Acute upper gastrointestinal bleeding is one of the common acute and critical illnesses in emergency departments. The annual incidence rate of adults is 1 million/100,000 to 18 million to 100,000, and the mortality rate is 2%-15%. Standardizing the emergency diagnosis and treatment process is of great significance to improving the prognosis. In the past five years, many progress have been made in clinical diagnosis and treatment of acute upper gastrointestinal bleeding. Therefore, the Emergency Physicians Branch of the Chinese Medical Association organized experts from multiple disciplines such as emergency departments, gastrointestinal departments, interventional departments, and surgery to update the 2020 version of the expert consensus on emergency diagnosis and treatment process for acute upper gastrointestinal bleeding on the basis of the 2015 version of the consensus.

One, method

The 2015 edition of the expert consensus is mainly based on the evaluation of acute upper gastrointestinal bleeding, circulation stability, drug selection and hemostasis treatment. Based on the 2015 edition, this update focuses on re-optimizing the diagnosis and treatment process. At the same time, the members of the expert group have extensively discussed and modified the consensus content in risk stratification, dynamic assessment, treatment strategy, endoscopic intervention timing and drug management for special populations, so as to finally reach a consensus statement. This update refers to the latest evidence-based guidelines and literature at home and abroad, and combines the actual situation of emergency clinical practice in my country, and uses the improved Delphi method to reach a consensus statement. Each statement needs to be approved by at least 80% of all experts. This update focuses on evidence-based medicine. After discussion at the full expert meeting, the evidence level is divided into three levels.

2. Consensus content

2.1 Emergency diagnosis and treatment process

This version of the consensus still adheres to the concept of emergency diagnosis and treatment of acute upper gastrointestinal bleeding, striving to meet the operability and practicality of the clinical practice, for reference by emergency physicians, see Figure 1.

2.2 Emergency assessment, diagnosis and stratified treatment

2.2.1 Emergency Assessment

Consciousness Assessment: First of all, judging consciousness is that consciousness disorders not only indicate severe blood loss but also a high-risk factor for misaccination.

Airway assessment: Assess the risk of airway patency and obstruction.

Respiratory Assessment: Assess the respiratory rate, rhythm, force and blood oxygen saturation.

Circulation assessment: Monitor heart rate, blood pressure, urine volume and peripheral perfusion. Invasive hemodynamic monitoring is performed whenever conditions allow.

2.2.2. Diagnosis

Patients with typical symptoms of hemorrhage, black stool or bloody stool are easily diagnosed. Positive gastric juice, vomit or stool occult blood suggests that it may be bleeding. For patients who visit patients with atypical symptoms such as dizziness, fatigue, fainting, especially those with unstable vital signs, pale complexion and unexplained acute hemoglobin reduction, they should be wary of the possibility of upper gastrointestinal bleeding. Any of the active bleeding, circulatory failure, respiratory failure, disordered consciousness, aspiration, or GBS1 should be considered as dangerous acute upper gastrointestinal bleeding.

Severe anemia, persistent vomiting of blood or bloody stools, fainting, low blood pressure or low Hb level all indicate severe blood loss. When vomiting of blood and the amount of black stool does not match the degree of anemia, you should be wary of hidden upper gastrointestinal bleeding. Vomiting blood and brown liquid both indicate critical condition.

Statement 1: The patient's consciousness, airway, breathing and circulation should be evaluated first. After preliminary diagnosis and differentiation of acute upper gastrointestinal bleeding, the degree of disease risk should be determined based on the GBS score.

2.2.3 Layered treatment

The overall clinical manifestations can divide the patient's risk into 5 layers, namely extremely high-risk, high-risk, medium-risk, low-risk and extremely low-risk. It is classified into the corresponding area for diagnosis and treatment according to the risk level. Risk bleeding should be diagnosed and treated in the emergency clinic. Patients with loss of consciousness and cannot reach the pulmonary pulsation of the major artery should undergo cardiopulmonary resuscitation immediately.

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Patients with fainting, persistent vomiting/bloody stools, dampness and cold limb extremities, heart rate of 100 beats/min, systolic blood pressure <90mmHg or basal systolic blood pressure reduction of 30mmHg, and hemoglobin <70g/L should immediately be admitted to the emergency room to start resuscitation treatment. Patients with stable vital signs can be treated in the emergency general diagnosis and treatment area. GBS ≤1 indicates extremely low risk of bleeding. Only 1.2% of these patients need blood transfusion or emergency intervention, and can be further diagnosed and treated in the outpatient clinic.

Statement 2: Patients with acute upper gastrointestinal bleeding should be treated in a stratified manner according to the degree of danger. Risk bleeding should be diagnosed and treated in the emergency room.

