Therapy

• urgently ^a to control bleeding ^a
• to make a diagnosis and determine future risk of bleeding or death (using the Rockall score) ^a
  Look out for endoscopic stigmata of recent haemorrhage ^a  
  • blood in upper GI tract
  • an adherent clot
  • a visible or spurting vessel
  
  Remember 
  • endoscopy is not necessary for all patients ^d  
  • endoscopy is safe ^b - though monitor patients who have received midazolam for hypoxia ^a

• a Mallory-Weiss tear or an ulcer (with a clean base, a flat pigmented spot or an adherent clot) can start eating immediately on recovery from endoscopy ^d  

• give a concentrate of factors II, VII, IX, and X at a dose of 50 units of factor IX per kg body weight ^c
• if no concentrate is available give fresh frozen plasma (~ 1litre for an adult) ^d
• stop warfarin if your patient is on it and safe to do so ^c  
• consider giving 5 mg vitamin K by slow (5 minute) iv infusion ^a

• somatostatin or octreotide ^a  
• thiamine 100 mg  ^d iv  ^c  to alcoholics or malnourished patients ^d

• immediate surgery for all patients with non-variceal bleeding ^c  
• giving proton-pump inhibitors ^d or H₂ antagonists ^d to all patients

Ulcers

There is no clear reduction in bleeding or mortality from adding 

• alcohol ^d
• ethanolamine ^d
• polidocinol ^d
• laser photocoagulation ^d
• heat probe coagulation ^d

There is no clear benefit from a routine repeat endoscopy ^d  

Give antacids. ^a  

Advise patients to stop smoking. ^b  

Discuss any patient likely to rebleed (see Rockall score)  with surgeons and anaesthetists to determine criteria for operation. ^d

Consider surgery for patients who have evidence of: ^d  

• persistent haemorrhage despite endoscopic therapy
• recurrent haemorrhage despite endoscopic therapy

• tranexamic acid ^a  for patients likely to rebleed  ^d (3-6 g iv daily for 3 days, followed by 3-6 g po daily for 3 to 5 days) 
• iron supplements ^b for patients with anaemia e.g. oral ferrous sulphate 200 mg three times a day  ^d

Varices

Perform

• endoscopic ligation ^a  
• or sclerotherapy ^a within 6 hours ^b  
• and give in addition any of
  • terlipression (e.g. 1-2 mg iv every 4 to 6 hours for up to 5 days)
  • octreotide
  • somatostatin  (e.g. somatostatin 6 mg in 500 ml saline iv over 24 hours for 5 days) 

• balloon tamponade ^a  for patients who do not stop bleeding ^d
• performing a porto-caval shunt ^a for patients who do not stop bleeding ^d
  Options include
  • transjugular intrahepatic portosystemic shunts (TIPS) ^a
  • distal spleno-renal shunts ^a  
  
  Avoid staple transection of the oesophagus