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

• Angiodysplasia
• Duodenal ulcer
• Duodenitis
• Esophagitis
• Gastric ulcer
• Gastritis
• 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 ❑ 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 Patients with suspected varices ❑ Refer Varices and variceal bleed resident survival guide

EGD

Variceal bleed

Non variceal bleed

Refer variceal bleed

❑ Active spurting ❑ Oozing blood ❑ Non-bleeding visible vessel

Adherent Clot

❑ Clean base ulcer ❑ Flat pigmented spot

❑ Endoscopic therapy: * Thermal therapy with bipolar electrocoagulation PLUS sclerosant injection (e.g absolute alcohol) * Epinephrin injection PLUS thermal therapy or sclerotherapy or clips * Clips ❑IV PPI therapy * 80 mg bolus followed by 8 mg/hr infusion for 72 hours

❑ Consider endoscopic therapy in patients with clot resistant to irrigation ❑ IV PPI therapy

❑ No endoscopic therapy ❑ Oral PPI therapy (once daily) ❑ Regular diet after endoscopy Early prompt discharge after endoscopy in following patients: ❑ Hemodynamic stability ❑ No other comorbdity ❑ Easy access to hospital

❑ Hospital admission for 3 days ❑ Clear liquids can be fed soon after endocopy ❑ Discharge after 3 days if no re-bleeding occurs

If re-bleeding occurs clinically

Repeat endoscopy with hemostatic therapy

Bleeding could not be controlled?

Bleeding controlled

Surgery Arterial embolization

IV PPI therapy for 72 hours Oral therapy thereafter

References

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