Prevention
In those with significant varices or cirrhosis nonselective β-blockers reduce the risk of future bleeding. With a target heart rate of 55 beats per minute they reduce the absolute risk of bleeding by 10%. Endoscopic band ligation (EBL) is also effective at improving outcomes. Either B-blockers or EBL are recommended as initial preventative measures. In those who have had a previous variceal bleed both treatments are recommended. Some evidence supports the addition of isosorbide mononitrate. Testing for and treating those who are positive for H. pylori is recommended. Transjugular intrahepatic portosystemic shunting (TIPS) may be used to prevent bleeding in people who re-bleed despite other measures.Among people admitted to the ICU who are at high risk, a PPI or H2RA if appears useful. Treatment
The initial focus is on resuscitation beginning with airway management and fluid resuscitation using either intravenous fluids and or blood. A number of medications may improve outcomes depending on the source of the bleeding. Peptic ulcers
Based on evidence from people with other health problems crystalloid and colloids are believed to be equivalent for peptic ulcer bleeding. Proton pump inhibitor (PPI) treatment before endoscopy may decrease the need for endoscopic hemostatic treatment, however it is not clear if this treatment reduces mortality, the risk of re-bleeding, or the and the need for surgery. Oral and intravenous formulations may be equivalent; however, the evidence to support this is suboptimal. In those with less severe disease and where endoscopy is rapidly available, they are of less immediate clinical importance.
Blood products
The evidence for benefit of blood transfusions in GI bleed is poor with some evidence finding harm. In those in shock O-negative packed red blood cells are recommended. If large amounts of pack red blood cells are used additional platelets and fresh frozen plasma (FFP) should be administered to prevent coagulopathies. In alcoholics FFP is suggested before confirmation of a coagulopathy due to presumed blood clotting problems. Evidence supports holding off on blood transfusions in those who have a hemoglobin greater than 7 to 8 g/dL and moderate bleeding, including in those with preexisting coronary artery disease.If the INR is greater than 1.5 to 1.8 correction with fresh frozen plasma or prothrombin complex may decrease mortality. Evidence of a harm or benefit of recombinant activated factor VII in those with liver diseases and gastrointestinal bleeding is not determined. A massive transfusion protocol may be used, but there is a lack of evidence for this indication. Procedures
The benefits versus risks of placing a nasogastric tube in those with upper GI bleeding are not determined. Endoscopy within 24 hours is recommended, in addition to medical management. A number of endoscopic treatments may be used, including: epinephrine injection, band ligation, sclerotherapy, and fibrin glue depending on what is found. Prokinetic agents such as erythromycin before endoscopy can decrease the amount of blood in the stomach and thus improve the operators view. They also decrease the amount of blood transfusions required. Early endoscopy decreases hospital and the amount of blood transfusions needed.