Critical Pearls for Acute Upper GI Bleeds

Dr. Michael Winters is an Associate Professor in both Emergency Medicine and Internal Medicine at the University of Maryland.  He is an internationally known speaker in the area of critical care specifically in the Emergency Department setting and an amazing clinician as well.  We were fortunate enough to have Dr. Winters come and speak to us about a topic we frequently encounter in the ICU – upper GI bleeds.  By time they hit the ICU – do you have everything and everyone prepared for the probable “stormy course”?  if not, this is a must listen because you most likely will see this patient in the next couple of days…


  1. Pre-endoscopy PPIs: Low risk-benefit profile and 2010 ACP guidelines still recommend them.  However, Sreedharan A et al. systematic review – no difference in mortality, need for surgery, or re-bleeding rates.
  2. The dose of vasopressin for massive upper GI bleeding is NOT the same as the vasopressin replacement dosing used in sepsis.  Use an infusion rate of 0.2 – 0.4 units/min IV, and titrate by doubling the dose q 30 min until bleeding stops of MAP > 65.
  3. Early antibiotic therapy is one of the only medications that has a proven mortality benefit in cirrhotics or those with suspected variceal upper GI bleeds.  Most recommend giving a 3rd generation cephalosporin or a fluroquinolone.
  4. Balloon tamponade devices can be left in place for approximately 24 hours; avoid inflating esophageal balloon > 45 mmHg, as this can increase risk of rupture.
  5. TIPS Procedure: Indicated for patient with:
    • Child B with active bleeding
    • Child C < 14 points
    • Consider early: preferably 24 hours, generally within 72 hours.

BONUS PEARL: Consider IV erythromycin (+/- NGT) to improve stomach visualization during endoscopy; Dose: 250 mg IV


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