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| ==Background==
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| *Bleeding originating proximal to ligament of Treitz
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| | </translate> |
| | {{GI bleeding pages}} |
| | <translate> |
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| ==Diagnosis== | | == Calculators == |
| ===History===
| | {{Glasgow_Blatchford_Calculator}} |
| *Hematemesis
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| *Coffee-ground emesis
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| *Melena + age <50 suggests upper GI bleed
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| *Vomiting + retching followed by hematemesis = Mallory-Weiss
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| *Aortic graft = aortoenteric fistula
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| *Meds
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| **ASA, steroids, NSAIDs, anticoagulants
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| *ETOH abuse
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| **Peptic ulcer disease, gastritis, varices
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| *Pseudo-melena
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| **Iron or bismuth use
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| ===Physical Exam===
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| *Tachycardia, hypotension
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| *Liver disease
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| **Spider angiomata, palmar erythema, jaundice, gynecomastia
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| *Coagulopathy
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| **Petechiae/purpura
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| *ENT exam
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| **Swallowed blood may result in coffee-ground emesis or melena
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| *Rectal exam
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| ==DDX== | | ==References== |
| #Peptic ulcer disease (most common cause)
| | <references/> |
| #Gastritis/esophagitis
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| #Gastric/esophageal varices
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| #Mallory-Weiss Syndrome
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| #Stress ulcer
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| #Malignancy
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| #ENT sources of bleeding
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| #Aortoenteric fistula
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| ==Workup==
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| #2 large bore IV
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| #Type and cross
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| #CBC & serial Hb
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| #Chemistry
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| ##BUN/Cr >30 suggests UGI if no hx of renal failure (incr absorption/digestion of hb)
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| #Coags (if INR > 1.5 transfuse FFP)
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| #LFTs
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| #Guaiac
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| #?ECG (if >50 yo or if suspicious for silent MI)
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| #?CXR (if suspect perforation)
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| #?NG lavage
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| ##Controversial
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| ###Pros
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| ####Positive aspirate proves strong evidence for an UGI source of bleeding
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| ####Can assess presence of ongoing active bleeding
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| ####Can prepare pt for endoscopy
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| ###Cons
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| ####Uncomfortable
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| ####Negative aspirate does not conclusively exclude UGI source
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| ####Provides useful information in only minority of pts w/o hematemesis
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| ####Erythromycin 200mg IV can provide equal endoscopy conditions as lavage
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| ==Treatment==
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| #IVF
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| #Blood
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| ##Indications for tranfusion:
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| ###Continued active bleeding
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| ###Failure to improve perfusion and vital signs after infusion of 2L NS
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| #FFP as needed
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| #PPI
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| ##Pantoprazole/esomeprazole 80mg x 1; then 8mg/hr
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| ##Lansoprazole 60mg x 1; then 6mg/hr
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| #Octreotide
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| ##25-50mcg x 1; then 25-50 mcg/hr
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| ###Use lower dosage for elderly or severe liver disease
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| #Ceftriaxone
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| #Endoscopy
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| #Surgery
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| #Balloon tamponade (for life-threatening hemorrhage if endoscopy is not available)
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| ##Sengstaken-Blakemore tube
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| ###Tube consists of gastric and esophageal balloons
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| ####First inflate gastric balloon; if bleeding continues inflate esophageal balloon
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| #####Esophageal pressure must not exceed 40-50 mmHg
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| ###Adverse reactions are frequent
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| ####Mucosal ulceration
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| ####Esophageal/gastric rupture
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| ####Tracheal compression (consider intubation prior to balloon insertion)
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| ==Disposition==
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| *Consider admission for:
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| #Initial hematocrit <30%
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| #Initial Sys BP < 100
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| #Red blood in NG lavage
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| #History of cirrhosis or ascites on exam
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| #History of vomiting red blood
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| *Consider discharge for Glasgow-Blatchford Bleeding Score of 0 (ALL of the following)
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| #BUN <18
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| #Hb >13 (men), Hb >12 (women)
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| #Sys BP >110
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| #HR <100
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| #Pt did NOT present w/ melena
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| #Pt did NOT present w/ syncope
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| #No hepatic disease
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| #No cardiac failure
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| ===Consider===
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| #Proctoscopy (22cm from anal verge)
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| #Sigmoidoscopy (60cm from anal verge)
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| #Angiography (requries arterial bledding >0.5cc/min)
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| #CT angio
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| ==DDX==
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| ===Adult===
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| #UGIB
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| ##PUD (Gastric 21%, Duodenal 24%)
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| ##Gastritis 23%
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| ##Esophagitis/Duodenitis 6%
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| ##Varicies
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| ##Mallory-Weiss <15%
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| ##Boerhaave's
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| ##Dieulafoy lesion
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| ##Angiodysplasia
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| ##Hemobilia
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| ##Aortoenteric fistula
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| #LGIB
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| #Upper GI bleed
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| #Diverticulosis (painless, voluminous)
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| #Infectious (virus, bacteria, parasites, C. dif)
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| #Ischemic Colitis 3-12% (acute onset; 90% > 70yo)
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| #IBD (fistula-in-ano)
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| #Mesenteric Vascular Insufficiency (abd pain out of proportion to PE)
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| #Angiodysplasia
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| #Cancer/polyps
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| #Rectal dz
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| #Hemorrhoids
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| ##External (below pectinate); Internal (above)
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| #Ulcer (HIV, syphilis, STDs)
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| #Fissures (painful defecation)
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| #Abscess, prolapse, proctitis, impaction
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| ===Peds===
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| #UGIB
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| ##Esophagitis
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| ##Gastritis
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| ##Ulcer
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| ##Esophageal varices
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| ##Mallory-Weiss
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| #LGIB
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| ##Anal fissure
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| ##Infectious colitis
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| ##IBD
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| ##Polyps
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| ##Intussusception
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| ==Disposition==
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| Rockall score
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| ===Home (very low risk)===
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| #No comorbid dz
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| #Normal vitals
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| #Norma/trace pos guiac
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| #Normal/near-normal Hb
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| #Home support
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| #F/U within 24hrs
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| ===Ward/Stable (low risk)===
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| #Age <60
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| #Initial SBP >100
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| #Normal vitals x 1hr
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| #No transfusion req
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| #No major comorbid
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| #No liver dz
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| ===ICU===
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| #Normal or dec Hct
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| #Blood in NG doesn't clear
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| #SBP<100, HR>100
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| #Gauaic +/- stool
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| ==False Positive Guaiac==
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| #Red fruits and meats
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| ##(Bananas, turnips, broccoli)
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| #Methylene blue
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| #Chlorophyll
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| #Iodide
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| #Cupric sulfate
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| #Bromide
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| #Iron (causes GI bleed by irritation)
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| ==Source ==
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| *Tintinalli
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| *Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Pateron D et al. Ann Emerg Med. (2011)
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| [[Category:GI]] | | [[Category:GI]] |
| | [[Category:Symptoms]] |
| | </translate> |
