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Practical Approach to Acute Gastrointestinal Bleeding Christopher S. Huang MD Assistant Professor of Medicine Boston University School of Medicine Section.

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Presentation on theme: "Practical Approach to Acute Gastrointestinal Bleeding Christopher S. Huang MD Assistant Professor of Medicine Boston University School of Medicine Section."— Presentation transcript:

1 Practical Approach to Acute Gastrointestinal Bleeding Christopher S. Huang MD Assistant Professor of Medicine Boston University School of Medicine Section of Gastroenterology Boston Medical Center

2 Learning Objectives UGIB – Nonvariceal (PUD) and variceal – Resuscitation, risk assessment, pre-endoscopy management – Role of endoscopy – Post-endoscopy management LGIB – Risk assessment – Role and timing of colonoscopy – Non-endoscopic diagnostic and treatment options

3 Definitions Upper GI bleed – arising from the esophagus, stomach, or proximal duodenum Mid-intestinal bleed – arising from distal duodenum to ileocecal valve Lower intestinal bleed – arising from colon/rectum

4 Stool color and origin/pace of bleeding Guaiac positive stool – Occult blood in stool – Does not provide any localizing information – Indicates slow pace, usually low volume bleeding Melena – Very dark, tarry, pungent stool – Usually suggestive of UGI origin (but can be small intestinal, proximal colon origin if slow pace) Hematochezia – Spectrum: bright red blood, dark red, maroon – Usually suggestive of colonic origin (but can be UGI origin if brisk pace/large volume)

5 Case Vignette – CC: 68 yo male presents with a chief complaint of a large amount of “bleeding from the rectum”

6 Case Vignette - HPI Describes bleeding as large volume, very dark maroon colored stool Has occurred 4 times over past 3 hours He felt light headed and nearly passed out upon trying to get up to go the bathroom

7 Case Vignette - HPI Denies abdominal pain, nausea, vomiting, antecedent retching No history of heartburn, dysphagia, weight loss No history of diarrhea or constipation/hard stools No prior history of GIB Screening colonoscopy 10 years ago – no polyps, (+) diverticulosis

8 Case Vignette – PMHx, Meds Hepatitis C CAD – h/o MI PVD AAA – s/p elective repair 3 years ago HTN Hypercholesterolemia Lumbago Medications: – Aspirin – Clopidogrel – Atorvastatin – Atenolol – Lisinopril

9 Case Vignette – Physical Exam Physical examination: – BP 105/70, Pulse 100, (+) orthostatic changes – Alert and mentating, but anxious appearing – Anicteric – Mid line scar, benign abdomen, nontender liver edge palpable in epigastrium, no splenomegaly – Rectal examination – no masses, dark maroon blood

10 Case Vignette - Labs Labs – Hct 21% (Baseline 33%) – Plt 110K – BUN 34, Cr 1.0 – Alb 3.5 – INR 1.6 – ALT 51, AST 76

11 Initial Considerations Differential diagnosis? – What is most likely source? – What diagnosis can you least afford to miss? How sick is this patient? (risk stratification) – Determines disposition – Guides resuscitation – Guides decision re: need for/timing of endoscopy

12 Differential Diagnosis – Upper GIB Peptic ulcer disease Gastroesophageal varices Erosive esophagitis/gastritis/duodenitis Mallory Weiss tear Vascular ectasia Neoplasm Dieulafoy’s lesion Aortoenteric fistula Hemobilia, hemosuccus pancreaticus Rare, but cannot afford to miss Most common

13 Differential Diagnosis – Lower GIB Diverticulosis Angioectasias Hemorrhoids Colitis (IBD, Infectious, Ischemic) Neoplasm Post-polypectomy bleed (up to 2 weeks after procedure) Dieulafoy’s lesion Most common diagnosis

14 History and Physical History Localizing symptoms History of prior GIB NSAID/aspirin use Liver disease/cirrhosis Vascular disease Aortic valvular disease, chronic renal failure AAA repair Radiation exposure Family history of GIB Physical Examination Vital signs, orthostatics Abdominal tenderness Skin, oral examination Stigmata of liver disease Rectal examination – Objective description of stool/blood – Assess for mass, hemorrhoids – No need for guaiac test

