Undifferentiated upper gastrointestinal bleeding: Difference between revisions

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**Can assess presence of ongoing active bleeding
**Can assess presence of ongoing active bleeding
**Can prepare pt for endoscopy
**Can prepare pt for endoscopy
*Cons
*'''Cons'''<ref name="ali"></ref>
**Uncomfortable
**Uncomfortable
**Negative aspirate does not conclusively exclude UGI source<ref name="ali"></ref>
**Negative aspirate does not conclusively exclude UGI source
**Provides useful information in only minority of pts w/o hematemesis
**Provides useful information in only minority of pts w/o hematemesis
**[[Erythromycin]] 200mg IV can provide equal endoscopy conditions as lavage
**[[Erythromycin]] 200mg IV can provide equal endoscopy conditions as lavage

Revision as of 02:26, 3 April 2015

Background

  • Bleeding originating proximal to ligament of Treitz.
  • In the acute setting, the hemoglobin/hematocrit may be normal until dilutional anemia appears after volume resuscitation

Prehospital

  • Airway: suction to prevent aspiration, provide oxygen as needed
  • Breathing: maintain patient is position of comfort
  • Circulation: monitor for early signs of shock, and provide fluid resuscitation if hypotensive. Blood products should be individualized based on local protocols
  • Antiemetics can be given to decrease nausea and vomitting
  • Assume the patient is hepatitis positive and wear appropriate personal protective gear

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

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

Differential Diagnosis

Mimics of GI Bleeding

Workup

  • 2 large bore IVs
  • Type and cross
  • CBC & serial Hb
  • Chemistry
    • BUN/Cr >30 suggests UGI if no hx of renal failure (incr absorption/digestion of hb)
  • Coags
  • LFTs
  • Guiac
  • ?ECG (if >50 yo or if suspicious for silent MI)
  • ?CXR (if suspect perforation)

NG Lavage Controversy

  • Pros[1]
    • Positive aspirate proves strong evidence for an UGI source of bleeding
    • Can assess presence of ongoing active bleeding
    • Can prepare pt for endoscopy
  • Cons[1]
    • Uncomfortable
    • Negative aspirate does not conclusively exclude UGI source
    • Provides useful information in only minority of pts w/o hematemesis
    • Erythromycin 200mg IV can provide equal endoscopy conditions as lavage

Treatment

  • Place 2 large bore IVs
  • PPI
    • Pantoprazole/esomeprazole 80mg x 1; then 8mg/hr
    • Reduces rate of endoscopic therapy but does not reduce morbidity or mortality
  • Antibiotics
    • Ceftriaxone 1gm daily x 7 days
    • Indicated for pts w/ cirrhosis or history of ETOH abuse (regardless of whether bleeding is variceal or not)
  • Erythromycin[2]
    • Achieves endoscopy conditions equal to lavage
    • 3mg/kg IV over 20-30min, 30-90min prior to endoscopy
  • Consider IVF
  • Blood products
    • Indications for PRBC transfusions:
      • Continued active bleeding
      • Failure to improve perfusion and vital signs after infusion of 2L NS
    • Varicele bleeding[3]
      • Cryopprecipitate to raise fibrinogen (goal >120mg/dL)
      • Platelets (goal >50-100k/μL
      • No role for FFP to correct the INR
  • Endoscopy

Balloon Tamponade with Sengstaken-Blakemore Tube

  • For life-threatening hemorrhage if endoscopy is not available)
  • Tube consists of gastric and esophageal balloons
    • First inflate gastric balloon; if bleeding continues inflate esophageal balloon
      • Esophageal pressure must not exceed 40-50 mmHg
  • Adverse reactions are frequent
    • Mucosal ulceration
    • Esophageal/gastric rupture
    • Tracheal compression (consider intubation prior to balloon insertion)

Treatments Not Supported by the Literature

  • 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
  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

  1. ↑ 1.0 1.1 Aljebreen AM et al. Nasogastric aspirate predicts high-risk endoscopic lesions in patients with acute upper-GI bleeding. Gastrointest Endosc. 2004;59(2):172-178.
  2. ↑ Pateron D, et al. Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Ann Emerg Med. 2011; 57(6):582-589.
  3. ↑ Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
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