Approach to Upper GI Bleeding

1. Approach to Upper GI Bleeding Core Topic UCI Internal Medicine Residency 2012

2. Learning Objectives • Review the major causes of upper GI bleeding and important elements of the history • Know the important elements of the physical exam and diagnostic evaluation • Understand acute management of upper GI bleeding

3. Clinical Scenario • 67 yo M with history of HTN and osteoarthritis who presents to the ED with 3 episodes of coffee –ground emesis today. • No abdominal pain, melena or hematochezia. No history of liver disease or coagulopathy, +occasional ETOH use. • Medications include HCTZ, Lisinopril, and Ibuprofen PRN for joint pain • VS on arrival: T 37, HR 102, BP 108/72, similar BP standing , Pox 99% RA • Examination: AOx3. No scleralicterus. Abdomen soft, non-tender, no HSM. Rectal with dark brown stool, guiac +. • Labs: Hgb9.8, Plt 245, INR 1, LFTs nl, BUN 28/Cr 1.4.

4. Initial Evaluation • Major causes • Peptic ulcer, esophagogastricvarices, arteriovenous malformation, tumor, esophageal (Mallory-Weiss) tear • Characteristics of bleeding • Hematemesis – coffee ground vs bright red blood • Melena • Hematochezia • History • Liver disease, alcoholism, coagulopathy • NSAID, antiplatelet or anticoagulant use • Abdominal Surgeries

5. Examination • Vitals • Tachycardia, hypotension • Abdominal examination • Significant tenderness, organomegaly, ascites • Rectal examination • Skin examination • NG lavage - if source of bleeding unclear • Diagnostic Evaluation • Hgb/Hct, plt count, coag studies • LFTs, albumin, BUN and creatinine • Type and screen /type and cross

6. Emergent Management • Closely monitor airway, clinical status, vital signs, cardiac rhythm •  two large bore IV lines (16 gauge or larger) • bolus infusions of isotonic crystalloid • Transfusion • pRBCs – Hgb <7, hemodynamic instability • FFP, platelets – coagulopathy, plt <50 or plt dysfunction • Triage – ICU vs Wards • Hemodynamic instability or active bleeding > ICU • Immediate GI consult

7. Medications • Acid Suppression • PPI • Protonix 80mg IV bolus, then 8mg/hr infusion • Esomeprazole at the same dose • Somatostatin analogues • Suspected variceal bleeding/cirrhosis • Octreotide 50mcg IV bolus, then 50mcg/hr infusion • Antibiotics • Suspected variceal bleeding/cirrhosis • Most common regimen is Ceftriaxone (1 g/day) for seven days • Can switch to Norfloxacin PO upon discharge

8. Clinical Scenario Conclusion • 67yo M on NSAIDS with 3 episodes of coffee –ground emesis, anemia, and tachycardia • What is the likely etiology of the bleeding? • What is the appropriate acute management?

9. Clinical Scenario Conclusion • 67yo M on NSAIDS with 3 episodes of coffee –ground emesis, anemia, and tachycardia • What is the likely etiology of the bleeding? • Suspect peptic ulcer disease or gastritis • What is the appropriate acute management? • Airway stable, cardiac monitoring • Two 16 gauge IVs, immediately given 1L NS bolus and tachycardia improved • Type and cross sent • Protonix 80mg IV x 1, then continuous infusion of 8mg/hr • GI consult called • Admitted to Medicine Wards

10. Take Home Points • Obtain a good history to identify potential sources of the upper GI bleed and assess the severity of the bleed • Exam and diagnostic data should focus on signs that indicate the severity of blood loss, help localize the source of the bleeding, and suggest complications (ie perforation) • Emergent management includes ABCs, two large caliber IVs, fluid resuscitation, possible transfusion • All patients should be treated initially with PPI. If you suspect variceal bleed, add somatostatin analogue and empiric antibiotics • Triage appropriately to ICU vs Wards, and contact GI immediately