Upper gastrointestinal bleeding resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]; Rim Halaby, M.D. [3] Aditya Ganti M.B.B.S. [4]

Overview

Upper gastrointestinal (GI) bleed refers to any bleeding originating from the gastrointestinal tract proximal to ligament of Treitz.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Severe upper GI bleed is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

• Angiodysplasia
• Aorto-enteric fistula
• Duodenal ulcer
• Duodenitis
• Esophagitis
• Gastric ulcer
• Gastritis
• Mallory-Weiss tear
• Variceal bleed

Management

Initial Management

Shown below is an algorithm depicting the initial approach to upper GI bleed.

Characterize the symptoms: ❑ Blood in vomiting ❑ Coffee ground emesis ❑ Black and tarry stools ❑ Frank blood in stools ❑ Maroon colored stool ❑ Abdominal pain ❑ Altered mental status ❑ Dizziness ❑ Syncope ❑ Palpitations Obtain the past medical history: ❑ Previous GI bleed ❑ Anticoagulants use ❑ NSAIDs use ❑ Alcohol intake ❑ Other comorbidities

Examine the patient: ❑ Abdominal tenderness ❑ Involuntary guarding ❑ Bowel sounds ❑ Hyperactive (suggestive of upper GI bleed) ❑ Hypoactive (suggestive of mesenteric ischemia or ileus) ❑ Signs of liver failure ❑ Rectal exam to assess the stool color ❑ Guaiac test ❑ Assess mental status ❑ Blood pressure ❑ Pulse ❑ Assess the hemodynamic status: Severity of blood loss Signs Mild to moderate Resting tachycardia 15% blood loss Orthostatic hypotension 40% blood loss Hypotension Shock Cold clammy extremities Weak and thready pulse Initiate resuscitative measures if needed: ❑ Ensure normal breathing and clear airway ❑ Consider intubation in patients with ongoing massive bleeding ❑ Cardiac monitoring

Order labs and tests: ❑ Blood type and cross-match ❑ CBC ❑ Platelet count ❑ Prothrombin time and INR ❑ Liver enzymes ❑ BUN ❑ Creatinine ❑ Electrolytes ❑ Order EKG and cardiac enzymes to rule out myocardial infarction in elderly patients

Stratify the patient by their hemodynamic status

Unstable patient and/or massive active bleeding and/or altered mental status

Stable patient

Resuscitate the patient: ❑ Keep patient NPO ❑ Insert 2 large bore IV lines ❑ Administer supplemental oxygen ❑ Ensure fluid resuscitation ❑ Administer 500 ml of NS during first 30 min and simultaneously send blood sample for cross-matching ❑ Consider increasing fluid administration if blood pressure fails to rise ❑ Consider blood transfusion to target Hb ≥ 7 g/dL (higher target in case of CAD or intravascular volume depletion) ❑ Admit to ICU ❑ Monitor the urine output ❑ Request a surgical consult

❑ Ensure fluid resuscitation ❑ Assess if Blatchford score is 0: (Score is zero if the following criteria are fulfilled) ❑ Urea Nitrogen < 18.2 mg/dl ❑ Hemoglobin ≥ 13 g/dL (12 g/dL for women) ❑ Systolic blood pressure ≥ 110 mmHg ❑ Pulse <100/min ❑ Absence of melena, cardiac failure, syncope and liver disease

> 0

0

❑ Discharge from the emergency room without endoscopy

❑ Prepare patient for early endoscopy

BUN: Blood urea nitrogen; CAD: Coronary artery disease; CBC: Complete blood count; EKG: Electrocardiogram; Hb: Hemoglobin; ICU: Intensive care unit; INR: International normalized ratio; IV: Intravenous; GI: Gastrointestinal; NPO: Nil per os; NSAIDs: Non steroid anti-inflammatory drugs

Endoscopic Management

Shown below is algorithm depicting the endoscopic management of upper GI bleeding based on the guidelines issued by the American College of Gastroenterology (ACG).