15 History and Physical History Localizing symptoms History of prior GIB NSAID/aspirin use Liver disease/cirrhosis Vascular disease Aortic valvular disease, chronic renal failure AAA repair Radiation exposure Family history of GIB Physical Examination Vital signs, orthostatics Abdominal tenderness Skin, oral examination Stigmata of liver disease Rectal examination – Objective description of stool/blood – Assess for mass, hemorrhoids – No need for guaiac test

16 Always get objective description of stool Take Home Point # 1 Avoid noninformative terms such as “grossly guaiac positive”

17 If you need a card to tell you whether there’s blood in the stool, it’s NOT an acute GIB Take Home Point #2

18 Narrowing the DDx: Upper or Lower Source? Predictors of UGI source: – Age <50 – Melenic stool – BUN/Creatinine ratio If ratio ≥ 30, think upper GIB J Clin Gastroenterol 1990;12:500 Am J Gastroenterol 1997;92:1796 Am J Emerg Med 2006;24:280

19 Most useful situation: patients with severe hematochezia, and unsure if UGIB vs. LGIB – Positive aspirate (blood/coffee grounds) indicates UGIB Can provide prognostic info: – Red blood per NGT – predictive of high risk endoscopic lesion – Coffee grounds – less severe/inactive bleeding Negative aspirate – not as helpful; 15-20% of patients with UGIB have negative NG aspirate Ann Emerg Med 2004;43:525 Arch Intern Med 1990;150:1381 Gastrointest Endosc 2004;59:172 Utility of NG Tube

20 Take Home Point #3 Upper GI bleed must still be considered in patients with severe hematochezia, even if NG aspirate negative

21 Initial Assessment Always remember to assess A,B,C’s Assess degree of hypovolemic shock

22 Resuscitation IV access: large bore peripheral IVs best (alt: cordis catheter) Use crystalloids first Anticipate need for blood transfusion Threshold should be based on underlying condition, hemodynamic status, markers of tissue hypoxia Should be administered if Hgb ≤ 7 g/dL 1 U PRBC should raise Hgb by 1 (HCT by 3%) Remember that initial Hct can be misleading (Hct remains the same with loss of whole blood, until re-equilibration occurs) Correct coagulopathy

23 Resuscitation IV access: large bore peripheral IVs best (alt: cordis catheter) Use crystalloids first Anticipate need for blood transfusion Threshold should be based on underlying condition, hemodynamic status, markers of tissue hypoxia Should be administered if Hgb ≤ 7 g/dL 1 U PRBC should raise Hgb by 1 (HCT by 3%) Remember that initial Hct can be misleading (Hct remains the same with loss of whole blood, until re-equilibration occurs) Correct coagulopathy 40% 20% bleed Time IVFs

24 Transfusion Strategy Randomized trial: – 921 subjects with severe acute UGIB – Restrictive (tx when Hgb<7; target 7-9) vs. Liberal (tx when Hgb<9; target 9-11) – Primary outcome: all cause mortality rate within 45 days NEJM 2013;368;11-21

25 Restrictive Strategy Superior RestrictiveLiberalP value Mortality rate5%9%0.02 Rate of further bleeding 10%16%0.01 Overall complication rate 40%48%0.02 NEJM 2013;368;11-21 Benefit seen primarily in Child A/B cirrhotics

26 Resuscitation IV access: large bore peripheral IVs best (alt: cordis catheter) Use crystalloids first Anticipate need for blood transfusion Threshold should be based on underlying condition, hemodynamic status, markers of tissue hypoxia Should be administered if Hgb ≤ 7 g/dL 1 U PRBC should raise Hgb by 1 (HCT by 3%) Remember that initial Hct can be misleading (Hct remains the same with loss of whole blood, until re-equilibration occurs) Correct coagulopathy Weigh risks and benefits of reversing anticoagulation Assess degree of coagulopathy Vitamin K – slow acting, long- lived FFP – fast acting, short lived - Give 1 U FFP for every 4 U PRBCs Weigh risks and benefits of reversing anticoagulation Assess degree of coagulopathy Vitamin K – slow acting, long- lived FFP – fast acting, short lived - Give 1 U FFP for every 4 U PRBCs

