APPROACH TO PPH

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The management of gastrointestinal (GI) bleeding involves immediate patient stabilization, localization of the bleeding source, and subsequent specific pharmacologic or surgical interventions, depending on the site (upper or lower GI tract) and cause of the hemorrhage.

The primary goals of initial therapy are hemodynamic resuscitation and correction of circulatory collapse.

1. Hemodynamic Support: Immediate assessment of airway, breathing, and circulation (ABCs) is mandatory.

   • Vascular Access:
   • Fluid Management: Administer intravenous fluid resuscitation using Normal Saline or balanced crystalloids (e.g., lactated Ringer solution). This practice improves mortality in critically ill patients.
   • Monitoring: Continuous monitoring of vital signs (telemetry, pulse oximetry, BP) and urine output is essential. Hypotension (systolic BP <100 mmHg) or a pulse rate over 100 bpm indicates significant blood volume loss.
   • Positioning: Placing the patient in the Trendelenburg position temporarily can help maintain cerebral blood flow.

2. Blood and Coagulation Management:

   • Transfusion: Blood transfusions are typically performed to maintain haemoglobin (Hb) levels above 7 g/dL (70 g per L) in non-acutely bleeding or minimally bleeding patients.
   • Coagulopathy: Correcting coagulopathy (e.g., administering Vitamin K) and infusing platelets are necessary, especially if thrombocytopenia is symptomatic (platelet count <50,000/µL).

Upper GI bleeding originates proximal to the ligament of Treitz. Endoscopy (Esophagogastroduodenoscopy, EGD) is the definitive first-line procedure for diagnosis and intervention, ideally performed within 24 hours of stabilization.

1. Mucosal Bleeding (Non-Variceal, e.g., Ulcers, Erosions): Therapy is directed at neutralising and/or preventing the release of acid.

   • Proton Pump Inhibitors (PPIs): These are the mainstay of therapy, irreversibly blocking the gastric proton pump (H+/K+ ATPase) to significantly reduce acid secretion. Standard intensive dosing involves an IV bolus (e.g., 80 mg) followed by a continuous infusion (e.g., 8 mg/h) for 72 hours.
   • H2 Receptor Antagonists (H2RAs): These block histamine action on parietal cells. IV administration shows mixed, mild benefit in gastric ulcers but no benefit in duodenal ulcers.
   • Sucralfate: This forms a viscous protective barrier over ulcers in an acidic environment (pH<4).

2. Variceal Bleeding (Portal Hypertension): Vasoactive drugs are started immediately after haemodynamic stabilization to reduce splanchnic pressures.

   • Octreotide: Given as an IV bolus (50 µg in adults, or 1 mcg/kg up to 50 mcg maximum) followed by a continuous infusion (e.g., 50 µg/h or 1 mcg/kg/h up to 4 mcg/kg/h maximum) for 2–5 days once bleeding is controlled.
   • Vasopressin/Terlipressin (Glypressin): Terlipressin (2 mg IV every 4 hours until a bleeding-free interval of 24–48 hours is achieved) and Vasopressin (0.002 to 0.005 units/kg per minute for 12 hours, then tapered) are also used.

1. Non-Variceal Management (EGD): Endoscopic therapy is essential for ulcers presenting with active bleeding or high-risk stigmata (like a nonbleeding visible vessel). Modalities include:Variceal Management:

1. Surgical Intervention (Both Types): Surgery is indicated in cases of uncontrolled or recurrent bleeding that fails medical and endoscopic management, or when the patient remains hemodynamically unstable despite aggressive resuscitation (e.g., requiring >6 units of blood transfusion).

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