Transcript Upper GI Bleed

Approach to Upper
GI Bleeding
Julia Lee, PGY-2
March 2016
UCI Internal Medicine Residency
Learning Objectives
• Review the major causes of upper GI bleeding
• Learn how to triage patients with upper GI
bleeding to ICU vs floors
• Understand acute management of upper GI
bleeding
Major Causes
Cause
Prevalence
Peptic ulcer
33.9%
Esophagogastric varices
32.8%
Erosive esophagitis
8.1%
Mallory-Weiss tear
6.4%
Erosion
5.1%
Tumor
5.1%
Esophageal ulcer
2.1%
Portal gastropathy
1.0%
Dieulafoy lesion
0.9%
Cameron lesion
0.7%
Other
2.7%
Characteristics of Bleeding
• Hematemesis – coffee ground vs bright red blood
• Bright red blood: moderate to severe bleeding
• Coffee-ground emesis: slower bleed
• Melena – dark, tarry, pungent
• Usually due to an upper GI bleed
• Can also be from the small intestine or proximal
colon if it’s a slow bleed
• Hematochezia – bright red blood
• Usually lower GI bleed
• Can be seen with massive/brisk upper GI bleeding
Examination
 Vitals
 Signs of hemodynamic instability
 Abdominal examination
 Stigmata of liver disease
 Signs of perforation
 Rectal examination
 NG lavage (not required for upper GIB), but can
help differentiate between upper and lower GIB
Labs
•
•
•
•
CBC, coags
LFTs, albumin
BUN/Cr >30
Note: Guaiac testing does not provide
information in location
Emergent Management
• Monitor hemodynamic stability
• Triage – ICU vs Wards
•
•
•
•
• Hemodynamic instability or active bleeding -> ICU
Immediate GI consult
Two large bore IV lines (16 gauge or larger)
Bolus infusions of isotonic crystalloid
Transfusion
• STAT Type and Cross
• pRBCs – Hgb <7, hemodynamic instability
• FFP, platelets – coagulopathy, plt <50 or plt dysfunction
• Trend H/H q6 hours
• NPO
Triage
• Rockall Score (most commonly used) to help triage
Score 0
Score 1
Score 2
Age
<60
60-79
>80
Shock
None
Pulse >100
SBP <100
Major
Comorbidity
None
Cardiac Failure,
Ischemic Heart
Disease, similar
major morbidity
Evidence of
bleeding
None
Blood, adherent
clot, spurting vessel
Diagnosis
Mallory-Weiss tear,
but no major lesions
and no stigmata of
recent bleed
Other nonmalignant
gastrointestinal
diagnoses
Score < 3 carries good prognosis
Score >8 carries high risk of mortality
Upper
gastrointestinal
tract malignancy
Score 3
Renal failure, liver
failure, metastatic
cancer
Medications
• PPI
•
•
Protonix 80mg IV bolus, then 8mg/hr infusion
Studies have shown that intermittent PPI boluses are
noninferior to bolus followed by infusion
• Avoid NSAIDs, ASA, anticoagulants,
antiplatelets
Suspected variceal
bleeding/cirrhosis
• Somatostatin analogues
• Octreotide 50mcg IV bolus, then 50mcg/hr infusion
• Antibiotics
• Most common regimen is Ceftriaxone (1 g/day) x5-7
days
• Can switch to Norfloxacin PO upon discharge
Triage
No
Floors
Yes
ICU
Hemodynamically
unstable? Active
bleeding?
Protonix
Assessment &
Resuscitation
(vitals, exam, labs,
stabilization, IV
fluids, transfusion)
Medications
Octreotide
If variceal
bleeding/cirrhosis:
GI Consult
NPO
Antibiotics
Clinical Scenario
• 67 yo M with medical history significant for HTN
and osteoarthritis who presents to the ED with 3
episodes of coffee–ground emesis today.
• Denies previous episodes of hematemesis. No
history of liver disease or coagulopathy. Denies
any abdominal pain, melena, hematochezia,
lightheadedness or dizziness.
• Surgeries: None
• Social:
• Occasionally uses EtOH on weekends.
• No other tobacco or illicit drug use.
• Medications: HCTZ, Lisinopril, and Ibuprofen PRN
for joint pain
• Allergies: None
Physical exam
• Vital Signs on arrival:
•
•
•
•
•
•
• T 98.9, HR 102, BP 108/72 (lying), 106/68 (standing) , Pox
99% on RA
General: AAOx3, conversant
HEENT: NC/AT, no scleral icterus, conjunctiva pink.
CV: Tachycardic, no m/r/g
Lungs: CTAB
Abdomen: soft, non-tender, non-distended, no HSM
Rectal: dark brown stool present, +guaiac
Labs
•
•
•
•
WBC 7.8, Hgb 9.8, Plt 245
PT 12, INR 1.0,
AST 20, ALT 17, ALP 50, Albumin 3.7, TP 7, Bili 0.6
BUN 28, Cr 1.4
Clinical Scenario
• What is the likely etiology of the bleeding?
• Where should the patient be triaged?
• What is the appropriate acute management?
Take-Home Points
 Obtain a good history
 Triage to ICU vs Wards
 Contact GI immediately
 Exam and diagnostic data
 Emergent management
 ABCs, two large bore peripheral IVs, fluid resuscitation,
possible transfusion
 PPI
 If you suspect variceal bleed/cirrhosis, add somatostatin
analogue and empiric antibiotics
References
• Saltzman J, Feldman M. (2015, November 12) Approach to acute upper
gastrointestinal bleeding in adults. Retrieved from www.uptodate.com.
• Srygley F, Gerardo CJ, Tran T, Fisher DA. Does This Patient Have a Severe
Upper Gastrointestinal Bleed?. JAMA.2012;307(10):1072-1079.
• 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):1755-1762.
• Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute
upper gastrointestinal bleeding. N Engl J Med.2013;368(1):11-21.
• MKSAP 17