Gis Kanama, Siroz ve Assit
Özet
Gastrointestinal sistem (GİS) kanamaları, acil tıp pratiğinde sık karşılaşılan, hemodinamik instabilite potansiyeli ve eşlik eden komorbiditeler nedeniyle yüksek morbidite ve mortalite ile seyreden kritik klinik tablolardır. Anatomik olarak Treitz ligamentine göre üst ve alt GİS kanaması olarak sınıflandırılan bu durumlarda, yönetim süreci agresif hemodinamik resüsitasyon ve risk sınıflaması ile başlar. Üst GİS kanamalarında, prognoz tayini için Glasgow-Blatchford Skoru (GBS) önerilirken; varis kanaması şüphesinde endoskopi öncesi vazoaktif ajanlar ve antibiyotik profilaksisi standart tedaviyi oluşturur. Alt GİS kanamalarında ise güvenli taburculuk kararında Oakland Skoru öne çıkmaktadır. Antitrombotik ilaç kullanan hastalarda, hemostaz ile tromboembolik risk arasındaki dengenin yönetimi, özellikle sekonder koruma hastalarında aspirinin kesilmemesi prensibine dayanır. Karaciğer sirozu, klinik süreci oldukça karmaşık hale getiren bir tablo olup; en sık görülen temel nedeni viral hepatit B enfeksiyonudur. Hastalığın uzun dönem prognozunu doğrudan etkilediği için; varis kanamaları, hepatik ensefalopati (HE) ve hepatorenal sendrom (HRS) gibi dekompansasyon bulgularının acil yönetimi hayati önem taşır. Bu klinik tabloda dekompansasyonun en belirgin göstergelerinden biri assittir. Acil servise karın şişliği şikayetiyle başvuran hastalar incelendiğinde, bu durumun altındaki temel nedenin karaciğer sirozu olduğu görülmektedir. Assit etiyolojisinin ayırıcı tanısında serum assit albümin gradyanı (SAAG) altın standart olarak kabul edilir. Tedavi sürecinde ise, özellikle Spontan Bakteriyel Peritonit (SBP) tanısı alan hastalarda, antibiyoterapiye eklenen albümin infüzyonunun mortaliteyi anlamlı ölçüde azalttığı kanıtlanmıştır.
Gastrointestinal (GI) bleeding is a critical clinical presentation frequently encountered in emergency medicine practice, characterized by high morbidity and mortality due to the potential for hemodynamic instability and accompanying comorbidities. In these conditions, which are anatomically classified as upper and lower GI bleeding according to the Ligament of Treitz, the management process begins with aggressive hemodynamic resuscitation and risk stratification. In upper GI bleeding, the Glasgow-Blatchford Score (GBS) is recommended for prognosis determination; whereas in suspected variceal bleeding, vasoactive agents and antibiotic prophylaxis prior to endoscopy constitute the standard treatment. In lower GI bleeding, the Oakland Score stands out for safe discharge decisions. In patients using antithrombotic drugs, the management of the balance between hemostasis and thromboembolic risk is based on the principle of not discontinuing aspirin, especially in secondary prevention patients. Liver cirrhosis is a condition that significantly complicates the clinical process; its most common underlying cause is viral hepatitis B infection. Emergency management of decompensation findings such as variceal bleeding, hepatic encephalopathy (HE), and hepatorenal syndrome (HRS) is of vital importance, as it directly affects the long-term prognosis of the disease. Ascites is one of the most prominent indicators of decompensation in this clinical picture. When patients presenting to the emergency department with a complaint of abdominal distension are examined, it is observed that liver cirrhosis is the underlying primary cause of this condition. The serum-ascites albumin gradient (SAAG) is considered the gold standard in the differential diagnosis of ascites etiology. In the treatment process, particularly in patients diagnosed with Spontaneous Bacterial Peritonitis (SBP), it has been proven that albumin infusion added to antibiotherapy significantly reduces mortality. In this section; the initial evaluation, risk stratification, and treatment strategies accompanied by current guidelines for patients with gastrointestinal (GI) bleeding and cirrhosis in the emergency department are comprehensively discussed.
