calcium falls due to transfusion of citrated blood.
6. Start empirical drug therapy with antacids , H2 receptor blockers, omeprazole although they are of unproven benefit.
7. In cases of bleeding due to varices give the specific treatment with octreotide, endoscopic sclerosis or band ligation and propranolol as prophylaxis of recurrent bleeding.
Indications for Emergency Surgery
- Uncontrolled or prolonged bleeding
- Severe rebleeding
- Aortoenteric fistula
- Intractable variceal bleeding – consider TIPS ( transjugular intrahepatic porto sytemic shunt)