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

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

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 scleral icterus. Abdomen soft, non-tender, no HSM. Rectal with dark brown stool, guiac +. Labs: Hgb 9.8, Plt 245, INR 1, LFTs nl, BUN 28/Cr 1.4.

Initial Evaluation Major causes Characteristics of bleeding History Peptic ulcer, esophagogastric varices, 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 Characteristics of Bleeding Hematemesis – suggests bleeding proximal to the ligament of Treitz. Bright red blood suggests moderate to severe bleeding that may be ongoing, coffee-ground emesis suggests slower bleed Melena – usually due to an upper GI bleed Hematochezia – most often with lower GI bleed, but can be seen with massive upper GI bleeding History Important to get a good history about factors that predispose patients to bleeding Abdominal surgeries – you can think of rare causes of bleeding, such as aorto-enteric fistula in pt with aortic aneurysm or an aortic graft or ulcers at the site of anastomoses in pts with bowel resection

Diagnostic Evaluation 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 Examination You can mention that resting tachycardia usually means mild to mod hypovolemia, while orthostatic hypotension is ~15% blood volume loss, and supine hypotension can mean ~40% blood volume loss Significant abdominal tenderness or rebound – think perforation Rectal exam can provide a clue to the location of the bleeding, but it is not very reliable Skin exam looking for evidence of liver disease, such as jaundice, telangiectasias, etc. NG lavage if unsure if bleed is upper GI

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 - First step is always ABCs. - Two large bore IVs can actually infuse more fluid faster than a central line. - Adequate resuscitation is essential prior to endoscopy or other intervention. - You will typically transfuse for a Hgb <7, active bleeding or hemodynamic instability. Consider transfusion of Hgb <10 with active cardiac ischemia.

Medications Acid Suppression Somatostatin analogues Antibiotics 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 Most common regimen is Ceftriaxone (1 g/day) for seven days Can switch to Norfloxacin PO upon discharge Acid suppression H2 blockers have not been shown to reduce re-bleeding in PUD. Always use PPIs. Protonix and Esomeprazole are the only two IV formulations available in US. Somatostatin Analogues Decrease portal venous inflow, portal pressures, azygos flow, and intravariceal pressures decrease  Antibiotics: Bacterial infections are present in up to 20 percent of patients with cirrhosis who are hospitalized with gastrointestinal bleeding; up to an additional 50 percent develop an infection while hospitalized. most common regimen is Ceftriaxone can also use Ciprofloxacin, but there is a high rate of FQ resistance

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?

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 You suspect PUD or gastritis due to NSAID use The patient is appropriately triaged to wards – No signs of active bleeding, tachycardia improved with IVFs, no orthostasis

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