Referanslar
DiGregorio AM, Alvey H. Gastrointestinal Bleeding. Accessed January 26, 2026. https://www.ncbi.nlm.nih.gov/books/NBK537291/.
Ziebell CM, Kitlowski AD, Welch J, Friesen P. Upper Gastrointestinal Bleeding. In: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill’s AccessMedicine; 2020. p. 495-498.
Saltzman JR, Gralnek IM. Approach to acute upper gastrointestinal bleeding in adults. UpToDate. 2025. Updated November 19, 2025. Accessed January 26, 2026. https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults
Lo B. Lower Gastrointestinal Bleeding. In: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill’s AccessMedicine; 2020. p. 498-500.
Sengupta N, Feuerstein JD, Jairath V, Shergill AK, Strate LL, Wong RJ, et al. Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline. The American Journal of Gastroenterology. 2023;118(2):208-231. doi:10.14309/ajg.0000000000002130
Abraham NS, Barkun AN, Sauer BG, Douketis J, Laine L, Noseworthy PA, et al. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. The American Journal of Gastroenterology. 2022;117(4):542-558. doi:10.14309/ajg.0000000000001627
Sanyal AJ, Garcia-Pagan JC. Overview of the management of patients with variceal bleeding. Published online January 12, 2026. https://www.uptodate.com/contents/overview-of-the-management-of-patients-with-variceal-bleeding
Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021. Endoscopy. 2021;53(3):300-332. doi:10.1055/a-1369-5274
Vimonsuntirungsri T, Thungsuk R, Nopjaroonsri P, Faknak N, Pittayanon R. The Efficacy of Metoclopramide for Gastric Visualization by Endoscopy in Patients With Active Upper Gastrointestinal Bleeding: Double-Blind Randomized Controlled Trial. The American Journal of Gastroenterology. 2024;119(5):846-855. doi:10.14309/ajg.0000000000002620
Calderon Martinez E, Briceño Silva GD, Sanchez Cruz C, Woldehana NA, Shah Y, Dahiya DS, et al. Tranexamic acid as treatment for acute gastrointestinal bleeding: A comprehensive systematic review and meta-analysis. Indian Journal of Gastroenterology. 2025;44(3):311-329. doi:10.1007/s12664-025-01749-9
Roberts I, Shakur-Still H, Afolabi A, Akere A, Arribas M, Brenner A, et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet. 2020;395(10241):1927-1936. doi:10.1016/S0140-6736(20)30848-5
Karakonstantis S, Tzagkarakis E, Kalemaki D, Lydakis C, Paspatis G. Nasogastric aspiration/lavage in patients with gastrointestinal bleeding: a review of the evidence. Expert Review of Gastroenterology & Hepatology. 2018;12(1):63-72. doi:10.1080/17474124.2018.1398646
Rockey DC. Etiology of upper gastrointestinal bleeding in adults. Accessed January 26, 2026. https://www.uptodate.com/contents/etiology-of-upper-gastrointestinal-bleeding-in-adults
Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. The American Journal of Gastroenterology. 2021;116(5):899-917. doi:10.14309/ajg.0000000000001245
Thiebaud PC, Wassermann E, De Caluwe M, Prebin C, Noel F, Dechartres A, et al. Assessment of Prognostic Scores for Emergency Department Patients With Upper Gastrointestinal Bleeding. Annals of Emergency Medicine. 2025;85(1):31-42. doi:10.1016/j.annemergmed.2024.06.024
Strate L. Etiology of lower gastrointestinal bleeding in adults. UpToDate. Published online March 31, 2025. https://www.uptodate.com/contents/etiology-of-lower-gastrointestinal-bleeding-in-adults
DiGregorio AM, Alvey H. Gastrointestinal Bleeding. In: StatPearls. StatPearls Publishing; 2025. Accessed January 28, 2026. http://www.ncbi.nlm.nih.gov/books/NBK537291/
Oakland K, Jairath V, Uberoi R, Guy R, Ayaru L, Mortensen N, et al. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. The Lancet Gastroenterology & Hepatology. 2017;2(9):635-643. doi:10.1016/S2468-1253(17)30150-4
Strate L. Approach to acute lower gastrointestinal bleeding in adults. Published online January 12, 2026. Accessed January 26, 2026. https://www.uptodate.com/contents/approach-to-acute-lower-gastrointestinal-bleeding-in-adults?source=autocomplete&index=2~5#H25594387
