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

2. 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

3. 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.

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

5. 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

6. 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.

7. 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

8. 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?

9. 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

10. 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