Undifferentiated upper gastrointestinal bleeding

Background

• Bleeding originating proximal to ligament of Treitz

Diagnosis

History

• Hematemesis
• Coffee-ground emesis
• Melena + age <50 suggests upper GI bleed
• Vomiting + retching followed by hematemesis = Mallory-Weiss
• Aortic graft = aortoenteric fistula
• Meds
  • ASA, steroids, NSAIDs, anticoagulants
• ETOH abuse
  • Peptic ulcer disease, gastritis, varices
• Pseudo-melena
  • Iron or bismuth use

Physical Exam

• Tachycardia, hypotension
• Liver disease
  • Spider angiomata, palmar erythema, jaundice, gynecomastia
• Coagulopathy
  • Petechiae/purpura
• ENT exam
  • Swallowed blood may result in coffee-ground emesis or melena
• Rectal exam

DDX

1. Peptic ulcer disease (most common cause)
2. Gastritis/esophagitis
3. Gastric/esophageal varices
4. Mallory-Weiss tear
5. Stress ulcer
6. Malignancy
7. ENT sources of bleeding
8. Aortoenteric fistula
9. Boerhaave
10. Dieulafoy's lesion
11. Angiodysplasia
12. Hemobilia

Workup

1. 2 large bore IV
2. Type and cross
3. CBC & serial Hb
4. Chemistry
   1. BUN/Cr >30 suggests UGI if no hx of renal failure (incr absorption/digestion of hb)
5. Coags (if INR > 1.5 transfuse FFP)
6. LFTs
7. Guiac
8. ?ECG (if >50 yo or if suspicious for silent MI)
9. ?CXR (if suspect perforation)
10. ?NG lavage
    1. Controversial
       1. Pros
          1. Positive aspirate proves strong evidence for an UGI source of bleeding
          2. Can assess presence of ongoing active bleeding
          3. Can prepare pt for endoscopy
       2. Cons
          1. Uncomfortable
          2. Negative aspirate does not conclusively exclude UGI source
          3. Provides useful information in only minority of pts w/o hematemesis
          4. Erythromycin 200mg IV can provide equal endoscopy conditions as lavage

Treatment

1. IVF
2. Blood
   1. Indications for tranfusion:
      1. Continued active bleeding
      2. Failure to improve perfusion and vital signs after infusion of 2L NS
3. There is no role for FFP to correct the INR in varicele bleeding in cirrhosis
4. Platelets as needed
5. PPI (reduces rate of endoscopic therapy but does not reduce morbidity or mortality)
   1. Pantoprazole/esomeprazole 80mg x 1; then 8mg/hr
6. Antibiotics
   1. Indicated for pts w/ cirrhosis or history of ETOH abuse (regardless of whether bleeding is variceal or not)
   2. Ceftriaxone 1gm daily x 7 days
7. Erythromycin
   1. Achieves endoscopy conditions equal to lavage
   2. 3mg/kg IV over 20-30min, 30-90min prior to endoscopy
8. Endoscopy
9. Surgery
10. Balloon tamponade (for life-threatening hemorrhage if endoscopy is not available)
    1. Sengstaken-Blakemore tube
       1. Tube consists of gastric and esophageal balloons
          1. First inflate gastric balloon; if bleeding continues inflate esophageal balloon
             1. Esophageal pressure must not exceed 40-50 mmHg
       2. Adverse reactions are frequent
          1. Mucosal ulceration
          2. Esophageal/gastric rupture
          3. Tracheal compression (consider intubation prior to balloon insertion)

^No evidence to support octreotide use

Disposition

• Consider admission for:

1. Age >60yr
2. Transfusion required
3. Initial Sys BP < 100
4. Red blood in NG lavage
5. History of cirrhosis or ascites on exam
6. History of vomiting red blood

• Consider discharge for Glasgow-Blatchford Bleeding Score of 0, must meet ALL of the following (<1% chance of requiring intervention):

1. BUN <18
2. Hb >13 (men), Hb >12 (women)
3. Sys BP >110
4. HR <100
5. Pt did NOT present w/ melena
6. Pt did NOT present w/ syncope
7. No hepatic disease
8. No cardiac failure

See Also

Lower GI Bleeding

Upper GI Bleed Guidelines

Source

• Does this patient have a severe upper gastrointestinal bleed? JAMA, 2012
• Tintinalli
• Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Pateron D et al. Ann Emerg Med. (2011)