Upper GI Bleeding Tad Kim, M.D. Connie Lee, M.D.
GIB: Definitions • UGIB = proximal to ligament of Treitz • Hematemesis = vomiting blood - bright red or coffee-ground (typically UGI source) • Melena = black tarry stool (often UGI) • Hematochezia = bloody stool (LGI > UGI) • Occult blood = UGI or LGI source
UGIB: DDx • Peptic Ulcer Disease (PUD) >50% cases • Gastritis / Duodenitis (15-30%) • Subset due to NSAID use • Esophageal varices from portal hypertension (10-20%) • Gastric varices • Mallory-Weiss tears at GE junction (5%) • Esophagitis (3-5%) • Malignancy (3%) • Dieulafoy’s lesion (1-3%) • Nasopharyngeal bleed – swallowed blood • Other- aortoenteric fistula, angiodysplasia, Crohn’s, hemobilia, hemosuccus pancreaticus, AVM, watermelon stomach
Examples Gastric varices Dieulafoy’s lesion Watermelon stomach
UGIB: Initial Evaluation • Evaluate ABCs/PE: • Can the pt protect his airway? • Is the pt hemodynamically unstable? • Does the pt have adequate IV access, Foley, NGT? • Resuscitate as appropriate • Orders: NPO, IVF, NGT to LCWS, Foley, HOB>30, continuous pulse oximetry & telemetry • Labs: type & cross, CBC, INR/PT/PTT, BMP, LFTs • Additional question to ask yourself: • Does the pt require a higher level of care?
UGIB: H&P • Risk factors: older age, male, cardiovascular disease, renal disease, DM, oral anticoagulant use, h/o prior GIB, PUD, NSAID use, tobacco use, liver disease, splenic vein thrombosis, sepsis, burn injury, severe vomiting, h/o H. pylori, GI instrumentation, trauma • History: OPQRST, PMHx, PSHx, Meds, ALL, SHx. • PE: remember to examine for signs of cirrhosis & portal HTN • Tests: T&C, CBC, coags, BMP, LFT, CXR/KUB
UGIB: Management • Assess magnitude of hemorrhage • Place 2 large-bore IV, volume resuscitation w/ isotonic IVF. Be prepared to transfuse blood. • Place NGT & lavage, place Foley • Monitor for continued blood loss • Start proton pump inhibitor (PPI) infusion • For varices: start octreotide infusion
UGIB: Diagnostic Procedures • NGT • EGD - 95% diagnostic accuracy if used w/in 24 hrs Angiography (Diagnostic & Therapeutic) • Intra-arterial vasopressin • Embolization • Can detect bleeding rate > 0.5 mL/min • Technetium labeled RBC scan • Only diagnostic & usually for occult bleeding • More sensitive than angiography • Can detect bleeding rate > 0.1 mL/min
UGIB: Indications for Surgical Intervention • Refractory or recurrent bleeding • Inability to identify bleeding source
UGIB: Long-Term Management • Test for H. pylori. Treatment = amoxicillin, clarithromycin, and PPI • Limit NSAID use • H2B, PPI
UGIB: Take Home Points • Start with ABCs • Remember: NPO, NGT, IVF via 2 large-bore IV • Resuscitate prior to intervention • Evaluate UGIB with EGD > angiography, tagged RBC scan