1. Approach to Upper Gastrointestinal Bleeding Ryan D. Madanick, MD Assistant Professor of Medicine Director, UNC GI/Hepatology Fellowship Division of Gastroenterology and Hepatology or… What to do when the nurse starts panicking

2. The 3:00 AM Bleed You are the covering intern for Med U. The nurse from 8 Bedtower calls you to say that Mrs. Johnson has just vomited blood. The nurse is panicking because she doesn’t like GI bleeds.

3. The 3:00 AM Bleed Do you: A.Say “Thanks,” and hang up the phone B.Tell her that you’re not covering Mrs. Johnson C.Call the resident or fellow cause you have no idea what to do D.Tell her you’ll be right there (after you’ve made a quick telephone assessment)

4. The 3:00 AM Bleed Your answer should no longer be: C. Call your resident cause you have no idea what to do You should have said: D. Tell her you’ll be right there (after you’ve made a quick telephone assessment)

5. Management of UGI Bleeding Step 1: The Telephone Game Step 2: At The Bedside (the makeshift ER) Step 3: Calling for Reinforcement Based on this case, we will discuss the acute management of GI bleeding. You should learn about:

6. Step One: The Telephone Game

7. The Telephone Game What do you need to know first? Vital signs Appearance (diaphoretic?) Amount of bleeding Anticoagulants?

8. The Telephone Game BP: 95/45 P: 120 Pulse ox: 93% on room air You find out that she has just vomited about 250 cc of coffee-ground material. She is somewhat uncomfortable and diaphoretic. She is hospitalized for unstable angina and is on heparin and aspirin.

9. The Telephone Game Start 2 large bore IV’s Draw STAT labs Nasogastric tube to bedside Consider: fluids, PPI, octreotide Hold anticoagulants “I’ll be right there” What should you tell the nurse?

10. Step Two: At The Bedside (the makeshift ER)

11. “While usual medical teaching focuses around the importance of an accurate history and physical, the clinical status of the patient may make rapid intervention more important than a prolonged interview and examination.” At The Bedside (the makeshift ER)

12. Do a quick survey (ie, ABC’s, general) Quick history and physical  Cardiovascular/pulmonary status (TILT?)  Abdominal exam  Rectal START TREATING THE PATIENT What do you do now? At The Bedside (the makeshift ER)

13. Your rapid assessment: Appears somewhat uncomfortable and diaphoretic Responsive and breathing normally Tachycardic with a thready pulse Mild epigastric tenderness with normoactive bowel sounds Not actively bleeding or passing melena At The Bedside (the makeshift ER)

14. Volume resuscitation Place nasogastric tube Lavage the stomach Correct coagulopathy What intervention should you do now? At The Bedside (the makeshift ER)

15. You decide to start normal saline wide open. You successfully pass the nasogastric tube and lavage with saline. The gastric contents contain clots and coffee-ground material. After a liter the lavage begins to clear and eventually you withdraw bile. The tube is pulled. At The Bedside (the makeshift ER)

16. Hypovolemic shock Certain etiologies:  Varices  Vascular-enteric fistula What are some major concerns? CALL SOMEONE IMMEDIATELY At The Bedside (the makeshift ER)

17. Step Three: Calling for Reinforcement

18. Calling for Reinforcement Call someone (resident, unit team, GI, surgeon) Assess bleeding activity Review data (chart, H&P, labs) Order (and follow) serial H/H Consider diagnostic studies What more needs to be done?

19. Calling for Reinforcement You see that her admission hemoglobin was 10.5 g/dL and her STAT result is 9.9 g/dL. Her chart review reveals that she is 65 and healthy, but presented two days ago with unstable angina. Her cardiopulmonary and renal function is relatively normal. You decide to continue NS at 150 cc/hour, and you order H/H q6h. Her BP is now 128/80 and pulse is 90. She feels much better and thanks you.

20. Calling for Reinforcement You call the GI fellow, who applauds you for managing the situation well. He schedules her for an EGD in the morning. You ask the fellow: “Shouldn’t she be scoped NOW? Should we get a bleeding scan or angiogram?”

21. Calling for Reinforcement The fellow explains that since the bleeding has stopped (probably), angiography and nuclear scintigraphy are unlikely to be positive. Endoscopy can now be safely delayed until morning, since the patient has been adequately stabilized.