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

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

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
❑ 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

❑ Initial fluid resuscitation

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

Endoscopic Management

Pre-endoscopic medications:

❑ Administer IV infusion of erythromycin (250 mg for 30 min)
❑ Consider IV PPI therapy (80 mg bolus followed by 8 mg/h infusion

References

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