27 Resuscitation Early intensive resuscitation reduces mortality – Consecutive series of patients with hemodynamically significant UGIB – First 36 subjects = Observation Group (no intervention) – Second 36 subjects = Intensive Resuscitation Group (intense guidance provided) – goal was to decrease time to correction of hemodynamics, Hct and coagulopathy Am J Gastroenterol 2004;99:619

28 Early Intensive Resuscitation Reduces UGIB Mortality Am J Gastroenterol 2004;99:619 (groups are essentially the same) Intervention: Faster correction of hemodynamics, Hct and coags. Time to endoscopy similar

29 Observation group – 5 MI – 4 deaths Intense group – 2 MI – 1 death (sepsis) Early Intensive Resuscitation Reduces UGIB Mortality Am J Gastroenterol 2004;99:619

30 Causes of Mortality in Patients with Peptic Ulcer Bleeding Patients rarely bleed to death Prospective cohort study >10,000 cases of peptic ulcer bleed Mortality rate 6.2% 80% of deaths not related to bleeding Am J Gastroenterol 2010;105:84

31 Causes of Mortality in Patients with Peptic Ulcer Bleeding Most common causes of non-bleeding mortality: – Terminal malignancy (34%) – Multiorgan failure (24%) – Pulmonary disease (24%) – Cardiac disease (14%) Am J Gastroenterol 2010;105:84

32 Take Home Point #4 Early resuscitation and supportive measures are critical to reduce mortality from UGIB

33 Identify patients at high risk for adverse outcomes Helps determine disposition (ICU vs. floor vs. outpatient) May help guide appropriate timing of endoscopy Risk Stratification

34 Rockall Scoring System Validated predictor of mortality in patients with UGIB 2 components: clinical + endoscopic Variable0123 Age < ≥ 80 Shock No SBP ≥ 100 P<100 Tachy- SBP ≥ 100 P>100 Hypotension- SBP <100 Comorbidity No majorCardiac failure, CAD, other major Renal failure, liver failure, malignancy Gut 1996;38:316

35 Clinical Rockall Score – Mortality Rates

36 AIMS65 Simple risk score that predicts in-hospital mortality, LOS, cost in patients with acute UGIB Gastrointest Endosc 2011;74:1215

37 AIMS65 Gastrointest Endosc 2011;74:1215

38 Blatchford Score Predicts need for endoscopic therapy Based on readily available clinical and lab data Can use UpToDate calculator Lancet 2000;356:1318

39 Blatchford Score Gastrointest Endosc 2010;71:1134

40 Blatchford Score Most useful for safely discriminating low risk UGIB patients who will likely NOT require endoscopic hemostasis “Fast track Blatchford” – patient at low risk if: BUN < 18 mg/dL Hgb > 13 (men), 12 (women) SBP >100 HR < 100

41 For Non-Variceal UGIB – IV PPI: 80 mg bolus, 8 mg/hr drip – Rationale: suppress acid, facilitate clot formation and stabilization – Duration: at least until EGD, then based on findings Pre-endoscopic Pharmacotherapy

42 Pre-endoscopy PPI Reduces the proportion of patients with high risk endoscopic stigmata (“downstages” lesion) Decreases need for endoscopic therapy Has not been shown to reduce rebleeding, surgery, or mortality rates N Engl J Med 2007;356:1631 Endoscopic treatment required: Omeprazole – 19% (23% of PUD) Placebo – 28% (37% of PUD) High risk Low risk

43 Early endoscopy (within 24 hours) is recommended for most patients with acute UGIB Achieves prompt diagnosis, provides risk stratification and hemostasis therapy in high- risk patients J Clin Gastroenterol 1996;22:267 Gastrointest Endosc 1999;49:145 Ann Intern Med 2010;152:101 Endoscopy - Nonvariceal UGIB

44 When is Endoscopic Therapy Required? ~80% bleeds spontaneously resolve Endoscopic stigmata of recent hemorrhage StigmataContinued/rebleeding rate Active bleeding55-90% Nonbleeding visible vessel40-50% Adherent clotVariable, depending on underlying lesion: 0-35% Flat pigmented spot7-10% Clean base< 5% major

45 Major Stigmata – Active Spurting Kelsey, PB (Dec ). Duodenum - Ulcer, Arterial Spurting, Treated with Injection and Clip. The DAVE Project. Retrieved Aug, 1, 2010, from