Sharma B, John S. Hepatic Cirrhosis. In: StatPearls. StatPearls Publishing; 2025. Accessed January 26, 2026. http://www.ncbi.nlm.nih.gov/books/NBK482419/
Fadlallah H, El Masri D, Bahmad HF, Abou-Kheir W, El Masri J. Update on the Complications and Management of Liver Cirrhosis. Medical Sciences. 2025;13(1):13. doi:10.3390/medsci13010013
Goldberg E, Chopra S. Cirrhosis in adults: Etiologies, clinical manifestations, and diagnosis. Published online January 8, 2025. Accessed January 26, 2026. https://www.uptodate.com/contents/cirrhosis-in-adults-etiologies-clinical-manifestations-and-diagnosis?search=cirrhosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Üçbilek E, Yıldırım AE, Ellik Z, Turan İ, Haktanıyan B, Orucu B, et al. Changing Trends in the Etiology of Cirrhosis in Türkiye: A Multicenter Nationwide Study. Turkish Journal of Gastroenterology. 2024;35(10):772-777. doi:10.5152/tjg.2024.23572
Goldberg E, Chopra S. Cirrhosis in adults: Overview of complications, general management, and prognosis. Published online January 12, 2026. Accessed January 20, 2026. https://www.uptodate.com/contents/cirrhosis-in-adults-overview-of-complications-general-management-and-prognosis?search=siroz&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
Bajaj JS, Sanyal AJ. Methods to achieve hemostasis in patients with acute variceal hemorrhage. Published online January 23, 2025. Accessed January 25, 2026. https://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage
Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management 2016 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2017;65(1):310-335. doi:10.1002/hep.28906
Gralnek IM, Camus Duboc M, Garcia-Pagan JC, Fuccio L, Karstensen JG, Hucl T, et al. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2022;54(11):1094-1120. doi:10.1055/a-1939-4887
Mandiga P, Kommu S, Bollu PC. Hepatic Encephalopathy. In: StatPearls. StatPearls Publishing; 2025. Accessed January 29, 2026. http://www.ncbi.nlm.nih.gov/books/NBK430869/
Allegretti AS, Wong F. Hepatorenal syndrome: Treatment and prognosis. Published online January 9, 2026. Accessed January 26, 2026. https://www.uptodate.com/contents/hepatorenal-syndrome-treatment-and-prognosis?search=cirrhosis&topicRef=2308&source=see_link#H3329389590
Tapper E, O’Brien A. Spontaneous bacterial peritonitis in adults: Management. Published online June 26, 2025. Accessed January 25, 2026. https://www.uptodate.com/contents/spontaneous-bacterial-peritonitis-in-adults-management
Biggins SW, Angeli P, Garcia-Tsao G, Ginès P, Ling SC, Nadim MK, et al. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;74(2):1014-1048. doi:10.1002/hep.31884
Goosenberg E, Kudaravalli P, Samant H. Ascites. In: StatPearls. StatPearls Publishing; 2025. Accessed January 26, 2026. http://www.ncbi.nlm.nih.gov/books/NBK470482/
Biggins SW. Evaluation of adults with ascites. Published online September 20, 2024. Accessed January 26, 2026. https://www.uptodate.com/contents/evaluation-of-adults-with-ascites
European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. Journal of Hepatology. 2010;53(3):397-417. doi:10.1016/j.jhep.2010.05.004
Referanslar
DiGregorio AM, Alvey H. Gastrointestinal Bleeding. Accessed January 26, 2026. https://www.ncbi.nlm.nih.gov/books/NBK537291/.
Ziebell CM, Kitlowski AD, Welch J, Friesen P. Upper Gastrointestinal Bleeding. In: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill’s AccessMedicine; 2020. p. 495-498.
Saltzman JR, Gralnek IM. Approach to acute upper gastrointestinal bleeding in adults. UpToDate. 2025. Updated November 19, 2025. Accessed January 26, 2026. https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults
Lo B. Lower Gastrointestinal Bleeding. In: Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 9th ed. McGraw-Hill’s AccessMedicine; 2020. p. 498-500.
