Monitoring
Most patients usually stop bleeding spontaneously before endoscopic evaluation. Serial hemoglobin (Hb) levels after endoscopic therapy should be considered only in patients with a high risk of rebleeding. Blood transfusion (packed red blood cells [RBCs]) may be necessary in certain cases (for ongoing bleeding, or low Hb at presentation). Guidelines differ in exact thresholds. The American College of Gastroenterologists (ACG) recommends transfusion for hemodynamically stable patients with upper gastrointestinal (GI) bleeding when Hb <7 g/dL.[39] Hypotensive patients may receive transfusion at a higher threshold, and in patients with preexisting cardiovascular disease, transfusion is reasonable when Hb <8 g/dL. Patients with acute coronary syndrome may be considered for transfusion when Hb >8 g/dL, but the guidelines note that this is based on very limited evidence.[39] The International Consensus Group suggests transfusion for patients with acute upper GI bleeding without cardiovascular disease when Hb is <8 g/dL, with a higher threshold for those with cardiovascular disease.[40] Similarly, although it does not specify ranges, the American College of Chest Physicians recommends a restrictive transfusion strategy over a permissive transfusion strategy in critically ill patients, notably including those with acute GI bleeding, but in critically ill patients with acute coronary syndrome it suggests against a restrictive transfusion strategy.[41] A post-transfusion target of Hb ≥10 g/dL should be aimed for in patients with cardiovascular disease (CVD), while a lower level of Hb 7-9 g/dL is considered appropriate for patients without CVD.[1] Prothrombin time/international normalized ratio (PT/INR) should be monitored and corrected as needed. Associated lesions should be identified during endoscopy and treated accordingly.
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