- Upper GI bleeding is common and affects 10-15% of people, usually caused by ulcers. Early resuscitation, antisecretory drugs, and endoscopy are used to manage bleeding. - This document summarizes clinical practice guidelines from 2004 for managing upper GI bleeding. It aims to standardize treatment based on evidence and expert consensus. - The guidelines recommend initial treatment for 1-2 days with antisecretory drugs, followed by endoscopy for diagnosis and possible intervention. Early management and resuscitation are emphasized to prevent complications.

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2004 Consensus for Clinical Practice Guideline
for the management of Upper GI Bleeding
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5. ○ ○ ○
Upper GI bleeding ○ ○ ○
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1 Hematemesis / Melena
2 Initial Assessment and Resuscitation
3 Risk Stratification
3 A Low Risk 3 B High Risk
PPI for Suspected Samotostain for
6 Non-variceal Suspected Variceal 7
4 Supportive Treatment
and Monitoring Bleeding Bleeding
Endoscopy Available
5 Elective Endoscopy
Yes No 8
Ulcer bleeding Variceal Bleeding Others Refer
9 High risk 10 Low risk 16 Pharmacologic Therapy Endoscopic Hemostasis
(Somatostatin or analogue) for Major Stigmata
Hemorrhage
11 Endoscopy Feasible 15 Antisecretory 11 Endoscopy Feasible
Therapeutic
therapy
Therapeutic
18
Yes No Yes No Continue Pharmacologic
Therapy
13
17 EVL/EIS 19 SB 24-48 hrs Fail Success
12 Endoscopic
Hemostasis
Consult Surgeon
or Refer
Bleeding Stop Ongoing Bleed 22
20 21
Success Fail Success Fail
OR
Re-endoscopy Rebleed SB 24-48 hrs TIPS or Surgery 23
and Hemostasis or Refer
14 OR
Pharmacologic
Therapy and Re-endoscopy Fail
Monitoring Rebleed OR EVL/EIS
Success Rebleed
5 ○ ○ ○ ○ ○ ○

6. ○
○
○
○
○
○
○
○
○
6
1 Hematemesis / Melena
2 Initial Assessment and Resuscitation
·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬
○
3 Risk Stratification
○
○
3 A Low Risk 3 B High Risk
PPI for Suspected Samotostain for
6 Non-variceal Suspected Variceal 7
4 Supportive Treatment Bleeding Bleeding
and Monitoring
Endoscopy Available
5 Elective Endoscopy
Yes No 8

7. Yes No 8
Ulcer bleeding Variceal Bleeding Others Refer
9 High risk 10 Low risk Pharmacologic Therapy Endoscopic Hemostasis
16 (Somatostatin or analogue) for Major Stigmata
Hemorrhage
Therapeutic 15 Antisecretory 11 Therapeutic
11 Endoscopy Feasible therapy Endoscopy Feasible
○
○
18
○
Yes No Yes No Continue Pharmacologic
Therapy
13
Endoscopic Consult Surgeon 17 EVL/EIS 19 SB 24-48 hrs Fail Success
12 Hemostasis or Refer
7
Upper GI bleeding
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○

8. ○
○
○
○
○
○
○
○
○
8
13
Endoscopic Consult Surgeon 17 EVL/EIS 19 SB 24-48 hrs Fail Success
12 Hemostasis or Refer
Bleeding Stop Ongoing Bleed 22
·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬
20 21
○
○
Success Fail Success Fail
○
OR
Re-endoscopy Rebleed SB 24-48 hrs TIPS or Surgery 23
and Hemostasis or Refer
14 OR
Pharmacologic Re-endoscopy Fail
Therapy and OR EVL/EIS
Monitoring Rebleed
Success Rebleed

9. ○ ○ ○
Upper GI bleeding ○ ○ ○
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○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○ ○
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Õ“°“√Õ“‡®’¬π‡ªìπ‡≈◊Õ¥ À√◊Õ∂à“¬ melena
2. Initial Assessment and Resuscitation
ë Supportive Treatment
a. Maintain airway
b. History and physical examination for assessment of severity
and causes
c. NG irrigation
d. Fluid resuscitation
e. Blood for CBC, cross-match blood group for blood transfusion
À¡“¬‡Àµÿ : √“¬≈–‡Õ’¬¥°“√¥Ÿ·≈√—°…“„Àâª√—∫µ“¡§«“¡‡À¡“– ¡¢ÕߺŸâªÉ«¬
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3. Risk Stratification
3A Low clinical risk factors
3B High clinical risk factors include
ë Host factors
- Age > 60 years
- Co-morbid conditions e.g. renal failure, cirrhosis, cardio-
vascular disease, COPD
- Hemodynamic instability e.g. orthostatic hypotension,
pulse >100 /min, systolic BP < 100 mmHg
- Coagulopathy including drug-related
ë Bleeding character
- Continuous red blood from NG after irrigation
9 ○ ○ ○ ○ ○ ○

