1. Managing Upper GI Bleeds
LMHER January 24, 2017
Prepared by Shane Barclay

2. What the endoscopist sees

3. What we see

4. Objectives Managing Upper GI Bleeds
1. Learn causes and various characteristics. 2. Learn appropriate workup and treatment. 3. Review intubating the unstable upper GI bleed.

5. Outline
Definition and causes Clinical characteristics Laboratory investigations Treatment Intubating the unstable upper GI bleed

6. Definition of Upper GI Bleeding
Bleeding that originates from the GI tract proximal to the Ligament of Treitz.

7. Outline
Causes of upper GI bleeding Clinical characteristics/Evaluation Laboratory investigations Treatment Intubating the unstable upper GI bleed

8. Causes
Peptic ulcer 35-50% Esophagitis 20-30% Esophageal varices 5-10% Arteriovenous malformations 2-3% Tumor 2-5% Esophageal Tear 2-5%

9. Mortality
10 – 14% This figure has not changed in over 50 years! Majority of these are over 60 years of age.

10. Outline
Definition and causes Clinical characteristics/Evaluation Laboratory investigations Treatment Intubating the unstable upper GI bleed

11. Initial Evaluation
Most patients will present with hematemesis and/or melena. The history and physical exam may give clues as to the source. However the first priority is to assess the severity of the bleed and co-morbidities that may affect management and outcome.

12. Initial Evaluation
The presence of hematemesis (red blood) suggests acute upper GI bleeding. Coffee ground emesis only suggests more limited bleeding. Melena can be seen with as little as 50 ml blood loss from anywhere in the GI tract. Therefore melena is not a major predictor of bleeding severity (nor specific site).

13. Initial Evaluation
Hematochezia is usually due to lower GI bleeding. However if it is present from a known upper GI bleed, it usually indicates a massive upper GI bleed and is often associated with cardiovascular deterioration.

14. Initial Evaluation
Past Medical History: Liver disease – varices or portal hypertension History of AAA or aortic graft – Aorto-enteric fistula Renal disease, aortic stenosis – angiodysplasia History of NASIDS, H pylori – peptic ulcer

15. Initial Evaluation
Comorbid conditions that affect management: CAD, pulmonary disease – may need earlier transfusions. Renal disease, heart failure – may need less fluids and close monitoring. Coagulopathies, hepatic disease – may need Fresh Frozen plasma or platelets. Dementia, hepatic encephalopathies – may aspirate. May need to be intubated.

16. Outline
Define causes Clinical characteristics Laboratory investigations Treatment Intubating the unstable upper GI bleed

17. Laboratory Evaluation
Initial Hg may not be that low. Do serial Hg. With time however, influx of extravascular fluid will dilute the Hg. This also occurs with IV fluid administration. Patients should have CBC, full electrolytes, troponin, BUN, Creat, INR, Type X-M , ECGs.

18. Laboratory Evaluation
Blood is absorbed in the small bowel, causing an elevated BUN and increased BUN-to-Creatinine ratio. (> 100:1) Causes of increased BUN/Creat ratio Upper GI bleed Dehydration/Prerenal failure Corticosteroids Protein rich diet Severe catabolic state

19. Outline
Define causes Clinical characteristics Laboratory investigations Treatment/Management Intubating the unstable upper GI bleed

20. Management Oxygen. Large bore IV x 2. Vitals.
Treat hypotension with normal saline.
NG tubes – only indicated for clearing the stomach prior to endoscopy OR if trying to establish if bleeding is upper or lower GI, OR prior to intubation.
Are not contraindicated in upper GI bleeding.

21. Management
6. Transfuse if: Hemodynamically unstable despite N/S Hg < 90 in high risk (CAD, elderly) Hg < 70 low risk 7. PPI pantoprazole 40 mg IV bid

22. Management
8. If Variceal bleed or cirrhosis Octreotide 50 mcg IV bolus. Then 50 mcg/hour IV infusion. Ceftriaxone 2 gm Note: Octreotide is NOT recommended for routine upper GI bleeding with non-variceal bleeding. Consult gastroenterologist.

23. Management
9. Active bleeding and low platelets and/or an INR > 1.2 should ideally receive platelets and Fresh Frozen Plasma respectively. However since neither are available in our hospital this is academic.

24. Management
10. Tranexamic acid: NO benefit has been found with regard to bleeding, need for surgery or transfusion UNLESS endoscopy is not available. Again, consult gastroenterologist on call.

25. Outline
Define causes Clinical characteristics Laboratory investigations Treatment Intubating the unstable upper GI bleed

26. Intubating the Unstable Upper GI Bleed
But I’m off call
in 10 minutes!

27. Intubating the Unstable Upper GI Bleed Patient
Goggles or better yet, full face mask.
Place NG tube to empty stomach
Consider Metoclopramide 10 mg IV
Elevate head of bed 45 degrees
If they vomit place in Trendelenburg
Pre-oxygenate with mask x 3 min. Do not bag.

28. Intubating the Unstable Upper GI Bleed Patient
7. Have all your RSI equipment ready (use RSI checklist) 8. Meds – use ketamine 1 mg/kg (1/2 dose) Rocuronium (1.2 mg/kg) (may help increase lower esophageal sphincter tone) 9. If patient does aspirate, no need for antibiotics. However if bleed cause was varices, the patient may already have gotten an antibiotic.

29. Intubating the Unstable Upper GI Bleed Patient
10. If patient does aspirate, beware of sepsis - like hypotension. Have pressors ready. 11. Try to intubate the first time! Use video laryngoscope 12. Good Luck!

30. Scenario
61 year old male with known alcoholism and history of CAD (stent x ). Smokes 1ppd. Presents with 3-4 hour history of vomiting bright red blood. He states he hasn’t been drinking for a week now, due to nausea and feeling ‘flu like’. Meds: Ramipril 5 mg (hasn’t taken for a week) Metoprolol 25 mg bid (stopped a month ago) Atorvastatin 20 mg (hasn’t taken for – can’t remember) ASA 81 mg (takes occasionally)

31. Scenario
Patient looks pale and unwell. Front of shirt is blood stained. BP 105/55 (normal 145/85), HR 130 Sats 92% RA Exam: Chest is clear, skin has stigmata of alcoholism. Heart sounds normal. Abdomen is diffusely tender. Rectal exam is negative for occult blood.

32. Scenario What are you going to do?
RN has tried 3 IV sites with no success.
He has oxygen nasal prongs on at 5 l/m.
What are you going to do?
Besides that!

33. Summary Managing Upper GI Bleed
ABCDE
Labs – CBC, Na, K, Ca, Mg, troponin, BUN, Creat, ECG, CXR, INR, Type X-M.
Normal Saline
NG tube IF clearing stomach for Intubation or endoscopy, OR if trying to determine if bleeding is upper or lower site.
Transfuse if Hg < 90 in high risk (CAD, elderly)
Hg < 70 in low risk
6. Pantoprazole 40 mg IV
7. If Variceal bleed or Cirrhosis
Octreotide 50 mcg IV bolus then 50 mcg/hr infusion
Ceftriaxone 2 gm IV

34. Summary Managing Upper GI Bleed
If need for Intubation:
Eye protection
Place NG tube
Metoclopramide 10 mg IV
Elevate head of bed degrees
Pre-oxygenate with mask at 15 L/m x 3 minutes
RSI checklist
Ketamine 1 mg/Kg
Rocuronium 1.2 mg/Kg
Have push dose pressor ready