Upper gastrointestinal bleeding resident survival guide: Difference between revisions
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{{familytree | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | }} | {{familytree | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | | }} | ||
{{familytree | | | | | C01 | | C02 | | | {{familytree | | | | | C01 | | C02 | | C03 | | | | | | | | |C01=<div style="float: left; text-align: left; height: 10em; width: 20em; padding:1em;">❑ Active spurting<br>❑ Oozing blood<br>❑ Non-bleeding visible vessel</div>|C02= Adherent Clot|C03=<div style="float: left; text-align: left; height: 10em; width: 20em; padding:1em;">❑ Clean base ulcer<br>❑ Flat pigmented spot</div>}} | ||
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{{familytree | | | | | D01 | | D02 | | | {{familytree | | | | | D01 | | D02 | | D03 | | | | | | | | | | | | | | | | | | |D01=<div style="float: left; text-align: left; height: 20em; width: 20em; padding:1em;"> ❑ [[Endoscopic therapy]]:<br> | ||
: * Thermal therapy with bipolar electrocoagulation PLUS [[sclerosant]] injection (e.g absolute alcohol)<br> | : * Thermal therapy with bipolar electrocoagulation PLUS [[sclerosant]] injection (e.g absolute alcohol)<br> | ||
: * Epinephrin injection PLUS thermal therapy or [[sclerotherapy]] or clips<br> | : * Epinephrin injection PLUS thermal therapy or [[sclerotherapy]] or clips<br> | ||
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</div> |D02= | </div> |D02= | ||
<div style="float: left; text-align: left; height: 20em; width: 20em; padding:1em;"> ❑ Consider endoscopic therapy in patients with clot resistant to irrigation<br> | <div style="float: left; text-align: left; height: 20em; width: 20em; padding:1em;"> ❑ Consider endoscopic therapy in patients with clot resistant to irrigation<br> | ||
❑ IV PPI therapy </div> | ❑ IV PPI therapy </div>|D03=<div style="float: left; text-align: left; height: 20em; width: 20em; padding:1em;"> ❑ No endoscopic therapy<br>❑ oral [[PPI]] therapy (once daily)<br> | ||
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Early prompt discharge after endoscopy in following patients:<br> | |||
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❑ Hemodynamic stability<br>❑ No other comorbdity<br>❑ Easy access to hospital</div>}} | |||
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Revision as of 03:18, 26 January 2014
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]
Definition
Upper GI bleed refers to any bleeding occurring from gastrointestinal tract proximal to ligament of Treitz.
Causes
Life Threatening Causes
Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.
- Variceal bleed
- Perforated ulcer
- Aorto-enteric fistula
- Hemosuccus pancreaticus
Any cause leading to severe gastrointestinal bleeding can be life threatening without immediate appropriate management.
Common Causes
- Angiodysplasia
- Duodenitis
- Esophagitis
- Gastritis
- Gastrointestinal ulcer
- Mallory-Weiss tear
- Variceal bleed
Initial Assessment and Management
Shown below is an algorithm summarizing the approach to [[disease name]].
Characterize the symptoms: ❑ Blood in vomiting ❑ Coffee ground emesis ❑ Black, tarry stools ❑ Frank blood in stools ❑ Maroon colored stool ❑ Abdominal pain ❑ Altered mental status ❑ Dizziness ❑ Syncope ❑ Palpitations Elicit past medical history about previous GI bleed, anticoagulants, NSAIDs, alcohol intake and other comorbities | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Physical examination Abdominal examination ❑ Abdominal tenderness
❑ Signs of liver failure ❑ Signs of hypovolemia:
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Order tests ❑ Blood type and cross-match ❑ Order EKG and cardiac enzymes to rule out myocardial infarction in elderly patients | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Initial assessment ❑ Ensure normal breathing and clear airway
❑ Monitor vital signs ❑ Cardiac monitoring ❑ Assess mental status | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Risk assessment | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Patient is unstable and/or massive active bleeding and/or altered mental status | Patient is stable | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Consider admission to ICU after urgent initial resuscitation Initial resuscitative measures ❑ Nil per oral ❑ 2 large bore IV lines ❑ Supplemental oxygen ❑Fluid resuscitation
❑ Consider blood transfusion in patients with Hb < 7 g/dL ❑ Order a surgical consult | ❑ Initial fluid resuscitation Blatchford score = 0 ? Blatchford Score = 0 if: ❑ Urea Nitrogen < 18.2 mg/dl | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
No | Yes | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Discharge from emergency room without endoscopy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Prepare patient for early endoscopy | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
Endoscopic Management
Pre-endoscopic medications: ❑ Administer IV infusion of erythromycin (250 mg for 30 min) Patients with suspected varices | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
EGD | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Active spurting ❑ Oozing blood ❑ Non-bleeding visible vessel | Adherent Clot | ❑ Clean base ulcer ❑ Flat pigmented spot | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
❑ Endoscopic therapy:
❑IV PPI therapy
| ❑ Consider endoscopic therapy in patients with clot resistant to irrigation ❑ IV PPI therapy | ❑ No endoscopic therapy ❑ oral PPI therapy (once daily) Early prompt discharge after endoscopy in following patients: ❑ Hemodynamic stability ❑ No other comorbdity ❑ Easy access to hospital | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||