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Abstract ummary UGIB is a common problem in the ICU representing a substantial economic and clinical burden. Despite the introduction of endoscopic therapy that reduces the rate of rebleeding, the mortality has decreased only minimally. This has been attributed to increased incidence in the elderly who have a worse prognosis because of their frequent use of NSAIDs, antiplatelets or anticoagulants, and their frequent comorbid conditions. The ICU provider plays an important role in coordinating and managing the care of high-risk patients with acute UGIB. These patients require intensive clinical and hemodynamic monitoring, correction of coagulopathy, appropriate pharmacologic intervention, and rapid diagnostic and therapeutic intervention. Clinical assessment of UGIB patients provides a rational basis for key early decisions on their medical management. The medical history, physical examination, and initial investigations are important in assessing resuscitation requirements, triage, endoscopy timing, consultation requirements and prognostication. Scoring tools have been developed to try to identify patients with UGIB at greatest risk for mortality and rebleeding. These tools could be used to triage patients to a higher level of Summary 120 hospital care or more urgent endoscopy. Pre-endoscopy scoring systems include the clinical Rockall score and the Glasgow- Blatchford score. Whereas, the most commonly used postendoscopy scoring system is the complete Rockall score. The initial management of any UGIB patient is resuscitation. This includes stabilizing the airway, breathing, and circulation, ensuring stable hemodynamics. Early aggressive resuscitation of UGIB patients significantly decreases mortality and myocardial infarction rates. Routine prophylactic endotracheal intubation in UGIB patients does not significantly change the incidence of cardiovascular events, aspiration pneumonia or mortality in these patients. However, common sense supports that endotracheal intubation should be performed before endoscopy in patients with ongoing hematemesis, hemodynamic instability in spite of volume loading, agitation with the absence of cooperation, GCS < 8 or the patient that becomes agitated or suffers from renewed hematemesis during endoscopy. The choice of fluid for resuscitation is an area of ongoing research, in patients with a tentative diagnosis of nonvariceal bleeding crystalloids and/or colloids constitute a reasonable initial approach. In patients with a strong suspicion of variceal bleeding due to liver cirrhosis, albumin 5% is deemed to be the preferred volume expander. Summary 121 Current guidelines support the use of a restrictive transfusion strategy for the management of UGIB as it improves the outcomes among these patients compared with a liberal transfusion strategy. Recommending a hemoglobin threshold for transfusion of 7 g//dL, with a target level of 7 to 9 g/dL. However, a higher target level of hemoglobin should be pursued in patients who have low tolerance to anemia because of comorbidities such as coronary artery disease, cardiac or renal failure. Coagulopathy should be corrected in an UGIB bleeding patient for endoscopic hemostasis but should not delay endoscopy. In hemorrhagic shock due to UGIB, early treatment with fresh-frozen plasma is recommended when bleeding is massive but is much debated in cirrhotic patients for fear of overtransfusion and subsequent worsening of portal hypertension. Currently, the real benefit of nasogastric tube insertion and gastric lavage has been challenged by modern endoscope with good irrigation system. However, nasogastric tube insertion has advantages as a diagnostic bedside maneuver to evaluate GI Bleeding, help clear the gastric blood for better endoscopic visualization and to minimize the risk of aspiration. Summary 122 Although the use of pre-endoscopy prokinetic agents may improve diagnostic yield in selected patients with suspected blood in the stomach and reduce the need for a repeat EGD, they are not warranted for routine use in all UGIB patients. However, they may be useful in patients who are suspected to have substantial amounts of blood or clot in their UGI tract or those who have recently eaten. PPIs have become the dominant acid suppressive therapy used in the treatment of nonvariceal UGIB. Pre-endoscopic PPI administration significantly reduces high-risk stigmata at index endoscopy and need for endoscopic intervention but should not delay endoscopy. However, no effect on clinically important outcome measures such as rebleeding, mortality and need for surgery was seen. Vasoactive agents improve clinical outcomes in acute variceal bleeding patients as they can control bleeding in up to 80% of these patients and reduce the risk of rebleeding. They are now considered as an integral part of the evidence-based standard of care in cirrhotic patients presenting with acute UGIB. Although it is beneficial in treating UGIB due to varices, their benefit has not been confirmed in patients with nonvariceal UGIB. Summary 123 Bacterial infections are more common in cirrhotic patients with variceal bleeding than in noncirrhotic hospitalized patients. Recent studies have shown that reduction in recurrent bleeding rate can be facilitated by giving antimicrobial prophylaxis in cirrhotic patients who presented with UGIB. EGD is the prime diagnostic and therapeutic tool for UGIB. Early endoscopy can dramatically reduce the risk of rebleeding or continued bleeding, the need for surgery, the transfusion requirements, and the length of hospital stay. Post-endoscopic ICU admission is recommended in high risk individual and high risk bleeding stigmata. PPI therapy, administered following EGD, has been proven to be effective, as well, leading to a decrease in recurrent PUD bleeding, mortality rate, need for blood transfusion, need for surgery and duration of hospital stay. PPIs are recommended for 6-8 weeks following UGIH and/or endoscopic treatment of PUD to allow for full mucosal healing. It is recommended that ASA be resumed as soon as possible in high cardiothrombotic risk patients after achieving endoscopic hemostasis. PPIs should be administered for as long as ASA is used. Summary 124 Patients admitted to ICU with kidney failure, coagulopathy, receiving antiplatelet therapy, requiring mechanical ventilation for more than 48h and for whom enteral feeding is not possible should be considered to be at risk of stress ulcer bleeding and they should be given ulcer prophylaxis. |