3.3 Emergency response

Conventional measures, namely, inhaling oxygen, monitoring and establishing intravenous pathways. Continuous monitoring of electrocardiogram, blood pressure, and blood oxygen saturation. Patients with conscious disorders or shock can have a urinary catheter to record urine volume. Patients with severe bleeding should open at least two venous pathways, and central vein cannons should be placed in a central vein if necessary. For patients with conscious disorders, respiratory or circulatory failure, attention should be paid to airway protection and prevention of misaccination. If necessary, oxygen therapy or artificial ventilation support should be given, and resuscitation treatment should be initiated.

Resuscitation treatment mainly includes volume resuscitation, blood transfusion and vasoactive drugs. Patients with high-risk acute upper gastrointestinal bleeding must be absolutely bedridden. In the past, gastric tubes were used to assist in assessing bleeding, but the current evidence does not support the benefit of placing gastric tubes. Therefore, the placement of gastric tubes should be cautious, especially for patients with cirrhosis, rupture and bleeding of esophageal fundus varicose rupture or poor coordination, avoiding the operation to aggravate bleeding or causing discomfort to the patient.

Statement 3: Patients with high-risk acute upper gastrointestinal bleeding should be treated urgently.

3.3.1 Capacity recovery

Acute upper gastrointestinal bleeding with hemodynamic instability should actively resuscitate volume, but the specific resuscitation strategy currently lacks evidence-based evidence. Referring to the resuscitation concept of trauma and major bleeding, restrictive fluid resuscitation and permissive hypotension resuscitation strategies are adopted when bleeding is not controlled. It is recommended that systolic blood pressure be maintained at 80-90mmHg. The bleeding has been controlled and should be actively resuscitated according to the patient's basal blood pressure level. For patients with acute major bleeding, invasive hemodynamic monitoring should be performed, comprehensive clinical manifestations, ultrasound and laboratory examinations should be performed to guide volume resuscitation, and attention should be paid to prevent hypothermia, acidosis, coagulation and worsening of underlying diseases.

There is currently no consensus on the amount and type of intravenous infusion. In hemorrhagic shock, volume resuscitation should avoid infusion of large amounts of crystal fluid and minimize infusion of crystal fluid. Isotonic crystal fluid has no benefit except temporarily expanding the content of blood vessels. When infusion of large amounts of isotonic crystal fluid, the risk of complications such as respiratory failure, spacer syndrome and coagulation increases. Artificial colloids or hypertonic solutions, as early treatment for severe bleeding, have not brought significant benefits.

Blood pressure returns to the baseline level before bleeding, pulse is less than 100 times/min, urine volume is 0.5mL/, clear awareness, no significant dehydration, and normal arterial lactate recovery, indicating sufficient volume resuscitation. In addition, varicose rupture and bleeding infusion should be cautious, excessive infusion may aggravate bleeding. For patients with cardiopulmonary and kidney diseases, beware of heart failure or pulmonary edema caused by excessive infusion.

Statement 4: Acute upper gastrointestinal bleeding with hemodynamic instability should be resuscitated in a timely manner, and the perfusion of important organs should be restored and maintained.

3.3.2 Blood transfusion

Patients with large numbers of blood loss need to appropriately inject blood products to ensure tissue oxygen supply and maintain normal coagulation function. Blood transfusion should be considered in the following situations: systolic blood pressure <90mmHg; heart rate 110 beats/min; Hb <70g/L; hematocrit <25% or hemorrhagic shock may occur. For acute massive bleeding, local large-scale blood transfusion schemes should be initiated immediately for blood transfusion. Although the proportion of red blood cells, plasma and platelets is not yet determined, pre-set ratios of blood products and the use of auxiliary drugs such as calcium agents can provide survival benefits. Inactive bleeding and hemodynamic stability do not require platelet transfusion, active bleeding and platelet count <50×109/L should be injected.

The risk and benefits of blood transfusion should be individually weighed. A restricted blood transfusion strategy is generally adopted. The recommended Hb target value is 70-90g/L. Varicocele bleeding requires strict restrictions on the blood transfusion indication Hb < 70g/L, otherwise it may increase the mortality rate. However, it is not appropriate to adopt a restricted blood transfusion strategy in patients with elderly patients with basic cardiovascular and cerebrovascular diseases, hemodynamic instability or continuous large-scale bleeding. The blood transfusion indication can be relaxed to Hb < 90g/L or above to avoid the worsening of underlying diseases caused by large-scale blood loss.

For patients with coagulation dysfunction, it is necessary to dynamically observe the changes in the coagulation index or thromboelastography to evaluate the coagulation function status in real time. For active bleeding, if the time of prothrombin or activated part of the thromboplastin is greater than 1.5 times normal, fresh frozen plasma should be infused. If the fibrinogen level is still lower than 1.5g/L after using FFP, fibrinogen or cold precipitation is recommended. If the cirrhosis is bleeding, if FIB is <1g/L, FFP should be infused.

