Upper gastrointestinal bleeding resident survival guide

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Twinkle Singh, M.B.B.S. [2]; Rim Halaby, M.D. [3] Aditya Ganti M.B.B.S. [4]

Overview

Upper gastrointestinal (GI) bleed refers to any bleeding originating from the gastrointestinal tract proximal to ligament of Treitz.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated. Severe upper GI bleed is a life-threatening condition and must be treated as such irrespective of the causes.

Common Causes

Management

Initial Management

Shown below is an algorithm depicting the initial approach to upper GI bleed.[1][2]

 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms:
❑ Blood in vomiting
❑ Coffee ground emesis
❑ Black and tarry stools
❑ Frank blood in stools
❑ Maroon colored stool
Abdominal pain
Altered mental status
Dizziness
Syncope
Palpitations

Obtain the past medical history:
❑ Previous GI bleed
Anticoagulants use
NSAIDs use
❑ Alcohol intake
❑ Other comorbidities
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Examine the patient:

Abdominal tenderness
❑ Involuntary guarding
❑ Bowel sounds

❑ Hyperactive (suggestive of upper GI bleed)
❑ Hypoactive (suggestive of mesenteric ischemia or ileus)

Signs of liver failure
Rectal exam to assess the stool color
Guaiac test
❑ Assess mental status
Blood pressure
Pulse


Assess the hemodynamic status:[3]

Severity of blood lossSigns
Mild to moderate Resting tachycardia
15% blood lossOrthostatic hypotension
40% blood lossHypotension
ShockCold clammy extremities
Weak and thready pulse

Initiate resuscitative measures if needed:
❑ Ensure normal breathing and clear airway
❑ Consider intubation in patients with ongoing massive bleeding

Cardiac monitoring
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Order labs and tests:
Blood type and cross-match
CBC
Platelet count
Prothrombin time and INR
Liver enzymes
BUN
Creatinine
Electrolytes
❑ Order EKG and cardiac enzymes to rule out myocardial infarction in elderly patients
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Stratify the patient by their hemodynamic status
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Unstable patient and/or massive active bleeding
and/or altered mental status
 
Stable patient
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Resuscitate the patient:[3]
❑ Keep patient NPO
❑ Insert 2 large bore IV lines
❑ Administer supplemental oxygen
❑ Ensure fluid resuscitation
❑ Administer 500 ml of NS during first 30 min and simultaneously send blood sample for cross-matching
❑ Consider increasing fluid administration if blood pressure fails to rise

❑ Consider blood transfusion to target Hb ≥ 7 g/dL (higher target in case of CAD or intravascular volume depletion)
❑ Admit to ICU
❑ Monitor the urine output

❑ Request a surgical consult
 

❑ Ensure fluid resuscitation


Assess if Blatchford score is 0:
(Score is zero if the following criteria are fulfilled)

Urea Nitrogen < 18.2 mg/dl
Hemoglobin ≥ 13 g/dL (12 g/dL for women)
Systolic blood pressure ≥ 110 mmHg
Pulse <100/min
❑ Absence of melena, cardiac failure, syncope and liver disease
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
> 0
 
0
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Discharge from the emergency room without endoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Prepare patient for early endoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

BUN: Blood urea nitrogen; CAD: Coronary artery disease; CBC: Complete blood count; EKG: Electrocardiogram; Hb: Hemoglobin; ICU: Intensive care unit; INR: International normalized ratio; IV: Intravenous; GI: Gastrointestinal; NPO: Nil per os; NSAIDs: Non steroid anti-inflammatory drugs

Endoscopic Management

Shown below is algorithm depicting the endoscopic management of upper GI bleeding based on the guidelines issued by the American College of Gastroenterology (ACG).[1]

 
 
 
 
 
 
 
 
Medications before endoscopy:
❑ Consider IV infusion of erythromycin (250 mg 30 minutes prior to the endoscopy)
❑ Consider IV PPI therapy (80 mg bolus followed by 8 mg/hour infusion)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Request endoscopy:
❑ As soon as possible for stable patients, OR
❑ Within 24 hours for hemodynamically unstable patients, OR
❑ Within 12 hours for patients with tachycardia, hypotension, or bloody emesis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non variceal bleed
 
Variceal bleed
Click here for the detailed management
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Assess stigmata of recent hemorrhage
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Active spurting
❑ Oozing blood
❑ Non-bleeding visible vessel
 
❑ Adherent clot
 
❑ Clean base ulcer
❑ Flat pigmented spot
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Endoscopic therapy:
❑ Thermal therapy with bipolar electrocoagulation PLUS sclerosant injection (e.g absolute alcohol)
❑ Epinephrine injection PLUS another modality (thermal therapy or sclerotherapy or clips)
❑ Clips
❑ IV PPI therapy with 80 mg bolus followed by 8 mg/hr infusion for 72 hours
 