46 Major Stigmata - NBVV

47 Adherent Clot Role of endoscopic therapy of ulcers with adherent clot is controversial Clot removal usually attempted Underlying lesion can then be assessed, treated if necessary

48 Minor Stigmata Flat pigmented spotClean base Low rebleeding risk – no endoscopic therapy needed

49 Endoscopic Hemostasis Therapy Epinephrine injection Thermal electrocoagulation Mechanical (hemoclips) Combination therapy superior to monotherapy Kelsey, PB (Nov ). Stomach - Gastric Ulcer, Visible Vessel. The DAVE Project. Retrieved Aug, 1, 2010, from Baron, TH (May ). Duodenum - Bleeding Ulcer Treated with Thermal Therapy, Perforation Closed with Hemoclips. The DAVE Project. Retrieved Aug, 1, 2010, from

50 Nonvariceal UGIB – Post-endoscopy management Patients with low risk ulcers can be fed promptly, put on oral PPI therapy. Patients with ulcers requiring endoscopic therapy should receive PPI gtt x 72 hours – Significantly reduces 30 day rebleeding rate vs placebo (6.7% vs. 22.5%) – Note: there may not be major advantage with high dose over non-high dose PPI therapy N Engl J Med 2000;343:310 Arch Intern Med 2010;170:751

51 Determine H. pylori status in all ulcer patients Discharge patients on PPI (once to twice daily), duration dictated by underlying etiology and need for NSAIDs/aspirin In patients with cardiovascular disease on low dose aspirin: restart as soon as bleeding has resolved – RCT demonstrates increased risk of rebleeding (10% v 5%) but decreased 30 day mortality (1.3% v 13%) Nonvariceal UGIB – Post-endoscopy management Ann Intern Med 2010;152:1

52 Determine H. pylori status in all ulcer patients Discharge patients on PPI (once to twice daily), duration dictated by underlying etiology and need for NSAIDs/aspirin In patients with cardiovascular disease on low dose aspirin: restart as soon as bleeding has resolved – RCT demonstrates increased risk of rebleeding (10% v 5%) but decreased 30 day mortality (1.3% v 13%) Nonvariceal UGIB – Post-endoscopy management Ann Intern Med 2010;152:1 Not dying is more important than not rebleeding Not dying is more important than not rebleeding

53 Variceal Bleeding Occurs in 1/3 of patients with cirrhosis 1/3 initial bleeding episodes are fatal Among survivors, 1/3 will rebleed within 6 weeks Only 1/3 will survive 1 year or more

54 Predictors of large esophageal varices Severity of liver disease (Child Pugh) Platelet count < 88K Palpable spleen Platelet count/spleen diameter (mm) ratio <909 Gut 2003;52:1200 J Clin Gastroenterol 2010;44:146 J Gastroenterol Hepatol 2007;22:1909 Arch Intern Med 2001;161:2564 Am J Gastroenterol 1999;94:3103

55

56 Goal: Reduce splanchnic blood flow Terlipressin – only agent shown to improve control of bleeding and survival in RCTs and meta-analysis – Not available in US Vasopressin + nitroglycerine – too many adverse effects Somatostatin – not available in US Octreotide (somatostatin analogue) Decreases splanchnic blood flow (variably) Efficacy is controversial; no proven mortality benefit Standard dose: 50 mcg bolus, then 50 mcg/hr drip for 3-5 days Gastroenterology 2001;120:946 Cochrane Database Syst Rev 2008;16:CD N Engl J Med 1995;333:555 Am J Gastroenterol 2009;104:617

57 Bacterial infection occurs in up to 66% of patients with cirrhosis and variceal bleed Negative impact on hemostasis (endogenous heparinoids) Prophylactic antibiotics reduces incidence of bacterial infection, significantly reduces early rebleeding – Ceftriaxone 1 g IV QD x 5-7 days – Alt: Norfloxacin 400 mg po BID Hepatology 2004;39:746 J Korean Med Sci 2006;21:883 Hepatogastroenterology 2004;51:541

58 Promptly but with caution Goal = maintain hemodynamic stability, Hgb ~7-8, CVP 4-8 mmHg Avoid excessively rapid overexpansion of volume; may increase portal pressure, greater bleeding

