What is the most important first step in managing a GI bleed? C.L.I.P.S. How Common is GI Bleed? Why do we care about them? 300,000 hospitalizations annually in the U.S. UGIB mortality rate 6 -10 % Massive LGIB mortality rate 4 -10% Mortality increases in the elderly, patients with hepatic and renal dysfunction, CAD and malignancies (people usually die from another complication, NOT exsanguination). How do they usually present? UGIB - hematemesis, coffee ground emesis, melena, nausea with epigastric pain, hypotension, hematochezia, AMS (in cirrhosis) LGIB – Same but typically more hematochezia. (Melena comes prior to the ligament of What are the main causes? UGIB - PUD 40-79%, Gastritis/duodenitis 5-30%, Esophageal varices 6-21%, Mallory-Weiss tear 3-15%, Esophagitis 2-8%, Gastric cancer 2-3%, Dieulafoy’s lesion <1%, AVM <1%, Portal gastropathy <1% LGIB – Large Bowel – diverticuli 17-40%, AVM 2-30%, colitis (ischemia, infectious, IBD, radiation) 9-21%, colonic neoplasms/post-polypectomy bleeding 11-14%, anorectal causes (hemorrhoids and rectal varicies) 4-10%, colonic tuberculosis LGIB – Small Bowel – angiodysplasia, jejunoileal diverticula, Meckel’s diverticulum, Neoplasms/lymphomas, enteritis, Crohn’s disease, aortoduodenal fistula in patient with synthetic vascular graft GI Bleed “fake outs?” Epistaxis, charcoal, iron, bismuth, beets What are the fundamental principles of treating GI Bleeds? Stabilize, risk stratify, predict the cause and then focus on management details What is the most important first step in managing a GI bleed? Stabilization! Updated 1/18 Stromberg

Why do we use ceftriaxone in patients with Cirrhosis and UGIBs? GI Bleed(2) C.L.I.P.S. Initial management? (Stabilize) Vitals (hypotension = 20-25% blood loss; othostatic tachycardia = 10-20%) IV Access – Isotonic Fluids NPO, stop anticoagulants. Labs – CBC, BUN, coags, T&S or cross if needed, stool guaiac, ROTEM? Blood products consider if bleeding rapidly or Hb less than 7 & 9 (in CAD) Risk Stratify MICU? Yes if hypotensive, active bleeding, or respiratory distress. Blatchford score for UGIBs can be helpful. Upper VS Lower Bleed? NG Lavage? NOT good at ruling out UGIB. Has no mortality benefit or change in LOS In one study, 11% of hematochezia was from an UGIB. What diseases do you want to identify that will change your management? In patients with cirrhosis, we add octreotide and ceftriaxone. UGIB management and their evidence? PPI – reduces rebleeding rate, LOS and transfusion. Good evidence. Octreotide – In esophageal varices: may reduce initial hemostasis failure and number of transfusions. May not reduce mortality. Ceftriaxone - Bacterial infections exist in 20% of patients admitted with UGIB and 50% develop an infection during hospitalization. Good evidence Consult GI – EGD, Tagged RBC scan? Angiography? TIPS procedure? LGIB Mgt Rule out an upper GI bleed! GI, tagged RBC scan? angiography? Push enteroscopy? Barium UGI series? Capsule endoscopy? How do I order a transfusion Adult General Transfusion Orderset BB Prepare and cross match, BB Transfuse RBCs Why do we use ceftriaxone in patients with Cirrhosis and UGIBs? Antibiotic prophylaxis may reduce mortality and bacterial infection in cirrhotic inpatients with UGIBs