A major cause of morbidity and mortality in patients with active GI bleeding is aspiration of blood with subsequent respiratory compromise, particularly in patients who have inadequate gag reflexes or who are obtunded or unconscious. To prevent this complication in patients with altered mental status, endotracheal intubation should be considered to protect the airway. The Hct is a valuable index of blood loss but may be inaccurate if the bleeding has occurred over the preceding few hours, because complete restoration of blood volume by hemodilution may take several hours. Transfusions usually maintain the Hct at about 30 if there is risk of further hemorrhage, if complicating vascular disease is present, if severe comorbid conditions or critical illness is present, or if the patient is elderly. Most transfusion physicians now recommend only blood component therapy.
Specific therapy depends on the bleeding site.
For treatment of peptic ulcer after bleeding has been controlled, see Ch. 23. It is particularly important to consider early operative control of gastric bleeding in the elderly to minimize mortality rates. At the time of the diagnostic endoscopy, treatment of active ulcer bleeding or of nonbleeding visible vessels in ulcers is indicated with endoscopic coagulation. No method is clearly superior, although most hospitals use banding or sclerotherapy as the primary treatment of bleeding esophageal varices. For patients who fail banding or sclerotherapy, a TIPS procedure, shunt surgery, or liver transplantation should be considered.