Upper GI Bleeding

Upper GI Bleeding

Tad Kim, M.D.Connie Lee, M.D.

Upper GI Bleeding

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

Upper GI Bleeding

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

Upper GI Bleeding

Examples

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Dieulafoy’s lesion

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Gastric varices

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Watermelon stomach

Upper GI Bleeding

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?

Upper GI Bleeding

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

Upper GI Bleeding

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

Upper GI Bleeding

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

Upper GI Bleeding

UGIB: Indications for Surgical Intervention

• Refractory or recurrent bleeding

• Inability to identify bleeding source

Upper GI Bleeding

UGIB: Long-Term Management

• Test for H. pylori. Treatment = amoxicillin, clarithromycin, and PPI

• Limit NSAID use

• H2B, PPI

Upper GI Bleeding

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