1. Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D.
Upper GI Hemorrhage
Tad Kim, M.D.
Connie Lee, M.D.
Michael Hong, M.D.

2. Definitions Enzymatic breakdown UGIH = proximal to ligament of Treitz
Hematemesis = vomiting blood - bright red or coffee-ground (typically UGI source)
Melena = black tarry stool (often UGI)
Enzymatic breakdown
Hematochezia = bloody stool (LGI > UGI)
Blood as cathartic agent
Occult blood = UGI or LGI source

3. DDx Peptic Ulcer Disease (PUD) >50% cases
Gastritis / Duodenitis (15-30%)
Subset due to NSAID use
Esophageal varices from portal hypertension (10-20%)
Gastric varices
Mallory-Weiss tears at GE junction (5%)
Esophagitis (3-5%)
Malignancy (3%)
Dieulafoy’s lesion (1-3%)
Nasopharyngeal bleed – swallowed blood
Other- aortoenteric fistula, angiodysplasia, Crohn’s, hemobilia, hemosuccus pancreaticus, AVM, watermelon stomach
LGI: diverticulosis, hemorrhoids, anal fissure, UC/Crohn’s, Meckel’s,

4. Initial Evaluation Evaluate ABCs/PE: Can the pt protect his airway?
Is the pt hemodynamically unstable?
Does the pt have adequate IV access, Foley, NGT?
Resuscitate as appropriate
Orders: NPO, IVF, NGT to LCWS, Foley, HOB>30, continuous pulse oximetry & telemetry
Labs: type & cross, CBC, INR/PT/PTT, BMP, LFTs
Additional question to ask yourself:
Does the pt require a higher level of care?

5. H&P
Risk factors: age, oral anticoagulant use, h/o prior GIB, PUD, NSAID use, alcohol/tobacco use, liver disease / portal HTN, burn/trauma, severe vomiting, h/o H. pylori, GI instrumentation, AAA repair
History: OPQRST, PMHx, PSHx, Meds, ALL, SHx.
Symptoms: none  postural hypotension, exertional dyspnea
Coffee ground emesis (UGI)
PE: remember to examine for signs of cirrhosis & portal HTN (ascites, caput medusa, rectal varices)
Tests: T&C, CBC, coags, BMP, LFT, CXR/KUB

6. Management Assess magnitude of hemorrhage
Place 2 large-bore IV, volume resuscitation w/ isotonic IVF. Be prepared to transfuse blood.
Place NGT & lavage, place Foley
NG lavage can identify UGI
Monitor for continued blood loss
Start proton pump inhibitor (PPI) infusion
For varices: start octreotide infusion
Reduces portal pressure, vasoconstricts

7. Sengstaken-Blakemore Tube

8. Diagnostic/Therapeutic Procedures
NGT
EGD - 95% diagnostic accuracy if used w/in 24 hrs
Inject sclerosing agents, vasopressin/epinephrine, electrocautery
Repeat endoscopy if needed
Angiography (Diagnostic & Therapeutic)
Intra-arterial vasopressin
Embolization
Can detect bleeding rate > 30-50mL/hr
Colonoscopy
Technetium labeled RBC scan
Only diagnostic & usually for occult bleeding
More sensitive than angiography
Can detect bleeding rate > 3-10mL/hr

9. Indications for Surgical Intervention
Spontaneous resolution in 80-90%
Refractory or recurrent bleeding
Inability to identify bleeding source

10. Long-Term Management
Test for H. pylori. Treatment = amoxicillin, clarithromycin, and PPI
Limit NSAID use
H2B, PPI

11. Take Home Points Start with ABCs
Remember: NPO, NGT, IVF via 2 large-bore IV
Resuscitate prior to intervention
Evaluate UGIH with EGD > angiography, tagged RBC scan