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

Differential Diagnosis

• Peptic ulcer disease (most common cause)
• Gastritis/esophagitis
• Gastric/esophageal varices
• Mallory-Weiss tear
• Stress ulcer
• Malignancy
• ENT sources of bleeding
• Aortoenteric fistula
• Boerhaave
• Dieulafoy's lesion
• Angiodysplasia
• Hemobilia

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
  • Positive aspirate proves strong evidence for an UGI source of bleeding
  • Can assess presence of ongoing active bleeding
  • Can prepare pt for endoscopy
• Cons
  • 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
  • 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
  • There is no role for FFP to correct the INR in varicele bleeding in cirrhosis
  • Platelets as needed
• Endoscopy
• Surgery
• Balloon tamponade (for life-threatening hemorrhage if endoscopy is not available)
  • Sengstaken-Blakemore tube
    • 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

• 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)