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Managing Upper GI Bleeds

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  1. Managing Upper GI Bleeds Prepared by Shane Barclay MD

  2. What the endoscopist sees

  3. What we see

  4. Objectives • 1. Learn causes and various characteristics of upper GI bleeds. • 2. Learn appropriate workup and treatment of upper GI bleeds. • 3. Review intubating the unstable upper GI bleed.

  5. Outline • Definition and causes • Clinical characteristics • Laboratory investigations • Treatment • Intubating the unstable upper GI bleed

  6. Definition of Upper GI Bleeding • Bleeding that originates from the GI tract proximal to the Ligament of Treitz.

  7. Outline • Causes of upper GI bleeding • Clinical characteristics/Evaluation • Laboratory investigations • Treatment • Intubating the unstable upper GI bleed

  8. Causes • Peptic ulcer 35-50% • Esophagitis 20-30% • Esophageal varices 5-10% • Arteriovenous malformations 2-3% • Tumor 2-5% • Esophageal Tear 2-5%

  9. Mortality • 10 – 14% • This figure has not changed in over 50 years! • Majority of these are over 60 years of age.

  10. Outline • Definition and causes • Clinical characteristics/Evaluation • Laboratory investigations • Treatment • Intubating the unstable upper GI bleed

  11. Initial Evaluation • Most patients will present with hematemesis and/or melena. • The history and physical exam may give clues as to the source. • However the first priority is to assess the severity of the bleed and co-morbidities that may affect management and outcome.

  12. Initial Evaluation • The presence of hematemesis (red blood) suggests acute upper GI bleeding. • Coffee ground emesis only suggests more limited bleeding. • Melena can be seen with as little as 50 ml blood loss from anywhere in the GI tract. • Therefore melena is not a major predictor of bleeding severity (nor specific site).

  13. Initial Evaluation • Hematochezia is usually due to lower GI bleeding. • However if it is present from a known upper GI bleed, it usually indicates a massive upper GI bleed and is often associated with cardiovascular deterioration.

  14. Initial Evaluation • Pertinent Past Medical History: • Liver disease – varices or portal hypertension • History of AAA or aortic graft – Aorto-enteric fistula • Renal disease, aortic stenosis – angiodysplasia • History of NASIDS, H pylori – peptic ulcer

  15. Initial Evaluation • Comorbid conditions that affect management: • CAD, pulmonary disease – may need earlier transfusions. • Renal disease, heart failure – may need less fluids and close monitoring. • Coagulopathies, hepatic disease – may need Fresh Frozen plasma or platelets. • Dementia, hepatic encephalopathies – may aspirate. May need to be intubated.

  16. Outline • Define causes • Clinical characteristics • Laboratory investigations • Treatment • Intubating the unstable upper GI bleed

  17. Laboratory Evaluation • Initial Hg may not be that low. Do serial Hg. • With time however, influx of extravascular fluid will dilute the Hg. This also occurs with IV fluid administration. • Patients should have CBC, full electrolytes, troponin, BUN, Creat, INR, Type X-M , ECGs.

  18. Laboratory Evaluation • Blood is absorbed in the small bowel, causing an elevated BUN and increased BUN-to-Creatinine ratio. (> 100:1) • Causes of increased BUN/Creat ratio • Upper GI bleed • Dehydration/Prerenal failure • Corticosteroids • Protein rich diet • Severe catabolic state

  19. Outline • Define causes • Clinical characteristics • Laboratory investigations • Treatment/Management • Intubating the unstable upper GI bleed

  20. Management • 1. Oxygen. • 2. Large bore IV x 2. • 3. Vitals, monitors. • 4. Treat hypotension with normal saline. • 5. NG tubes – only indicated for clearing the stomach prior to endoscopy OR if trying to establish if bleeding is upper or lower GI, OR prior to intubation. • Are not contraindicated in upper GI bleeding.

