Management of upper gastrointestinal haemorrhage

Endoscopic therapy is the first treatment modality in the management algorithm of upper gastrointestinal haemorrhage. In treating bleeding peptic ulcers, diluted epinephrine is first injected followed by targeted treatment to the vessel. Combination therapy adding thermocoagulation or thrombin/fibrin products has been shown to further improve the rate of haemostasis. There is also some evidence to suggest that adjuvant use of optimal acid suppression using high-dose proton pump inhibitors can reduce recurrent bleeding after initial endoscopic control. In treating acute variceal haemorrhage, early administration of vasoactive agents facilitates endoscopic treatment. These drugs should be continued during and after endoscopic therapy to prevent recurrent in-hospital bleeding. Firm evidence exists to date that band ligation is the endoscopic treatment of choice in the acute control of bleeding varices and their secondary prophylaxis against recurrent bleeding. The role of band ligation as primary prophylaxis for first bleeding remains controversial. Transjugular intrahepatic portosystemic shunts are used as a rescue procedure when endoscopic treatment fails. In selected patients with recurrent variceal haemorrhage and good hepatic reserves, surgical shunts may be indicated. (C) 2000 Blackwell Science Asia Pty Ltd.