Undifferentiated upper gastrointestinal bleeding

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

Clinical Presentation

History

  • Hematemesis
  • Coffee-ground emesis
  • Melena + age <50 suggests upper GI bleed
  • Vomiting + retching followed by hematemesis = Mallory-Weiss
  • Aortic graft = aortoenteric fistula
  • Meds
  • 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
    • Only 20% of patients with a positive fecal occult have an identified upper GI bleed. UGI Bleed should not be ruled out based on a negative test[1]

Differential Diagnosis

Mimics of GI Bleeding

Diagnosis

Sengstaken-Blakemore Tubel
Sengstaken-Blakemore Tube Placement

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[2]
    • Positive aspirate proves strong evidence for an UGI source of bleeding
    • Can assess presence of ongoing active bleeding
    • Can prepare pt for endoscopy
  • Cons[2]
    • 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[3]

Treatment

  • Place 2 large bore IVs and monitor airway status

Proton Pump Inhibitor

  • Pantoprazole/esomeprazole 80mg x 1; then 8mg/hr
  • Reduces the rate of rebelling and need for surgery if there is an ulcer, but does not reduce morbidity or mortality[4]
  • There is a mortality benefit in Asian patients[5]

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[6]
  • 3mg/kg IV over 20-30min, 30-90min prior to endoscopy

IVF

  • Crystalloid can be used for initial resuscitation but should be limited due to the dilutional anemia and dilatational coagulopathy that can result

PRBC transfusions

  • Indications for PRBC transfusions:
  • Hemoglobin <7 g/dl
    • Continued active bleeding
    • Failure to improve perfusion and vital signs after infusion of 2L NS
    • Varicele bleeding[7]
  • In hemodynamically stable patients, the goal transfusion threshold should be 7 g/dl
  • NICE guidelines recommend avoidance of over-transfusion[8]

Other Blood Products

  • Prothrombin complex concentrates[9]
  • Cryopprecipitate to raise fibrinogen (goal >120mg/dL)
  • Platelets (goal >50-100k/μL
  • FFP can be used to correct anti coagulated patients, but are not indicated in cirrhotics with variceal bleeding[10]

Endoscopy

  • Endoscopy should be performed at the discretion of the gastroenterologist. Early endoscopy does not necessarily improve clinical outcomes[11]

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 (50 mcg IV bolus, then 50 mcg/hr continuous)
  • Vasopressin associated with too many vasoconstrictive complications

Disposition

Admission

  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

must meet ALL of the following:

  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

Source

  1. ↑ Allard J et al. Gastroscopy following a positive fecal occult blood test and negative colonoscopy: systematic review and guideline. Can J Gastroenterol.2010;24(2):113-120.
  2. ↑ 2.0 2.1 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.
  3. ↑ Huang ES et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc. 2011;74(5):971-980.
  4. ↑ Leontiadis GI et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2004(3):CD002094.
  5. ↑ Singh M. Proton pump inhibitors (PPIs) given for acute peptic ulcer bleeding 2013; bleeding/
  6. ↑ 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.
  7. ↑ Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
  8. ↑ Dworzynski K et al. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012;344:e3412.
  9. ↑ Makris M, et al. Warfarin anticoagulation reversal: management of the asymptomatic and bleeding patient. J Thromb Thrombolysis. 2010; 28:171–181.
  10. ↑ Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
  11. ↑ Sarin N et al. Time to endoscopy and out- comes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489-493.
  12. ↑ Tacke F, Fiedler K, Trautwein C. A simple clinical score pre- dicts high risk for upper gastrointestinal hemorrhages from varices in patients with chronic liver disease. Scand J Gastro- enterol. 2007;42(3):374-382.
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