Upper gastrointestinal bleeding resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]

Definition

This section provides a short and straight to the point definition of the disease or symptom in one sentence.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

• Life threatening cause 1
• Life threatening cause 2
• Life threatening cause 3

Common Causes

• Common cause 1
• Common cause 2
• Common cause 3
• Common cause 4
• Common cause 5

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 ❑ History of previous GI bleed ❑ Patient taking anticoagulants ❑ History of NSAIDs intake ❑ History of other comorbities

Physical examination Abdominal examination ❑ Abdominal tenderness ❑ Involuntary guarding ❑ Bowel sounds Hyperactive: Suggests UGIB Hypoactive: Suggests mesenteric ischemia or ileus ❑ Signs of liver failure ❑ Rectal exam to assess stool color ❑ Guaiac test ❑ Signs of hypovolemia: Severity of blood loss Signs Mild to moderate Resting tachycardia 15% blood loss Orthostatic hypotension 40% blood loss Hypotension Shock Cold clammy extremities, Weak and thready pulse

Order tests ❑ Blood type and cross-match ❑ CBC ❑ Platelet count ❑ Prothrombin time and INR ❑ Liver enzymes ❑ BUN ❑ Creatinine ❑ Electrolytes ❑ Order EKG and cardiac enzymes to rule out myocardial infarction in elderly patients

Initial assessment ❑ Ensure normal breathing and clear airway Consider intubation in patients with ongoing massive bleeding ❑ Assess hemodynamic status ❑ 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 * Administer 500 ml of NS during first 30 min and simultaneously send blood sample for cross-matching * Consider increasing fluid administration if blood pressure fails to rise ❑ Consider blood transfusion in patients with Hb < 7 g/dL ❑ Cardiac monitoring in ICU ❑ Pulse oximetry ❑ Monitor urine output ❑ Order a surgical consult

Blatchford score = 0 ? Blatchford Score = 0 if: ❑ Urea Nitrogen < 18.2 mg/dl ❑ Hemoglobin < 13.2 g/dL (12 g/dL for women) ❑ Systolic blood pressure > 110 mmHg ❑ Pulse <100/min ❑ Absence of melena, cardiac failure, syncope and liver disease

No

Yes

Discharge from emergency room without endoscopy

Prepare patient for early endoscopy

References

Template:WikiDoc Sources