Large-scale blood transfusion can lead to blood transfusion complications, such as hypocalcemia and coagulation dysfunction. Calcium agents should be empirically given and ionic calcium levels should be closely monitored. During the massive blood transfusion process, attention should be paid to possible hypothermia, acidosis and hyperkalemia.

Statement 5: Weigh the risks and benefits of blood transfusion and adopt the best blood transfusion strategy.

3.3.3 Application of vasoactive drugs

Vascular active drugs can be used in severe persistent hypotension caused by hemorrhagic shock. However, there is currently a lack of high-level evidence to support it.

Statement 6: Persistent hypotension still exists after active volume resuscitation. To ensure the minimum effective perfusion of important organs, vasoactive drugs can be used.

3.3.4 Initial drug treatment

Although sufficient evidence is lacking in support of dangerous acute upper gastrointestinal bleeding, in cases where emergency gastroscopy intervention may be delayed, it can be taken to strive to minimize bleeding, serious complications and death, creating conditions for endoscopy or other subsequent treatments.

The causes of acute upper gastrointestinal bleeding are mostly non-variceal bleeding. Therefore, it is recommended to apply PPI before endoscopy when the cause is unclear. In addition, since patients with liver disease history or cirrhosis cannot rule out ulcer bleeding, it is also recommended to use PPI before endoscopy treatment. Patients with cirrhosis, chronic liver disease history or signs of portal hypertension are highly likely to have variceal bleeding. Such patients often have a large amount of bleeding and have a high early mortality rate. Drug treatment including vasoconstrictor drugs should be given before endoscopy is diagnosed.

Statement 7: When the cause of risk acute upper gastrointestinal bleeding is unknown, intravenous treatment can be combined with PPI and somatostatin, and then adjusted after the cause is clear.

Somatostatin is suitable for the treatment of severe acute esophageal varicose bleeding, severe acute gastric or duodenal ulcer bleeding, and concomitant acute erosion gastritis or hemorrhagic gastritis. Therefore, when the cause of dangerous acute upper gastrointestinal bleeding is unknown, PPI and somatostatin can be combined, and then adjusted after the cause is clear.

Statement 8: When varicose bleeding is highly suspected, it is recommended to use preventive antibiotics.

Because the prophylactic use of antibiotics for varicose bleeding can significantly improve the prognosis, antibiotics should be used prophylactic when varicose bleeding is highly suspected.

3.4 Comprehensive Assessment

3.4.1 Inferred cause of bleeding

Active bleeding, or major bleeding, life-threatening conditions are temporarily controlled. After fluid resuscitation and drug treatment begin, or when the condition is mild and vital signs are stable, a comprehensive evaluation should be initiated and the cause and location of the bleeding should be speculated. For suspected varicose bleeding, early identification should be paid attention to, and evaluation can be carried out based on signs and risk factors for portal hypertension.

The causes of acute upper gastrointestinal bleeding are divided into two categories: acute nonvariceal bleeding and variceal bleeding. Most of them are acute nonvariceal bleeding. The most common causes include gastroduodenal peptic ulcer, upper gastrointestinal tumor, stress ulcer, acute and chronic upper gastrointestinal mucosa inflammation, and other causes include cardia mucosal tear syndrome, upper gastrointestinal arteriovenous malformation, Dieulafoy lesions, etc. Isogenic factors include: taking nonsteroidal anti-inflammatory drugs, especially antiplatelet drugs, endoscopic mucosal resection/dissection, etc.

Statement 9: After initial disposal, the cause of the bleeding should be comprehensively evaluated.

3.4.2. Dynamic monitoring

Vital signs, blood routine, coagulation function, and blood urea nitrogen should be continuously monitored dynamically. In addition, blood lactate levels should be dynamically monitored to determine whether tissue ischemia is improved and the efficacy of fluid resuscitation, and the fluid resuscitation plan should be optimized. Active bleeding should be considered in the following situations:

If you vomit blood, the number of black stools increases, the vomit turns from brown to bright red or the excreted feces will change from black dry stools to dark red bloody stools, or it may be accompanied by active intestinal rumbling;

There is more fresh blood in the gastric tube drainage fluid.

After rapid infusion and blood transfusion, the performance of peripheral circulation and perfusion did not significantly improve, or even though it temporarily improved and worsened, the central venous pressure still fluctuated, and then decreased after a little stability;

Red blood cell count, hemoglobin and hematocrit continue to decline, and reticulocyte count continues to increase;

When the fluid replenishment and urine volume are sufficient, the blood urea nitrogen will continue to be abnormal or increase again.
Chapter completed!