Emergency Management of Upper Gastrointestinal Bleeding 2000.7.30

Emergency Management of Upper Gastrointestinal Bleeding 2000.7.30

Bleeding above the Treitz ligament is classified as upper gastrointestinal bleeding, including bleeding from the esophagus, stomach, duodenum, gallbladder, pancreas, and common bile duct. If the amount of bleeding exceeds 5 mL, fecal occult blood is (+); if it exceeds 50 mL, the stool turns black; if it exceeds 250 mL, there is hematemesis; and if it exceeds 500 mL, shock occurs. Normal hematocrit is 40%–50% (slightly lower in women), with 30% of bleeding reaching 600–1000 mL, and 20% reaching 1500–2000 mL. ① Mild hypovolemic shock: systolic pressure 80–90 mmHg, pulse 100 beats per minute, central venous pressure (CVP) slightly decreased, with bleeding accounting for about one-quarter of total blood volume; ② Moderate hypovolemic shock: systolic pressure 60–70 mmHg, pulse 120 beats per minute, CVP significantly decreased, with bleeding accounting for about one-third of total blood volume; ③ Severe hypovolemic shock: systolic pressure below 60 mmHg, pale skin, cold extremities, CVP at zero, with bleeding accounting for more than half of total blood volume.

Treatment: ① Massive blood transfusion: every 400 mL of fresh blood can raise hemoglobin by 10 g/L; for those receiving more than 2000 mL, stored citrate blood can be used, but calcium gluconate should also be supplemented. Large-scale infusion of stored blood can lead to hyperkalemia, which in turn can cause ARDS. The infusion rate should be controlled at no more than 10 mL per minute; for critically ill patients requiring 2000 mL in the first hour, dual-channel or pressurized infusion is recommended. ② Patients with portal hypertension can receive posterior pituitary hormone, 10 U intravenously or 0.3–0.4 U/min intravenously. This drug has many side effects, including abdominal pain and increased bowel movements, which are common complications, while myocardial ischemia is rare. ③ Recently, sandostatin (octapeptide somatostatin) or somatostatin (tetrapeptide somatostatin) have been used; the former is administered intravenously at 100 µg in 10% glucose solution, while the latter is administered at 3 mg in 10% glucose solution. These two drugs are currently recognized as the best options for lowering portal pressure. ④ Vasoactive drugs, such as alamine, dopamine, and isoproterenol. ⑤ Hemostatic drugs: hemostatic acid, hemostatic agent, hexamethylenediamine can be used, with reliable efficacy; each hemostatic injection is 1 ku, can be given intramuscularly or intravenously. Thrombin 2000 U dissolved in 40 mL of cold saline and taken at once, 8% renin cold saline taken at once. ⑥ Acid-suppressing drugs: ranitidine and cimetidine administered intravenously. ⑦ Correcting acid-base balance. ⑧ Cardiotonic diuretics, monitoring the heart. ⑨ Gastric tube, triple-lumen tube.