❑ Consider endoscopic therapy in patients with clot resistant to irrigation
❑ IV PPI therapy with 80 mg bolus followed by 8 mg/hr infusion for 72 hours
 
❑ No endoscopic therapy
❑ Oral PPI therapy (once daily)
❑ Regular diet after endoscopy
❑ Discharge hemodynamically stable patients who have no comorbidities
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Hospital admission for 3 days
❑ Clear liquids can be fed soon after endoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No re-bleeding
 
Re-bleeding
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Discharge after 3 days
 
❑ Repeat endoscopy with hemostatic therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bleeding is not controlled?
 
Bleeding is controlled
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Consider surgery, or
❑ Consider arterial embolization
 
❑ Administer IV PPI therapy for 72 hours
❑ Prescribe oral PPI therapy thereafter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

IV: Intravenous; PPI: Proton pump inhibitor

Long Term Prevention of Recurrent Ulcer Bleed

Shown below is an algorithm depicting the long term prevention of recurrent ulcer bleed based on the guidelines issued by American College of Gastroenterology (ACG).[1]

 
 
 
 
 
 
 
Determine the etiology of the upper GI bleed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
H. Pylori
 
NSAIDs
 
Aspirin
 
Idiopathic
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Test for H. Pylori
❑ Treat with H. Pylori eradication therapy
❑ Document cure of H. Pylori at > 1 month after eradication therapy is stopped
 
❑ Stop NSAIDs
❑ If NSAIDs have to be resumed, use celecoxib plus PPI therapy
❑ In patients on antithrombotics, continue PPI therapy
 
❑ Assess the indication for aspirin
 
❑ Continue daily PPI therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Primary prevention
❑ Stop aspirin
 
Secondary prevention
❑ Resume aspirin as soon as possible
❑ Start PPI
 
 
 
 

NSAIDs: Non steroidal anti-inflammatory drugs; PPI: Proton pump inhibitor

Do's

  • Rockall score (ranging from 0-7) can be used for risk assessment. Parameters included in rockall score are systolic blood pressure, pulse, age and comorbidities.
  • Administer IV proton pump inhibitors (PPI) therapy before endoscopy to decrease the number of patients with high risk of hemorrhage and patients requiring endoscopic therapy. However, PPI therapy does not affect the outcomes such as recurrent bleeding, surgery or death. If endoscopy is delayed for some reason, IV PPI therapy is indicated to decrease further bleeding.
  • Early endoscopy is strongly recommended, however patients with blood urea nitrogen<18.2 mg/dl, Hb>13.0 mg/dl in men, Hb>12.0 mg/dl in women, systolic blood pressure>110 mmHg, pulse<100beats per minute, absence of melena, syncope, cardiac failure and liver disease can be discharged without endoscopy.[1]
  • Consider endoscopy among patients with upper GI bleed within 24 hours of presentation, however in patients with tachycardia, hypotension, or bloody emesis, endoscopy should be done within 12 hours after presentation.
  • For active bleeding on endoscopy, thermal therapy or epinephrine plus a second modality are preferred over clips or sclerosant alone.[1]
  • As for the epinephrine therapy, dilute epinephrine (1:10,000 or 1:20,000 in saline) and inject it in doses of 0.5-2 ml in and around the bleeding site. Continue the injections until the active bleeding stops.
  • Test for H-pylori by an endoscopic biopsy based test for H. Pylori. If the biopsy is negative, confirm with a non endoscopic H. Pylori test.
  • Document cure of H. Pylori 1 month following the end of the eradication therapy eradication therapy by either a urea breath test, stool antigen test, or endoscopy.[1][2]

Dont's

  • Do not administer nasogastric lavage in patients with upper GI bleed for diagnosis, prognostic evaluation, visualization or therapeutic effect.[1]
  • Do not administer epinephrine therapy alone. Always combine epinephrine therapy with a second agent.
  • Do not request a repeat endoscopy for patients who have no evidence of bleeding after the endoscopic therapy.

References

  1. 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Laine L, Jensen DM (2012). "Management of patients with ulcer bleeding". Am J Gastroenterol. 107 (3): 345–60, quiz 361. doi:10.1038/ajg.2011.480. PMID 22310222.
  2. 2.0 2.1 Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M; et al. (2010). "International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding". Ann Intern Med. 152 (2): 101–13. doi:10.7326/0003-4819-152-2-201001190-00009. PMID 20083829.
  3. 3.0 3.1 Cappell MS, Friedel D (2008). "Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy". Med Clin North Am. 92 (3): 491–509, xi. doi:10.1016/j.mcna.2008.01.005. PMID 18387374.



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