Acute gastrointestinal bleeding: Part I

To review the management of acute gastrointestinal bleeding in the critically ill patient in a two part presentation.

Articles and a review of studies reported from 1991 to 2001 and identified through a MEDLINE search of the English language literature on acute gastrointestinal bleeding.

Gastrointestinal bleeding is a relatively frequent problem in the critically ill patient. Common causes include acute stress ulceration (ASU), peptic ulceration and bleeding oesophageal varices. Non-variceal upper gastrointestinal bleeding requires resuscitation and correction of coagulation disturbances before endoscopy is performed. If a bleeding ulcer is detected it is often managed by an adrenaline injection or electrocautery into the base of the lesion and a proton pump inhibitor (e.g. omeprazole 80 mg i.v. followed by 8 mg/hr for 72 hr then 20 mg orally for 8 weeks). Surgery is considered for all patients in whom bleeding persists despite endoscopic or medical therapy. While H(2) receptor antagonists have been used for the management of ASU, proton pump inhibitors are currently prescribed due to their greater gastric acid suppressant effect (e.g. omeprazole 40 mg i.v. daily for ASU prophylaxis, 40 mg daily or 12-hourly for ASU with mild blood loss and 80 mg i.v. followed by 8 mg/hr for 72 hrs for ASU with severe haemorrhage). With severe haemorrhage, fibrinolytic inhibitors (e.g. tranexamic acid 3-6 g i.v. daily) may also be of benefit. For lower gastrointestinal bleeding or if there is no obvious upper gastrointestinal lesion during endoscopy, then selective mesenteric angiography with embolisation of the bleeding point (if the bleeding is brisk, e.g. > 0.5-2.0 mL/min) or colonoscopy with electrocautery or adrenaline injection (for diverticular haemorrhage) may be considered as an alternative to surgery.

Acute upper gastrointestinal bleeding is often managed by intravenous proton pump inhibitors and endoscopy with electrocautery or adrenaline injection when a bleeding at the base of an ulcer is found. For lower gastrointestinal haemorrhage, selective mesenteric angiography with embolisation of the bleeding point is an alternative to surgery in critically ill patients. Fibrinolytic inhibitors may have added benefit.