Hemorragia digestiva alta e suas opções terapêuticas

Abstract

Introduction: Patients with acute upper gastrointestinal bleeding typically present with hematemesis (vomiting of blood or coffee-ground material) and/or melena (black, tarry stools). Some may also present with hematochezia (red/brown blood with stools). Initial evaluation of patients with acute bleeding involves assessment of hemodynamic stability and fluid resuscitation. Diagnostic studies (usually endoscopy) follow, with the goals of diagnosis and, when possible, treatment of the specific disorder. The goal is to assess the severity of the bleeding, identify possible sources, and determine whether there are conditions present that might affect subsequent management. The information collected is used to guide decisions about triage, resuscitation, empiric medical therapy, and diagnostic testing. Objective: To discuss the initial evaluation of upper gastrointestinal bleeding in adults. Methodology: Literature review from Scielo, PubMed, and BVS databases, from April to June 2024, with descriptors “Upper gastrointestinal bleeding”, “Adults”, “Initial assessment”, and “Management”. Articles from 2019-2024 (total 97) were included, excluding other criteria and choosing 05 full articles. Results and Discussion: Symptoms that suggest that bleeding is serious include orthostatic dizziness, confusion, angina, severe palpitations, and cold/cool extremities. Possible sources of bleeding suggested by a patient's medical history include: peptic ulcer disease (history of Helicobacter pylori (H. pylori) infection); nonsteroidal anti-inflammatory drug (NSAID) use; anticoagulant use); varicose veins/portal hypertensive gastropathy; gastrointestinal angiodysplasia; aortoenteric fistula; or malignancies. A complete medication history should be obtained, with special attention to medications that: predispose to peptic ulcer formation, such as aspirin and other NSAIDs, including COX-2 selective NSAIDs; are associated with pill esophagitis; increase the risk of bleeding, such as anticoagulants (including warfarin and direct oral anticoagulants) and antiplatelet agents (e.g., P2Y12 inhibitors and aspirin); associated with GI bleeding, including selective serotonin reuptake inhibitors (SSRIs), calcium channel blockers, and aldosterone antagonists. Physical examination is a key component of assessing hemodynamic stability. Signs of hypovolemia include: Mild to moderate hypovolemia (less than 15% of blood volume lost); Tachycardia at rest; Blood volume loss of at least 15%—orthostatic hypotension (a decrease in systolic blood pressure of more than 20 mmHg and/or an increase in heart rate of 20 beats per minute when rising from reclining to standing); Blood volume loss of at least 40%—supine hypotension. The presence of abdominal pain, especially if severe and associated with rebound tenderness or involuntary guarding, raises concern for perforation. If there are any signs of acute abdomen, further evaluation is necessary to exclude perforation before endoscopy. Laboratory tests include a complete blood count, serum chemistries, liver tests, and coagulation studies. In addition, we suggest ruling out myocardial infarction in older adult patients and those with known cardiovascular disease who have severe bleeding, especially if there has been hemodynamic instability. Before endoscopy, patients should receive general supportive measures, including: provision of supplemental oxygen by nasal cannula; fasting; two large-bore peripheral catheters (18 gauge or larger) or a central venous line. Nasogastric lavage is not routine. Medications include a proton pump inhibitor, erythromycin, antibiotics (for patients with cirrhosis), and somatostatin or analogues (for patients with suspected variceal bleeding). Conclusion: Peptic ulcers, diverticular disease (such as diverticulitis), and abnormal blood vessels (angiodysplasia) are the most common causes of severe bleeding. Bleeding from enlarged veins in the esophagus (esophageal varices) is less common than in younger people. Older people have poor tolerance to heavy gastrointestinal bleeding. The physician should diagnose older people quickly and treatment should begin earlier than in younger people, who can tolerate recurrent episodes of bleeding better.