Go back


    Massive GI Bleeds


    Last Updated May 14, 2021
    Read Disclaimer


    • Massive upper GI bleeds originate proximal to the ligament of Treitz in distal duodenum.
    • Etiologies include duodenal ulcers, gastric ulcers, gastritis, esophageal varices and esophagitis.
    • Patients with known varices still often bleed from peptic ulcer disease.
    • Upper GI bleeds carry higher morbidity and mortality than lower GI bleeds.
    • Medications like pantoprazole and octreotide do not have mortality benefit, so utilize your access points for resuscitative measures.
    • Initiate resuscitation based on the clinical picture rather than Hb level as this can be deceiving.
    • Remember that in patients with cirrhosis, beta blocker use may mask tachycardia and obscure their shock index.

    Recommended Treatment

    Initial Approach:

    • Resuscitate before intubate.
    • Start preoxygenation early with high flow nasal cannula.
    • Get two large bore (plain suction tubing or Du Canto suctions) at bedside.
    • Know where the Blakemore or Minnesota tube is in your facility.

    Initial Targets:

    Marker Goal
    MAP > 60 mmHg
    Hemoglobin > 70 g/L
    Platelets > 50 x 109/L
    Temperature > 36 oC
    Calcium > 2 mmol/L
    Lactate < 2 mmol/L
    Urine output > 0.5 mL/kg/hr

    Transfusion Approach:

    Transfusion Type Threshold
    pRBC Transfusion Hemodynamically unstable

    Shock index > 1

    Clinical assessment: volume blood loss, bleeding, briskness, symptomatology

    Massive Transfusion Activation Received 4U uncrossmatched pRBC

    Received 4U pRBC in 1 hour

    Shock Index > 1

    Airway Approach:

    Preparation Recommendation
    Preoxygenation High flow NP +/- apneic oxygenation
    Suction Double large bore suction
    Medications Ketamine 0.5 mg/kg

    Rocuronium 1.5 mg/kg

    Push dose pressors ready

    Patient Positioning Head of bed 45o

    If vomit then Trendelenburg

    Laryngoscope DL > VL



    Tips for Airway Decontamination and Securing the Airway:

    • Du Canto catheter and the SALAD approach.
    • Use a Seldinger approach with suction tubing to secure the airway and suction as you go. Tape a flexible stylet to outside of the distal end of suction tubing with silk tape. Bend to preferred ETT shape. Under DL, suction as intubate. When through the cords, cut end of suction tubing. Insert a bougie through the suction tubing. Exchange tubing for ETT.
    Problem Solution
    Can’t see Go where the bubbles are

    Assistant presses on chest for forced exhalation

    Bad view but see the cords whilst suctioning Seldinger technique

    Suction through cords

    Cut tubing

    Bougie through tube

    Exchange for ETT

    Accidentally intubated the esophagus Leave the ETT alone

    Inflate balloon and reduce airway contamination

    Advance ETT in esophagus so the end is flush with teeth

    Tape over the end of ETT

    BVM patient before second attempt


    Temporizing methods for ongoing hemorrhage:

    • Review Sengstaken-Blakemore Tube Insertion.
    • Review Minnesota Tube Insertion.

    Definitive Management:

    • Endoscopy for variceal ligation and sclerotherapy. For ulcers, clips, thermocoagulation, sclerosant injections alone or with epinephrine.
    • CTA abdomen with non-contrast, arterial and venous phase for localizing bleeding site.
    • Decision for OR vs IR depends on etiology of bleed and stability of patient.

    Criteria For Hospital Admission

    Admit to ICU.

    Criteria For Transfer To Another Facility

    Depending on stability of patient and local ability to continue patient monitoring and management.

    Criteria For Close Observation And/or Consult

    Will be required for all patients. ICU, GI and/or general surgery consultation depending on local practice patterns.

    Criteria For Safe Discharge Home

    All patients will be admitted.

    Quality Of Evidence?


    Moderate. Resuscitation targets based largely on expert opinion. Recommendations regarding massive upper GI bleed management is largely extrapolated from trauma literature.


    Related Information

    Reference List

    1. Dworzynski K, Pollit V, Kelsey A, Higgins B, Palmer K. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ (Clinical research ed.). 344:e3412. 2012.

    2. Open Airway. SALAD. https://openairway.org/salad/. Accessed May 14, 2021.

    3. Villanueva C, Colomo A, Bosch A. Transfusion for acute upper gastrointestinal bleeding. N Engl J Med. 2013;368(14):1362-3.

    4. Wolpaw, J. April 15, 2019. Episode 115: The Contaminated Airway with Steve Freiberg. Available at: https://podcasts.apple.com/ca/podcast/anesthesia-critical-care-reviews-commentary-accrac/id1116485154?i=1000434980499. Accessed May 14, 2021.


    COMMENTS (0)

    Add public comment…