Undifferentiated upper gastrointestinal bleeding: Difference between revisions

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**Octreotide (50 mcg IV bolus, then 50 mcg/hr continuous, maintained at 2-5 days)<ref>Augustin S et al. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol. 2010 Jul 27; 2(7): 261–274.</ref>
**Octreotide (50 mcg IV bolus, then 50 mcg/hr continuous, maintained at 2-5 days)<ref>Augustin S et al. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol. 2010 Jul 27; 2(7): 261–274.</ref>
**Judicious IVF and blood products
**Judicious IVF and blood products
**Emergency endoscopy for ligation, banding, and/or sclerotherapy
**Antibiotics
**Antibiotics
***For short-term prophylaxis against SBP and bacteremia<ref>Lee YY et al. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol. 2014 Feb 21; 20(7): 1790–1796. </ref>
***For short-term prophylaxis against SBP and bacteremia<ref>Lee YY et al. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol. 2014 Feb 21; 20(7): 1790–1796. </ref>
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***OR [[ceftriaxone]] 1gm daily x 7 days
***OR [[ceftriaxone]] 1gm daily x 7 days
****Indicated for pts w/ cirrhosis or history of ETOH abuse (regardless of whether bleeding is variceal or not)
****Indicated for pts w/ cirrhosis or history of ETOH abuse (regardless of whether bleeding is variceal or not)
****Used over ciprofloxacin in high quinolone-resistant areas**Emergency endoscopy for ligation, banding, and/or sclerotherapy
****Used over ciprofloxacin in high quinolone-resistant areas
*Vasopressin associated with many vasoconstrictive complications to include peripheral necrosis, dysrhythmias, myocardial ischemia <ref>GI Bleeding: An Evidence-Based ED Approach. EB Medicine. http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=75&seg_id=1507</ref>
*Vasopressin associated with many vasoconstrictive complications to include peripheral necrosis, dysrhythmias, myocardial ischemia <ref>GI Bleeding: An Evidence-Based ED Approach. EB Medicine. http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=75&seg_id=1507</ref>
**0.4 unit bolus, then infuse at 0.4 - 1 unit/min<ref>Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.</ref>
**0.4 unit bolus, then infuse at 0.4 - 1 unit/min<ref>Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.</ref>

Revision as of 16:44, 10 January 2016

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
  • Intermittent dosing of pantoprazole, esomeprazole, or omeprazole 40 mg IV BID not inferior to continuous infusion dosing[4]
  • Reduces the rate of re-bleeding and need for surgery if there is an ulcer, but does not reduce morbidity or mortality[5]
  • There is a mortality benefit in Asian patients[6]

Erythromycin

  • Achieves endoscopy conditions equal to lavage[7]
  • 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[8]
  • In hemodynamically stable patients, the goal transfusion threshold should be 7 g/dl
  • NICE guidelines recommend avoidance of over-transfusion[9]

Other Blood Products

  • Prothrombin complex concentrates[10]
  • Cryopprecipitate to raise fibrinogen (goal >120mg/dL)
  • Platelets (goal >50-100k/μL
  • FFP can be used to correct anticoagulated patients, but is not indicated in cirrhotics with variceal bleeding[11]

Endoscopy

  • Endoscopy should be performed at the discretion of the gastroenterologist. Early endoscopy does not necessarily improve clinical outcomes[12]

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)

Special Circumstances

  • Acute variceal bleeding
    • Octreotide (50 mcg IV bolus, then 50 mcg/hr continuous, maintained at 2-5 days)[13]
    • Judicious IVF and blood products
    • Emergency endoscopy for ligation, banding, and/or sclerotherapy
    • Antibiotics
      • For short-term prophylaxis against SBP and bacteremia[14]
      • Recommend administering antibiotics prior to endoscopy or as soon as possible after endoscopy
      • Ciprofloxacin IV or PO 500 mg BID x7 days
      • OR ceftriaxone 1gm daily x 7 days
        • Indicated for pts w/ cirrhosis or history of ETOH abuse (regardless of whether bleeding is variceal or not)
        • Used over ciprofloxacin in high quinolone-resistant areas
  • Vasopressin associated with many vasoconstrictive complications to include peripheral necrosis, dysrhythmias, myocardial ischemia [15]
    • 0.4 unit bolus, then infuse at 0.4 - 1 unit/min[16]
    • Give with IV nitroglycerin at 10 - 50 mcg/min to bolster portal hypotension and reduce vasopressin systemic effects[17]
    • Terlipressin (analog of vasopressin, available outside U.S.)
      • Alternative to vasopressin with mortality benefit
      • Given as 2 mg IV q4 hrs, then decrease to 1 mg IV q4 hrs until bleeding stops[18]