  21. Management • 6. Transfuse if: • Hemodynamically unstable despite N/S • Hg < 90 in high risk (CAD, elderly) • Hg < 70 low risk • 7. PPI • pantoprazole 40 mg IV bid

  22. Management • 8. If Variceal bleed or cirrhosis • Octreotide 50 mcg IV bolus. • Then 50 mcg/hour IV infusion. • Ceftriaxone 2 gm • Note: Octreotide is NOT recommended for routine upper GI bleeding. May be of value with variceal bleeds or cirrhosis. Consult gastroenterologist.

  23. Management • 9. Active bleeding and low platelets and/or an INR > 1.2 should ideally receive platelets and Fresh Frozen Plasma respectively. • However often in small rural hospitals, neither of these is available so this is rather academic.

  24. Management • 10. Tranexamic acid: NO benefit has been found with regard to bleeding, need for surgery or transfusion UNLESS endoscopy is not available. • Again, consult gastroenterologist on call.

  25. Outline • Define causes • Clinical characteristics • Laboratory investigations • Treatment • Intubating the unstable upper GI bleed

  26. Intubating the Unstable Upper GI Bleed But I’m off call in 10 minutes!

  27. Intubating the Unstable Upper GI Bleed Patient • 1. Goggles or better yet, full face mask. • 2. Place NG tube to empty stomach • 3. Consider Metoclopramide 10 mg IV • 4. Elevate head of bed 45 degrees • 5. If they vomit place in Trendelenburg • 6. Pre-oxygenate with mask x 3 min. Do not bag.

  28. Intubating the Unstable Upper GI Bleed Patient • 7. Have all your RSI equipment ready (use RSI checklist) • 8. Meds – use ketamine 1 mg/kg (1/2 dose) • Rocuronium (1.2 mg/kg) (may help increase lower esophageal sphincter tone) • 9. If patient does aspirate, no need for antibiotics. However if bleed cause was varices, the patient may already have gotten an antibiotic.

  29. Intubating the Unstable Upper GI Bleed Patient • 10. If patient does aspirate, beware of sepsis - like hypotension. Have pressors ready. • 11. Try to intubate the first time! Use video laryngoscope • 12. Good Luck!

  30. Scenario • 61 year old male with known alcoholism and history of CAD (stent x 2 2013). Smokes 1ppd. • Presents with 3-4 hour history of vomiting bright red blood. • He states he hasn’t been drinking for a week now, due to nausea and feeling ‘flu like’. • Meds: • Ramipril 5 mg (hasn’t taken for a week) • Metoprolol 25 mg bid (stopped a month ago) • Atorvastatin 20 mg (hasn’t taken for – can’t remember) • ASA 81 mg (takes occasionally)

  31. Scenario • Patient looks pale and unwell. • Front of shirt is blood stained. • BP 105/55 (normal 145/85), HR 130 • Sats 92% RA • Exam: • Chest is clear, skin has stigmata of alcoholism. • Heart sounds normal. • Abdomen is diffusely tender. • Rectal exam is negative for occult blood.

  32. Scenario • RN has tried 3 IV sites with no success. • He has oxygen nasal prongs on at 5 l/m. • What are you going to do? Besides that!

  33. Summary Managing Upper GI Bleed • 1. ABCDE • 2. Labs – CBC, Na, K, Ca, Mg, troponin, BUN, Creat, ECG, CXR, INR, Type X-M. • 3. Normal Saline • 4. NG tube IF clearing stomach for Intubation or endoscopy, OR if trying to determine if bleeding is upper or lower site. • 5. Transfuse if Hg < 90 in high risk (CAD, elderly) • Hg < 70 in low risk • 6. Pantoprazole 40 mg IV • 7. If Variceal bleed or Cirrhosis • Octreotide 50 mcg IV bolus then 50 mcg/hr infusion • Ceftriaxone 2 gm IV

  34. Summary Managing Upper GI Bleed • If need for Intubation: • Eye protection • Place NG tube • Metoclopramide 10 mg IV • Elevate head of bed 30-45 degrees • Pre-oxygenate with mask at 15 L/m x 3 minutes • RSI checklist • Ketamine 1 mg/Kg • Rocuronium 1.2 mg/Kg • Have push dose pressor ready

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