10. ○ ○ ○
·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ ○ ○ ○
- Red blood per rectum
ë Patient course
- Need blood transfusion
- Rebleeding
- Hemodynamic instability
Note: In special circumstances, patientsû referral may be considered if
- The patient has rare blood group (group AB, Rh negative)
- Taking more than 1 hr to the nearest referral hospital
- Blood transfusion is not available
4. Supportive Treatment and Monitoring
ë Supportive treatment as 2
ë Oral PPI double dose until endoscopy
5. Elective Endoscopy
ë Every patient should have endoscopy done if available
ë If endoscopy is not available, consider patientûs referral
6. Suspected non-variceal bleeding
ë Continuous IV infusion or bolus PPI or oral PPI double dose
ë If endoscopy is available with in 8 hr, PPI may not be needed
Note: - Continuous IV infusion PPI: Omeprazole or Pantoprazole 80
mg v bolus then infusion drip 8 mg/hr
- Bolus PPI: Omeprazole or Pantoprazole 40 mg v twice daily
7. Suspected variceal bleeding
ë Clinical signs include
- Previous documented of esophageal varices or gastric
varices
or - Signs of portal HT e.g. splenomegaly, ascites, hepatic en-
cephalopathy, dilated superficial vein
○ ○ ○ ○ ○ ○ 10

11. ○ ○ ○
Upper GI bleeding ○ ○ ○
or - Clinical cirrhosis with thrombocytopenia and/or spleno-
megaly
ë Medication: Somatostatin 250 microgram bolus followed with
somatostatin 250 microgram/hour IV or Octreotide 50 micro-
gram bolus followed with octreotide 50 microgram/hour IV
ë If endoscopy can be performed urgently, somatostatin or its
analogue may not be needed
8. Patient should be referred if
ë High risk of bleeding including recurrent bleeding and no endo-
scopic treatment or no surgical treatment available
ë Rare blood group
ë No blood transfusion available
9. High endoscopic risks
ë Arterial bleeding; spurting, oozing
ë Non-bleeding visible vessel
ë Adherent clot
10. Low endoscopic risks
ë Hematin spot
ë Clean-based ulcer
ë Gastritis
11. Therapeutic endoscopy feasible
ë Defined as ability to do any of therapeutic modalities (even 1
modality)
12. Endoscopic hemostasis
ë Spurting : injection with adrenaline and followed with thermal
coagulation or hemoclips
ë Clot adherent : injection with adrenaline then removal of clot,
11 ○ ○ ○ ○ ○ ○

12. ○ ○ ○
·π«∑“ß°“√¥Ÿ·≈√—°…“ºŸâªÉ«¬ ○ ○ ○
followed with thermal coagulation or hemoclips
ë Non bleeding visible vessel : thermal coagulation, fibrin sealant
or hemoclips
13. Consult surgeon as soon as possible or refer if no surgeon available
14. Pharmacologic therapy
ë Drugs : oral or IV infusion PPI is either used depending on
patients severity and physicianûs judgement
15. Antisecretory therapy
ë Drugs : oral or IV infusion PPI is either used depending on
patients severity and physicianûs judgement
ë In NSAID user including low dose ASA
- PPI is recommended in ongoing NSAIDs use
- H2RA is as effective as PPI if NSAIDs are stopped
16. Pharmacologic therapy in variceal bleeding
ë Somatostatin 250 microgram bolus, followed with somatosta-
tin 250 microgram/hour IV or Octreotide 50 microgram bolus,
followed with octreotide 50 microgram/hour IV
ë If the patient already received somatostatin or its analogue
before endoscopy, bolus dose is not needed
17. Endoscopic variceal ligation (EVL) or Endoscopic injection sclero-
therapy (EIS) depends on the experiences of the endoscopist
18. Continue pharmacologic therapy for 5 days
19. Sengstaken Blakemore tube (SB) insertion
20. Hemostatic success means bleeding stopped
ë May consider discharge somatostatin or its analogue if the EVL
or EIS is completely performed
○ ○ ○ ○ ○ ○ 12

13. ○ ○ ○
Upper GI bleeding ○ ○ ○
21. If hemostasis fail
ë Somatostatin or its analogue should be continued
ë Consider options according to healthcare resources, experi-
ences of the endoscopist and the patientûs conditions
- Consult for surgery or Transcutaneous intrahepatic porto-
systemic shunt (TIPS) with or without temporary tampon-
ade with Sengstaken Blakemore tube
- Temporary tamponade with Sengstaken Blakemore tube and
re-endoscopy after 24-48 hr
22. If bleeding is still ongoing more than 24-48 hour surgery or TIPS is
needed
23. The surgeon should be capable for shunt surgery otherwise refer
to the center that has more equipped facilities
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Consensus for Clinical Practice Guideline
for the management of Upper GI Bleeding
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