Sengupta N, Feuerstein JD, Jairath V, Shergill AK, Strate LL, Wong RJ, et al. Management of Patients With Acute Lower Gastrointestinal Bleeding: An Updated ACG Guideline. The American Journal of Gastroenterology. 2023;118(2):208-231. doi:10.14309/ajg.0000000000002130
Abraham NS, Barkun AN, Sauer BG, Douketis J, Laine L, Noseworthy PA, et al. American College of Gastroenterology-Canadian Association of Gastroenterology Clinical Practice Guideline: Management of Anticoagulants and Antiplatelets During Acute Gastrointestinal Bleeding and the Periendoscopic Period. The American Journal of Gastroenterology. 2022;117(4):542-558. doi:10.14309/ajg.0000000000001627
Sanyal AJ, Garcia-Pagan JC. Overview of the management of patients with variceal bleeding. Published online January 12, 2026. https://www.uptodate.com/contents/overview-of-the-management-of-patients-with-variceal-bleeding
Gralnek IM, Stanley AJ, Morris AJ, Camus M, Lau J, Lanas A, et al. Endoscopic diagnosis and management of nonvariceal upper gastrointestinal hemorrhage (NVUGIH): European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2021. Endoscopy. 2021;53(3):300-332. doi:10.1055/a-1369-5274
Vimonsuntirungsri T, Thungsuk R, Nopjaroonsri P, Faknak N, Pittayanon R. The Efficacy of Metoclopramide for Gastric Visualization by Endoscopy in Patients With Active Upper Gastrointestinal Bleeding: Double-Blind Randomized Controlled Trial. The American Journal of Gastroenterology. 2024;119(5):846-855. doi:10.14309/ajg.0000000000002620
Calderon Martinez E, Briceño Silva GD, Sanchez Cruz C, Woldehana NA, Shah Y, Dahiya DS, et al. Tranexamic acid as treatment for acute gastrointestinal bleeding: A comprehensive systematic review and meta-analysis. Indian Journal of Gastroenterology. 2025;44(3):311-329. doi:10.1007/s12664-025-01749-9
Roberts I, Shakur-Still H, Afolabi A, Akere A, Arribas M, Brenner A, et al. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. The Lancet. 2020;395(10241):1927-1936. doi:10.1016/S0140-6736(20)30848-5
Karakonstantis S, Tzagkarakis E, Kalemaki D, Lydakis C, Paspatis G. Nasogastric aspiration/lavage in patients with gastrointestinal bleeding: a review of the evidence. Expert Review of Gastroenterology & Hepatology. 2018;12(1):63-72. doi:10.1080/17474124.2018.1398646
Rockey DC. Etiology of upper gastrointestinal bleeding in adults. Accessed January 26, 2026. https://www.uptodate.com/contents/etiology-of-upper-gastrointestinal-bleeding-in-adults
Laine L, Barkun AN, Saltzman JR, Martel M, Leontiadis GI. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. The American Journal of Gastroenterology. 2021;116(5):899-917. doi:10.14309/ajg.0000000000001245
Thiebaud PC, Wassermann E, De Caluwe M, Prebin C, Noel F, Dechartres A, et al. Assessment of Prognostic Scores for Emergency Department Patients With Upper Gastrointestinal Bleeding. Annals of Emergency Medicine. 2025;85(1):31-42. doi:10.1016/j.annemergmed.2024.06.024
Strate L. Etiology of lower gastrointestinal bleeding in adults. UpToDate. Published online March 31, 2025. https://www.uptodate.com/contents/etiology-of-lower-gastrointestinal-bleeding-in-adults
DiGregorio AM, Alvey H. Gastrointestinal Bleeding. In: StatPearls. StatPearls Publishing; 2025. Accessed January 28, 2026. http://www.ncbi.nlm.nih.gov/books/NBK537291/
Oakland K, Jairath V, Uberoi R, Guy R, Ayaru L, Mortensen N, et al. Derivation and validation of a novel risk score for safe discharge after acute lower gastrointestinal bleeding: a modelling study. The Lancet Gastroenterology & Hepatology. 2017;2(9):635-643. doi:10.1016/S2468-1253(17)30150-4