Medications before endoscopy: ❑ Consider IV infusion of erythromycin (250 mg 30 minutes prior to the endoscopy) ❑ Consider IV PPI therapy (80 mg bolus followed by 8 mg/hour infusion)

Request endoscopy: ❑ As soon as possible for stable patients, OR ❑ Within 24 hours for hemodynamically unstable patients, OR ❑ Within 12 hours for patients with tachycardia, hypotension, or bloody emesis

Non variceal bleed

Variceal bleed Click here for the detailed management

❑ Assess stigmata of recent hemorrhage

❑ Active spurting ❑ Oozing blood ❑ Non-bleeding visible vessel

❑ Adherent clot

❑ Clean base ulcer ❑ Flat pigmented spot

❑ Endoscopic therapy: ❑ Thermal therapy with bipolar electrocoagulation PLUS sclerosant injection (e.g absolute alcohol) ❑ Epinephrine injection PLUS another modality (thermal therapy or sclerotherapy or clips) ❑ Clips ❑ IV PPI therapy with 80 mg bolus followed by 8 mg/hr infusion for 72 hours

❑ Consider endoscopic therapy in patients with clot resistant to irrigation ❑ IV PPI therapy with 80 mg bolus followed by 8 mg/hr infusion for 72 hours

❑ No endoscopic therapy ❑ Oral PPI therapy (once daily) ❑ Regular diet after endoscopy ❑ Discharge hemodynamically stable patients who have no comorbidities

❑ Hospital admission for 3 days ❑ Clear liquids can be fed soon after endoscopy

No re-bleeding

Re-bleeding

❑ Discharge after 3 days

❑ Repeat endoscopy with hemostatic therapy

Bleeding is not controlled?

Bleeding is controlled

❑ Consider surgery, or ❑ Consider arterial embolization

❑ Administer IV PPI therapy for 72 hours ❑ Prescribe oral PPI therapy thereafter

IV: Intravenous; PPI: Proton pump inhibitor

Long Term Prevention of Recurrent Ulcer Bleed

Shown below is an algorithm depicting the long term prevention of recurrent ulcer bleed based on the guidelines issued by American College of Gastroenterology (ACG).

❑ Determine the etiology of the upper GI bleed

H. Pylori

NSAIDs

Aspirin

Idiopathic

❑ Test for H. Pylori ❑ Treat with H. Pylori eradication therapy ❑ Document cure of H. Pylori at > 1 month after eradication therapy is stopped

❑ Stop NSAIDs ❑ If NSAIDs have to be resumed, use celecoxib plus PPI therapy ❑ In patients on antithrombotics, continue PPI therapy

❑ Assess the indication for aspirin

❑ Continue daily PPI therapy

Primary prevention ❑ Stop aspirin

Secondary prevention ❑ Resume aspirin as soon as possible ❑ Start PPI

NSAIDs: Non steroidal anti-inflammatory drugs; PPI: Proton pump inhibitor

Do's

• Rockall score (ranging from 0-7) can be used for risk assessment. Parameters included in rockall score are systolic blood pressure, pulse, age and comorbidities.

• Administer IV proton pump inhibitors (PPI) therapy before endoscopy to decrease the number of patients with high risk of hemorrhage and patients requiring endoscopic therapy. However, PPI therapy does not affect the outcomes such as recurrent bleeding, surgery or death. If endoscopy is delayed for some reason, IV PPI therapy is indicated to decrease further bleeding.

• Early endoscopy is strongly recommended, however patients with blood urea nitrogen<18.2 mg/dl, Hb>13.0 mg/dl in men, Hb>12.0 mg/dl in women, systolic blood pressure>110 mmHg, pulse<100beats per minute, absence of melena, syncope, cardiac failure and liver disease can be discharged without endoscopy.

• Consider endoscopy among patients with upper GI bleed within 24 hours of presentation, however in patients with tachycardia, hypotension, or bloody emesis, endoscopy should be done within 12 hours after presentation.

• For active bleeding on endoscopy, thermal therapy or epinephrine plus a second modality are preferred over clips or sclerosant alone.

• As for the epinephrine therapy, dilute epinephrine (1:10,000 or 1:20,000 in saline) and inject it in doses of 0.5-2 ml in and around the bleeding site. Continue the injections until the active bleeding stops.

• Test for H-pylori by an endoscopic biopsy based test for H. Pylori. If the biopsy is negative, confirm with a non endoscopic H. Pylori test.

• Document cure of H. Pylori 1 month following the end of the eradication therapy eradication therapy by either a urea breath test, stool antigen test, or endoscopy.

Dont's

• Do not administer nasogastric lavage in patients with upper GI bleed for diagnosis, prognostic evaluation, visualization or therapeutic effect.
• Do not administer epinephrine therapy alone. Always combine epinephrine therapy with a second agent.
• Do not request a repeat endoscopy for patients who have no evidence of bleeding after the endoscopic therapy.

References

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