369 Drug Update AACN Advanced Critical Care Volume 29, Number 4, pp 369-376 © 2018 AACN A cute upper gastrointestinal bleeding (UGIB) is a common medical emer- gency in the United States that is associated with significant morbidity and mortality, frequent hospital admissions, and costs of more than $2 billion annually to the health care system. 1 Upper gastrointestinal hemorrhage is defined as bleeding from any enteric source proximal to the ligament of Treitz. Upper gastrointestinal bleeding is approximately 5 times more likely to occur than lower gastrointestinal bleeding. 2 Male patients and elderly patients tend to be more commonly affected. 2 Initial management of clinically significant acute UGIB includes volume resuscitation to restore hemodynamic stability, diagnostic studies to identify the source and severity of bleeding, and pharmacological interventions to increase gastric pH and assist with hemostasis. Data on patients with UGIB from 1993 to 2000 showed a decreasing incidence of the condition, suggest- ing that prevention strategies are improving. Despite advances in therapeutic management of UGIB, however, the risk of rebleeding and mortality rates have remained unchanged. 3 In this article, we discuss risk factors, initial evaluation and restoration of intravascular volume, and pharmacological management of acute UGIB. Pathophysiology Upper gastrointestinal bleeding can be separated into 2 categories: nonvariceal and variceal. The most common etiology (62%) of UGIB is peptic ulcers. Other causes of nonvariceal bleeding include gastritis and duodenitis (8%), Mallory- Weiss tear (4%) and upper gastrointestinal tract malignancy (2%), and other diagnoses (10%); no exact cause is identified in 8% of cases. Gastroesopha- geal varices account for a small percentage (6%) of all UGIB cases but are present in 50% of cirrhotic patients and are the most common fatal complica- tion in this subset of patients. 4,5 Nonvariceal Bleeding Nonvariceal bleeding most commonly arises from peptic acid–related com- plications, either chronic peptic ulcer disease (PUD) or stress-related mucosal Whitney Gibson is Critical Care Pharmacist, Department of Pharmacy Services, Tampa General Hospital, 1 Tampa General Circle, Tampa, FL 33606 (wgibson@tgh.org). Nicholas Scaturo is Emergency Medicine Clinical Pharmacist, Sarasota Memorial Hospital, Sarasota, Florida. Christopher Allen is Critical Care Clinical Pharmacist, Trauma Surgical Critical Care, Department of Pharmacy Services, Tampa General Hospital, Tampa, Florida. The authors declare no conflicts of interest. Acute Management of Upper Gastrointestinal Bleeding Whitney Gibson, PharmD Nicholas Scaturo, PharmD Christopher Allen, PharmD, BCPS, BCNSP DOI: https://doi.org/10.4037/aacnacc2018644 Earnest Alexander, PharmD, BCCCP, FCCM, and John Allen, PharmD, CPh, BCPS, BCCCP Department Editors by AACN on April 30, 2019 http://acc.aacnjournals.org/ Downloaded from