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 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

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

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

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

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

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