59 Should be performed as soon as possible after resuscitation (within 12 hours) Endotracheal intubation frequently needed Band ligation is preferred method Layer, L. & Jaganmohan, S. & Raju, GS & DuPont, AW (Oct ). Esophagus - Band Ligation of Actively Bleeding Gastroesophageal Varices. The DAVE Project. Retrieved Aug, 2, 2010, from

60 TIPS – Transjugular Intrahepatic Portosystemic Shunt Early placement of shunt (within 24-72hrs) associated with improved survival among high-risk patients Preferred treatment for gastric variceal bleeding (rule out splenic vein thrombosis first) Fan, C. (Apr ). Vascular Interventions in the Abdomen: New Devices and Applications. The DAVE Project. Retrieved Aug, 2, 2010, from Hepatology 2004;40:793 Hepatology 2008;48:Suppl:373A N Engl J Med Jun 24;362:2370

61 TIPS+embolization of gastric varices

62 Sengstaken-Blakemore Tube Very effective for immediate, temporary control High complication rate – aspiration, migration, necrosis + perforation of esophagus Use as bridge to TIPS within 24 hours Airway protection strongly recommended

63 Specially designed covered metal stent Tamponades distal esophageal varices Removable; does not require airway protection Very limited data Self-Expanding Metal Stent Gastrointest Endosc 2010;71:71

64 Reduces risk for recurrent variceal hemorrhage Use nonselective beta blocker (e.g. Nadolol – splanchnic vasoconstriction, decrease cardiac output) and titrate up to maximum tolerated dose, HR – Start as inpatient, once acute bleeding has resolved and patient shows hemodynamic stability

65 Lower GI Bleed Bleeding arising from the colorectum In patients with severe hematochezia, first consider possibility of UGIB – 10-15% of patients with presumed LGIB are found to have upper GIB

66 Lower GI Bleed Differential Diagnosis - Diverticulosis (# 1 cause) - Angioectasias - Hemorrhoids - Colitis (IBD, Infectious, Ischemic) - Neoplasm - Post-polypectomy - Dieulafoy’s lesion - Diverticulosis (# 1 cause) - Angioectasias - Hemorrhoids - Colitis (IBD, Infectious, Ischemic) - Neoplasm - Post-polypectomy - Dieulafoy’s lesion Large volume, painless Smaller volume, pain, diarrhea

67 LGIB – Risk Stratification Predictors of severe * LGIB:  HR>100  SBP<115  Syncope  nontender abdominal examination  bleeding during first 4 hours of evaluation  aspirin use  >2 active comorbid conditions  HR>100  SBP<115  Syncope  nontender abdominal examination  bleeding during first 4 hours of evaluation  aspirin use  >2 active comorbid conditions 0 factors: ~6% risk 1-3 factors: ~40% >3 factors: ~80% 0 factors: ~6% risk 1-3 factors: ~40% >3 factors: ~80% Arch Intern Med 2003;163:838 Am J Gastroenterol 2005;100:1821 * Defined as continued bleeding within first 24 hours (transfusion of 2+ Units, decline in HCT of 20+%) and/or recurrent bleeding after 24 hours of stability

68 LGIB – Risk Factors for Mortality Age Intestinal ischemia Comorbid illnesses Secondary bleeding (developed during admission for a separate problem) Coagulopathy Hypovolemia Transfusion requirement Male gender Clinical Gastro Hepatol 2008;6:1004

69 Role of Colonoscopy Like UGIB, ~80% of LGIBs will resolve spontaneously; of these, ~30% will rebleed Lack of standardized approach – Traditional approach: elective colonoscopy after resolution of bleeding, bowel prep – low therapeutic benefit Angiography for massive bleeding, hemodynamically unstable patient – Urgent colonoscopy approach Similar to UGIB – identify stigmata of hemorrhage, perform therapy

70 Urgent Colonoscopy Within 6-12 hours of presentation Requires rapid “purge” prep with 5-6 L Golytely administered 1L every minutes Colonoscopy performed within 1 hour after clearance of stool, blood and clots Need for bowel prep and risks of procedural sedation may be prohibitive in unstable patient

71 Endoscopic Therapy Srinivasan, R. & Luthra, G. & Raju, GS (Jul ). Colon - Endoscopic Hemostasis of Diverticular Bleed. The DAVE Project. Retrieved Aug, 3, 2010, from

