Upper GI Bleed Flashcards
UGIB Causes
PEPTIC ULCER DISEASE EROSIVE GASTRITIS AND ESOPHAGITIS ESOPHAGEAL AND GASTRIC VARICES MALLORY-WEISS SYNDROME DIEULAFOY LESIONS OTHER CAUSES Arteriovenous malformation and malignancy are other causes of UGI hemorrhage. Significant bleeding from ear, nose, and throat sources can also masquerade as GI hemorrhage. An aortoenteric fistula secondary to a preexisting aortic graft is an unusual but important cause of bleeding to keep in mind. Classically, this presents as a self-limited “herald” bleed with hematemesis or hematochezia, which precedes massive hemorrhage and exsanguination.
UGIB Hx taking
HISTORY
-Ask about hematemesis, coffee-ground emesis, or melena.
-Classically, hematemesis and coffee-ground emesis suggest a UGI source.
-The presence of melena and age <50 years old more likely indicate an upper GI bleed versus a lower GI bleed, even in patients without hematemesis.
- Vomiting and retching, followed by hematemesis, suggest a Mallory-Weiss tear.
- Be sure to ask about prior episodes of GI bleeding and any interventions performed.
- A history of an aortic graft should suggest bleeding from an aortoenteric fistula.
- Review the patient’s medication list carefully. Salicylates, glucocorticoids, NSAIDs, and anticoagulants all place the patient at high risk for GI bleed.
- Alcohol abuse is strongly associated with a number of causes of bleeding, including peptic ulcer disease, erosive gastritis, and esophageal varices.
-Ingestion of iron or bismuth can simulate melena. Liquid medications with red dye, as well as certain foods, such as beets, can simulate hematochezia. In such cases, stool guaiac testing will be negative. Inquire about past history of GI bleeding, even though recurrent bleeding episodes may originate from different sources.
UGIB Physical Exam
Check that vom. out
- Visual inspection of the vomitus for a bloody, maroon, or coffee-ground appearance is the most reliable way to diagnose UGI bleeding in the ED.
- Vital signs may reveal obvious hypotension and tachycardia or more subtle findings such as decreased pulse pressure or tachypnea.
- Rectal oh joy. Perform rectal examination to detect the presence of blood and its appearance, whether bright red, maroon, or melanotic.
UGIB Labs
- if theyre profusely bleeding youre obvi gettig type and screen in case you need to transfuse
- CBC
- Lactate
-BUN..wil be elevated through igestion and absorptio of hemoglobin. A BUN:creatinine ratio ≥30 suggests a UGI source of bleeding.
- CMP
- Coags
- LFT UGI hemorrhage will elevate
- ECG-Silent cardiac or mesenteric ischemia can develop if bleeding decreases cardiac or mesenteric perfusion.
-A single elevated lactate level is a sentinel sign of severe illness.
The success or failure of resuscitation efforts can be assessed by following dynamic lactate levels, because a rising lactate level in the hospital setting is a clear predictor of in-hospital mortality.
If endoscopy is unavailable, you have another option…
In cases where traditional endoscopy is unavailable or endoscopic visualization is unable to find the source, consider tagged red-cell scintigraphy or visceral angiography. Both of these tests will demonstrate the source only in cases of active bleeding. Scintigraphy and angiography help localize the source of bleeding to determine whether medical or surgical management is optimal.
NG Lavage
NG intubation and aspiration are diagnostic and therapeutic.19 In patients without a history of hematemesis, a positive aspirate provides strong evidence for a UGI source of bleeding. High-risk lesions are more likely in patients with bloody aspirates.
Visual inspection of the aspirate for a bloody, maroon, or coffee-ground appearance is the most reliable way to diagnose UGI bleeding in the ED.
Tx of UGIB
Treatment of Upper GI Bleed
TreatmentDoseComments
Blood transfusionTransfuse if ≤7 grams/dL in most; ≤9 grams/dL in older patients or patients with comorbidities
Correct coagulopathyCorrect if INR is elevated or platelets <50,000; or if bleeding severe, correct coagulopathy unless contraindications to correction (e.g., stents)
Omeprazole80-milligram IV bolus then infusion of 8 milligrams/hLabeled use for ulcer bleeding
Octreotide50-microgram bolus then infusion of 25–50 micrograms/hUnlabeled use for varices; for elderly, begin at lower dose range of 25-microgram bolus and infusion of 25 micrograms/h
AntibioticsCiprofloxacin 400 milligrams IV or ceftriaxone 1 gram IVAntibiotics for cirrhotics with UGI bleeding
Endoscopy
GI endoscopy is the diagnostic study of choice. Endoscopy allows visualization of the source of bleeding (in most cases) and administration of hemostatic therapy.41 The optimal timing relates to the severity of the bleeding. Early endoscopy (within 24 hours of presentation) is recommended for most patients because it is associated with a significant cost reduction and decreased length of stay.19,20,41,42,43 An unstable patient may benefit from emergent endoscopy immediately following resuscitation.
Endoscopic treatment options commonly used for variceal bleeding include variceal ligation and sclerotherapy. Clips, thermocoagulation, and sclerosant injections alone or in combination with epinephrine injections are commonly used in ulcerative lesions.
Balloon Tamponade
Balloon tamponade is an effective short-term solution for life-threatening variceal bleeding. Because of the high rate of complications, it should be reserved for temporary stabilization of patients for transfer to an appropriate institution or until endoscopy can be done. The Sengstaken-Blakemore tube (which has a 250-cc gastric balloon, an esophageal balloon, and a single gastric suction port) (Figure 75–1) and the Minnesota tube (with an added esophageal suction port above the esophageal balloon) are examples of balloons that have been used. Adverse reactions include mucosal ulceration, esophageal or gastric rupture, asphyxiation from tracheal compression, and aspiration. Strongly consider intubation prior to balloon tamponade.
