1. Upper GI Bleeding Tad Kim, M.D. Connie Lee, M.D.

2. Upper GI Bleeding GIB: Definitions UGIB = proximal to ligament of Treitz Hematemesis = vomiting blood - bright red or coffee- ground (typically UGI source) Melena = black tarry stool (often UGI) Hematochezia = bloody stool (LGI > UGI) Occult blood = UGI or LGI source

3. Upper GI Bleeding UGIB: 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

4. Upper GI Bleeding Examples Dieulafoy’s lesion Gastric varices Watermelon stomach

5. Upper GI Bleeding UGIB: 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?

6. Upper GI Bleeding UGIB: H&P Risk factors: older age, male, cardiovascular disease, renal disease, DM, oral anticoagulant use, h/o prior GIB, PUD, NSAID use, tobacco use, liver disease, splenic vein thrombosis, sepsis, burn injury, severe vomiting, h/o H. pylori, GI instrumentation, trauma History: OPQRST, PMHx, PSHx, Meds, ALL, SHx. PE: remember to examine for signs of cirrhosis & portal HTN Tests: T&C, CBC, coags, BMP, LFT, CXR/KUB

7. Upper GI Bleeding UGIB: 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 Monitor for continued blood loss Start proton pump inhibitor (PPI) infusion For varices: start octreotide infusion

8. Upper GI Bleeding UGIB: Diagnostic Procedures NGT EGD - 95% diagnostic accuracy if used w/in 24 hrs Angiography (Diagnostic & Therapeutic) Intra-arterial vasopressin Embolization Can detect bleeding rate > 0.5 mL/min Technetium labeled RBC scan –Only diagnostic & usually for occult bleeding More sensitive than angiography Can detect bleeding rate > 0.1 mL/min

9. Upper GI Bleeding UGIB: Indications for Surgical Intervention Refractory or recurrent bleeding Inability to identify bleeding source

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

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