Strate L. Approach to acute lower gastrointestinal bleeding in adults. Published online January 12, 2026. Accessed January 26, 2026. https://www.uptodate.com/contents/approach-to-acute-lower-gastrointestinal-bleeding-in-adults?source=autocomplete&index=2~5#H25594387
Sharma B, John S. Hepatic Cirrhosis. In: StatPearls. StatPearls Publishing; 2025. Accessed January 26, 2026. http://www.ncbi.nlm.nih.gov/books/NBK482419/
Fadlallah H, El Masri D, Bahmad HF, Abou-Kheir W, El Masri J. Update on the Complications and Management of Liver Cirrhosis. Medical Sciences. 2025;13(1):13. doi:10.3390/medsci13010013
Goldberg E, Chopra S. Cirrhosis in adults: Etiologies, clinical manifestations, and diagnosis. Published online January 8, 2025. Accessed January 26, 2026. https://www.uptodate.com/contents/cirrhosis-in-adults-etiologies-clinical-manifestations-and-diagnosis?search=cirrhosis&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
Üçbilek E, Yıldırım AE, Ellik Z, Turan İ, Haktanıyan B, Orucu B, et al. Changing Trends in the Etiology of Cirrhosis in Türkiye: A Multicenter Nationwide Study. Turkish Journal of Gastroenterology. 2024;35(10):772-777. doi:10.5152/tjg.2024.23572
Goldberg E, Chopra S. Cirrhosis in adults: Overview of complications, general management, and prognosis. Published online January 12, 2026. Accessed January 20, 2026. https://www.uptodate.com/contents/cirrhosis-in-adults-overview-of-complications-general-management-and-prognosis?search=siroz&source=search_result&selectedTitle=2~150&usage_type=default&display_rank=2
Bajaj JS, Sanyal AJ. Methods to achieve hemostasis in patients with acute variceal hemorrhage. Published online January 23, 2025. Accessed January 25, 2026. https://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage
Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: Risk stratification, diagnosis, and management 2016 practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2017;65(1):310-335. doi:10.1002/hep.28906
Gralnek IM, Camus Duboc M, Garcia-Pagan JC, Fuccio L, Karstensen JG, Hucl T, et al. Endoscopic diagnosis and management of esophagogastric variceal hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy. 2022;54(11):1094-1120. doi:10.1055/a-1939-4887
Mandiga P, Kommu S, Bollu PC. Hepatic Encephalopathy. In: StatPearls. StatPearls Publishing; 2025. Accessed January 29, 2026. http://www.ncbi.nlm.nih.gov/books/NBK430869/
Allegretti AS, Wong F. Hepatorenal syndrome: Treatment and prognosis. Published online January 9, 2026. Accessed January 26, 2026. https://www.uptodate.com/contents/hepatorenal-syndrome-treatment-and-prognosis?search=cirrhosis&topicRef=2308&source=see_link#H3329389590
Tapper E, O’Brien A. Spontaneous bacterial peritonitis in adults: Management. Published online June 26, 2025. Accessed January 25, 2026. https://www.uptodate.com/contents/spontaneous-bacterial-peritonitis-in-adults-management
Biggins SW, Angeli P, Garcia-Tsao G, Ginès P, Ling SC, Nadim MK, et al. Diagnosis, Evaluation, and Management of Ascites, Spontaneous Bacterial Peritonitis and Hepatorenal Syndrome: 2021 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;74(2):1014-1048. doi:10.1002/hep.31884
Goosenberg E, Kudaravalli P, Samant H. Ascites. In: StatPearls. StatPearls Publishing; 2025. Accessed January 26, 2026. http://www.ncbi.nlm.nih.gov/books/NBK470482/
Biggins SW. Evaluation of adults with ascites. Published online September 20, 2024. Accessed January 26, 2026. https://www.uptodate.com/contents/evaluation-of-adults-with-ascites
European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. Journal of Hepatology. 2010;53(3):397-417. doi:10.1016/j.jhep.2010.05.004