Intubation

  • Protection of airway from massive aspiration, especially prior to endoscopy
  • Does not seem to protect against pneumonia or cardiopulmonary events[19]
  • Have bed-side push-dose pressors on hand
  • NO CHRISTMAS[20]
    • NGT (salem sump to remove stomach contents)
      • Varices not contraindication to NGT
      • Consider metoclopramide 10 mg IV
    • Good pre-Oxygenation critical
    • Chest and HOB elevation to 45 degrees - consider intubating from 45 degrees to prevent gastric contents coming up
    • RSI - consider halving dosages for lost blood volume
      • Etomidate or ketamine for sedation
      • Succinylcholine and vecuronium increases LES tone
    • Intubation with strong chance for first pass
    • Slow and gentle BVM breathes at 10 breathes/min if first pass fails
    • Trendelenberg if vomiting, keeping emesis out of lungs (have many suctions available before this happens)
    • Meconium aspirator may be hooked up to ETT for large bore suction
    • Antibiotics not needed in early phase of aspiration
      • Chemical pneumonitis in first 24 hours, no bacterial pneumonia
      • Early antibiotics may predispose pt to resistant bacterial superinfection
    • SIRS-like response often occurs from aspiration, but otherwise not sepsis if there is no other concerning source or suspicion
      • May require pressors and fluids
      • Consider withholding early antibiotics, but doing the rest of the sepsis treatments

Disposition

Admission

  • Age >60yr
  • Transfusion required
  • Initial Sys BP < 100
  • Red blood in NG lavage
  • History of cirrhosis or ascites on exam
  • History of vomiting red blood

Consider Discharge

If Glasgow-Blatchford Bleeding Score of 0 (<1% chance of requiring intervention):[21]. Must meet ALL of the following:

  • BUN <18
  • Hb >13 (men), Hb >12 (women)
  • Sys BP >110
  • HR <100
  • Pt did NOT present w/ melena
  • Pt did NOT present w/ syncope
  • No hepatic disease
  • No cardiac failure

See Also

References

  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. ↑ Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(11):1755.
  5. ↑ Leontiadis GI et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2004(3):CD002094.
  6. ↑ Singh M. Proton pump inhibitors (PPIs) given for acute peptic ulcer bleeding 2013; bleeding/
  7. ↑ 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.
  8. ↑ Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
  9. ↑ Dworzynski K et al. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012;344:e3412.
  10. ↑ Makris M, et al. Warfarin anticoagulation reversal: management of the asymptomatic and bleeding patient. J Thromb Thrombolysis. 2010; 28:171–181.
  11. ↑ Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
  12. ↑ Sarin N et al. Time to endoscopy and out- comes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489-493.
  13. ↑ Augustin S et al. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol. 2010 Jul 27; 2(7): 261–274.
  14. ↑ Lee YY et al. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol. 2014 Feb 21; 20(7): 1790–1796.
  15. ↑ GI Bleeding: An Evidence-Based ED Approach. EB Medicine. http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=75&seg_id=1507
  16. ↑ Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.
  17. ↑ Tsai YT, Lay CS, Lai KH, et al. Controlled trial of vasopressin plus nitroglycerin vs. vasopressin alone in the treatment of bleeding esophageal varices. Hepatology 1986; 6:406.
  18. ↑ Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.
  19. ↑ Rudolph SJ et al. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest Endosc. 2003 Jan;57(1):58-61.
  20. ↑ Weingart S. EMCrit Podcast 5 – Intubating the Critical GI Bleeder. June 2009. http://emcrit.org/podcasts/intubating-gi-bleeds/
  21. ↑ 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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