1. Approach to Upper GI Bleeding
Julia Lee, PGY-2
March 2016
UCI Internal Medicine Residency

2. Learning Objectives Review the major causes of upper GI bleeding
Learn how to triage patients with upper GI bleeding to ICU vs floors
Understand acute management of upper GI bleeding

3. Esophagogastric varices
Major Causes
Cause
Prevalence
Peptic ulcer
33.9%
Esophagogastric varices
32.8%
Erosive esophagitis
8.1%
Mallory-Weiss tear
6.4%
Erosion
5.1%
Tumor
Esophageal ulcer
2.1%
Portal gastropathy
1.0%
Dieulafoy lesion
0.9%
Cameron lesion
0.7%
Other
2.7%
When initially evaluating patients with upper GIB, think about the major causes
-Note that the majority of causes are 2/2 PUD and esophagogastric varices
-When asking about NSAID/aspiring or anticoagulant use, try to quantify amount, frequency, duration, last use
Image: clipartpanda.com
Data: MKSAP 17

4. Characteristics of Bleeding
Hematemesis – coffee ground vs bright red blood
Bright red blood: moderate to severe bleeding
Coffee-ground emesis: slower bleed
Melena – dark, tarry, pungent
Usually due to an upper GI bleed
Can also be from the small intestine or proximal colon if it’s a slow bleed
Hematochezia – bright red blood
Usually lower GI bleed
Can be seen with massive/brisk upper GI bleeding
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
Dark, tarry, pungent
Usually due to an upper GI bleed, but can also be from the small intestine or proximal colon if it’s a slow bleed
Stool can turn black with only cc of upper GIB
Note: iron and bismuth  melanotic stool
Hematochezia
Usually bright red blood
Most often with lower GI bleed, but can be seen with massive/brisk upper GI bleeding
Note: Beets  red stool
Image: surgsoc.ucc.ie

5. Examination Vitals Abdominal examination Rectal examination
Signs of hemodynamic instability
Abdominal examination
Stigmata of liver disease
Signs of perforation
Rectal examination
NG lavage (not required for upper GIB), but can help differentiate between upper and lower GIB
-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
Assess for any masses or hemorrhoids
Skin exam looking for evidence of liver disease, such as jaundice, telangiectasias, asterixis, caput, etc.
NG lavage if unsure if bleed is upper or lower GI
Note: Guaiac positive stool
-Occult blood in stool
-Does not provide information on location
-Indicates low volume, slow bleed

6. Labs CBC, coags LFTs, albumin BUN/Cr >30
Note: Guaiac testing does not provide information in location

7. Emergent Management Monitor hemodynamic stability
Triage – ICU vs Wards
Hemodynamic instability or active bleeding -> ICU
Immediate GI consult
Two large bore IV lines (16 gauge or larger)
Bolus infusions of isotonic crystalloid
Transfusion
STAT Type and Cross
pRBCs – Hgb <7, hemodynamic instability
FFP, platelets – coagulopathy, plt <50 or plt dysfunction
Trend H/H q6 hours
NPO
What do you do now that you’ve established an upper GI bleed?
-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
-Trend H/H: you can trend more or less frequently based on clinical judgment
-NPO for scoping/procedures; keep NPO until GI clears
Image: photosearch.com

8. Triage Rockall Score (most commonly used) to help triage
<60
60-79
>80
Shock
None
Pulse >100
SBP <100
Major Comorbidity
Cardiac Failure, Ischemic Heart Disease, similar major morbidity
Renal failure, liver failure, metastatic cancer
Evidence of bleeding
Blood, adherent clot, spurting vessel
Diagnosis
Mallory-Weiss tear, but no major lesions and no stigmata of recent bleed
Other nonmalignant gastrointestinal diagnoses
Upper gastrointestinal tract malignancy
Various tools exist to help assess GI bleeding, such as:
-Rockall Score
-Identifies patients at risk of adverse outcomes/mortality following acute UPPER GIB
-Blatchford Clinical Prediction Score
-For low-risk patients with specifically UPPER GIB and possible outpatient management
-JAMA published article in 2012 concluding that Blachford score is efficient in identifying low risk patients who do not require emergent intervention
-Srygley F, Gerardo CJ, Tran T, Fisher DA. Does This Patient Have a Severe Upper Gastrointestinal Bleed?. JAMA.2012;307(10):
-BLEED Criteria
-Applied at initial emergency department evaluation and before admission
-Predicts hospital outcomes for patients with acute UPPER OR LOWER GI bleeding (not just upper GIB)
Score < 3 carries good prognosis
Score >8 carries high risk of mortality