72 Urgent Colonoscopy Limited high quality evidence of benefit Establishes diagnosis earlier, shorter length of stay “Landmark” study supporting urgent colonoscopy for diverticular bleed published in 2000 – 2 consecutive prospective, non-randomized studies – Group 1 (n=73): urgent colonoscopy, surgical therapy – Group 2 (n=48): urgent colonoscopy, endoscopic therapy N Engl J Med 2000;342:78

73 Urgent Colonoscopy Group 1: 17 pts with definite diverticular bleed – 9 had recurrent/persistent bleeding – 6 required emergency surgery Group 2: 10 pts with definite diverticular bleed – All 10 patients treated endoscopically – 0 had recurrent bleed, complications, further transfusions, or surgery N Engl J Med 2000;342:78

74 Urgent Colonoscopy Two RCTs published to date Compared urgent colonoscopy (within 8 hours) vs. standard management Am J Gastroenterol 2005;100:2395 Standard Management Algorithm

75 Urgent Colonoscopy – RCT#1 Am J Gastroenterol 2005;100:2395 Definite bleeding source identified more frequently (42% vs 22%) But no significant difference in important outcomes (but underpowered)

76 Urgent Colonoscopy – RCT#2 85 patients with serious hematochezia (hemodynamically significant, Hgb drop > 1.5 g/dL, blood transfusion) EGD performed within 6 hours If EGD negative, randomized to urgent (<12 hr) or elective (36-60 hr) colonoscopy Primary endpoint= further bleeding Am J Gastroenterol 2010;105:2636

77 EGD positive in 15% No evidence of improved clinical outcomes with urgent colonoscopy – but prespecified sample size not reached Urgent Colonoscopy – RCT#2 Am J Gastroenterol 2010;105:2636

78 Urgent Colonoscopy In published series, endoscopic therapy is applied in 10-40% of patients undergoing colonoscopy for LGIB Taken together, evidence suggests that colonoscopy should be performed within hours in stable patients However, it is unclear how faster timing affects major clinical outcomes

79 Radiographic Studies Tagged RBC scan Noninvasive, highly sensitive ( ml/min) Ability to localize bleeding source correctly only ~66% More accurate when positive within 2 hours ( %) Lacks therapeutic capability Coordinate with IR so that positive scan is followed closely by angiography

80 Radiographic Studies Angiography Detects bleeding rates of ml/min Therapeutic capability – embolization with microcoils, polyvinyl alcohol, gelfoam Complications: bowel infarction, renal failure, hematomas, thromboses, dissection Recommended test for patients with brisk bleeding who cannot be stabilized or prepped for colonoscopy (or have had colonoscopy with failure to localize/treat bleeding site) Recommended test for patients with brisk bleeding who cannot be stabilized or prepped for colonoscopy (or have had colonoscopy with failure to localize/treat bleeding site)

81 Radiographic Studies Multi-Detector CT (CT angio) Readily available, can be performed in ER within 10 minutes Can detect bleeding rate of 0.5 ml/min Can localize site of bleeding (must be active) and provide info on etiology Useful in the actively bleeding but hemodynamically stable patient Gastrointest Endosc 2010;72:402

82 Role of Surgery Reserved for patients with life-threatening bleed who have failed other options General indications: hypotension/shock despite resuscitation, >6 U PRBCs transfused Preoperative localization of bleeding source important

83 Algorithmic Evaluation of Patient with Hematochezia Hematochezia Assess activity of bleed NG lavage Prep for Colonoscopy Positive EGD Negative activeinactive Risk for UGIB Hemodynamically stable? No risk for UGIB negative Treat lesion positive

84 Algorithmic Evaluation of Patient with Hematochezia Active Lower GIB Hemodynamically stable? Angiography (+/- Tagged RBC scan) Or Surgery if life- threatening Angiography (+/- Tagged RBC scan) Or Surgery if life- threatening Consider “urgent colonoscopy” vs. traditional approach YesNo

85 Take Home Points Always get objective description of stool color (best way – examine it yourself) Don’t order guaiac tests on inpatients Severe hematochezia can be from UGIB, even if NG lavage is negative

86 Take Home Points All bleeding eventually stops (and majority of nonvariceal bleeds will stop spontaneously, with the patient alive) Early resuscitation and supportive care are key to reducing morbidity and mortality from GIB


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