ส่วนที่ 1 ข้อมูลเอกสาร
| ชื่อ CNPG | การพยาบาลผู้ป่วย GI Bleeding & Liver Disease |
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| วัตถุประสงค์ | จัดการ GI bleeding ครอบคลุมการดูแลผู้ป่วย cirrhosis และ hepatic encephalopathy |
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| มาตรฐานอ้างอิง | ACG Guidelines 2021, AASLD, Baveno VII Consensus, HA Thailand |
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ส่วนที่ 2 Upper GI Bleeding
2.1 Clinical Presentation
- Hematemesis: bright red or coffee-ground
- Melena: black, tarry stool
- Hematochezia: massive UGIB can present this way
- Symptoms: dizziness, weakness, syncope
2.2 Etiology
- Peptic ulcer disease (most common, 50%)
- Esophageal/gastric varices (cirrhosis)
- Mallory-Weiss tear
- Erosive esophagitis/gastritis
- Malignancy
- Dieulafoy lesion
2.3 Risk Stratification — Glasgow-Blatchford Score
Score 0 = very low risk (outpatient OK)
Score ≥ 1 = admit for endoscopy
ส่วนที่ 3 Initial Management
3.1 Resuscitation (First Priority)
- 2 large-bore IV (16-18G)
- Labs: CBC, Coag, LFT, BUN/Cr, Type & Cross-match 2-4 units
- IV fluid: Crystalloid bolus
- Blood transfusion target: Hb > 7 (restrictive); > 8 if cardiac disease; > 9 if variceal bleeding
- FFP if INR > 1.5 + active bleeding; Platelets if < 50,000
- NPO, NG tube (controversial — lavage optional)
3.2 Pharmacologic Therapy
| Drug | Use | Dose |
|---|
| PPI (Pantoprazole) | All UGIB (before endoscopy) | 80 mg IV bolus → 8 mg/hr × 72 hr |
| Octreotide | Variceal bleeding | 50 mcg IV bolus → 50 mcg/hr × 3-5 days |
| Terlipressin | Variceal (superior) | 2 mg IV q 4h × 24-48h, then 1 mg q 4h |
| Antibiotic (Ceftriaxone) | Variceal bleeding (mandatory) | 1 g IV OD × 7 days |
| Vitamin K | Coagulopathy | 10 mg IV / SC |
3.3 Endoscopy
- Within 24 hours of presentation (urgent: < 12 hr if unstable)
- Therapeutic modalities:
- Epinephrine injection + clip/thermal (PUD)
- Band ligation (esophageal varices)
- Sclerotherapy / tissue glue (gastric varices)
3.4 Refractory Bleeding
- TIPS (Transjugular Intrahepatic Portosystemic Shunt) — refractory variceal
- Sengstaken-Blakemore tube — temporary (rarely used)
- Interventional radiology embolization
- Surgery
ส่วนที่ 4 Cirrhosis Complications
4.1 Hepatic Encephalopathy (HE)
West Haven Criteria
| Grade | Features |
|---|
| 0 (Minimal) | Subclinical, normal exam |
| 1 | Mild confusion, irritability, sleep disturbance |
| 2 | Lethargy, disoriented, asterixis |
| 3 | Somnolent but arousable, severe disorientation |
| 4 | Coma |
Treatment
- Lactulose 30-45 ml PO TID-QID — target 2-3 BMs/day
- Rifaximin 550 mg PO BID (prevent recurrence)
- Treat precipitants: infection, bleeding, electrolyte, constipation, sedatives
- Protein restriction NOT recommended routinely
4.2 Ascites
- Dietary sodium < 2 g/day
- Diuretics: Spironolactone 100-400 mg + Furosemide 40-160 mg
- Therapeutic paracentesis for tense ascites (> 5 L → albumin 8 g/L removed)
- SBP (spontaneous bacterial peritonitis): Ascites PMN ≥ 250 → Cefotaxime 2g IV q8h
4.3 Hepatorenal Syndrome
- Discontinue diuretics, nephrotoxins
- Albumin 1 g/kg day 1, then 20-40 g/day
- Terlipressin 0.5-2 mg IV q 4-6h + Albumin
- Liver transplant referral
ส่วนที่ 5 Nursing Care
5.1 Monitoring
- V/S q 15 นาที × 2 ชั่วโมง, then q 1 ชั่วโมง
- SpO₂, mental status
- Hb q 4-6h initially (check re-bleeding)
- Strict I/O, NG output
- Monitor for: fresh hematemesis, melena continuing
5.2 Aspiration Prevention
- HOB 30°
- Suction ready
- NPO until bleeding controlled
- Consider intubation if massive bleed + altered MS
5.3 Cirrhosis-specific Care
- Avoid NSAIDs, nephrotoxins, sedatives (precipitate HE)
- Monitor for HE signs (flapping tremor, confusion)
- Daily weights, abdominal girth
- Skin care (jaundice + pruritus — moisturizer, avoid hot water)
- Fall risk assessment (encephalopathy)
- Bleeding precautions (coagulopathy)
ส่วนที่ 6 Discharge Planning
- PPI for 4-8 weeks (PUD), H. pylori eradication if +ve
- Non-selective beta-blocker (Propranolol, Nadolol) — secondary prophylaxis for varices
- Follow-up EGD 2-4 weeks for variceal banding
- Cirrhosis: HCC screening (US + AFP q 6 months)
- Vaccinations: Hep A/B, pneumococcal, influenza
- Alcohol cessation counseling
KPIs
| KPI | Target |
|---|
| PPI administration before endoscopy | ≥ 95% |
| Antibiotic prophylaxis (variceal bleed) | 100% |
| Endoscopy within 24 hours | ≥ 90% |
| Re-bleeding rate | < 15% |
| UGIB mortality | < 10% |
| Variceal bleeding mortality | < 20% |
References
- Laine, L., et al. (2021). ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. American Journal of Gastroenterology, 116(5).
- de Franchis, R., et al. (2022). Baveno VII – Renewing consensus in portal hypertension. Journal of Hepatology, 76(4).
- American Association for the Study of Liver Diseases (AASLD). Guidelines for hepatic encephalopathy, ascites, HRS.
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