9. Medications PPI Avoid NSAIDs, ASA, anticoagulants, antiplatelets
Protonix 80mg IV bolus, then 8mg/hr infusion
Studies have shown that intermittent PPI boluses are noninferior to bolus followed by infusion
Avoid NSAIDs, ASA, anticoagulants, antiplatelets
Acid suppression
H2 blockers have not been shown to reduce re-bleeding in PUD. Always use PPIs.
Studies have shown that intermittent bolus PPI is noninferior to the traditional bolus followed by infusion.
Sachar H, Vaidya K, Laine L. Intermittent vs Continuous Proton Pump Inhibitor Therapy for High-Risk Bleeding Ulcers: A Systematic Review and Meta-analysis. JAMA Intern Med.2014;174(11): doi: /jamainternmed
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  (splanchnic circulation)
Antibiotics:
Bacterial infections are present in up to 20% of patients with cirrhosis who are hospitalized with gastrointestinal bleeding; up to an additional 50% develop an infection while hospitalized
Reduces variceal rebleeding, infection and mortality in patients with cirrhosis +/- ascites
Most common regimen is Ceftriaxone
Can also use Ciprofloxacin, but there is a high rate of FQ resistance

10. Suspected variceal bleeding/cirrhosis
Somatostatin analogues
Octreotide 50mcg IV bolus, then 50mcg/hr infusion
Antibiotics
Most common regimen is Ceftriaxone (1 g/day) x5-7 days
Can switch to Norfloxacin PO upon discharge

11. Assessment & Resuscitation (vitals, exam, labs, stabilization, IV fluids, transfusion)
Triage
Hemodynamically unstable? Active bleeding?
Floors
ICU
Medications
Protonix
If variceal bleeding/cirrhosis:
Octreotide
Antibiotics
GI Consult
NPO No
Yes

12. Clinical Scenario
67 yo M with medical history significant for HTN and osteoarthritis who presents to the ED with 3 episodes of coffee–ground emesis today.
Denies previous episodes of hematemesis. No history of liver disease or coagulopathy. Denies any abdominal pain, melena, hematochezia, lightheadedness or dizziness.
Surgeries: None
Social:
Occasionally uses EtOH on weekends.
No other tobacco or illicit drug use.
Medications: HCTZ, Lisinopril, and Ibuprofen PRN for joint pain
Allergies: None

13. Physical exam Vital Signs on arrival: General: AAOx3, conversant
T 98.9, HR 102, BP 108/72 (lying), 106/68 (standing) , Pox 99% on RA
General: AAOx3, conversant
HEENT: NC/AT, no scleral icterus, conjunctiva pink.
CV: Tachycardic, no m/r/g
Lungs: CTAB
Abdomen: soft, non-tender, non-distended, no HSM
Rectal: dark brown stool present, +guaiac

14. Labs
WBC 7.8, Hgb 9.8, Plt 245
PT 12, INR 1.0,
AST 20, ALT 17, ALP 50, Albumin 3.7, TP 7, Bili 0.6
BUN 28, Cr 1.4
-What stands out about these labs?
Hgb low at 9.8
Coags are WNL
Liver panel WNL
BUN and Cr are elevated
Image: alibaba.com

15. Clinical Scenario What is the likely etiology of the bleeding?
Where should the patient be triaged?
What is the appropriate acute management?
What is the likely etiology of the bleeding?
Suspect peptic ulcer disease or gastritis due to NSAID
Where should the patient be triaged?
Medicine Wards: no signs of active bleeding, tachycardia improved with IVFs, no orthostasis
What is the appropriate acute management?
Airway stabilization, 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
Image:

16. Take-Home Points Obtain a good history Triage to ICU vs Wards
Contact GI immediately
Exam and diagnostic data
Emergent management
ABCs, two large bore peripheral IVs, fluid resuscitation, possible transfusion
PPI
If you suspect variceal bleed/cirrhosis, add somatostatin analogue and empiric antibiotics

17. References
Saltzman J, Feldman M. (2015, November 12) Approach to acute upper gastrointestinal bleeding in adults. Retrieved from
Srygley F, Gerardo CJ, Tran T, Fisher DA. Does This Patient Have a Severe Upper Gastrointestinal Bleed?. JAMA.2012;307(10):
Sachar H, Vaidya K, Laine L. Intermittent vs Continuous Proton Pump Inhibitor Therapy for High-Risk Bleeding Ulcers: A Systematic Review and Meta-analysis. JAMA Intern Med.2014;174(11):
Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med.2013;368(1):11-21.
MKSAP 17