Upper gastrointestinal bleeding resident survival guide: Difference between revisions

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{{WikiDoc CMG}}; {{AE}} {{TS}}
{{WikiDoc CMG}}; {{AE}} {{TS}}; {{Rim}} {{ADG}}


==Definition==
==Overview==
Upper gastrointestinal (GI) bleed refers to any bleeding originating from the gastrointestinal tract proximal to [[ligament of Treitz]].
Upper gastrointestinal (GI) bleed refers to any bleeding originating from the gastrointestinal tract proximal to [[ligament of Treitz]].


==Causes==
==Causes==
===Life Threatening 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.
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.
 
* [[Variceal bleed]]
* [[Ulcer|Perforated ulcer]]
* [[Fistula|Aorto-enteric fistula]]
* [[Hemosuccus pancreaticus]]


===Common Causes===
===Common Causes===
* [[Angiodysplasia]]
* [[Angiodysplasia]]
* [[Fistula|Aorto-enteric fistula]]
* [[Duodenal ulcer]]
* [[Duodenal ulcer]]
* [[Duodenitis]]
* [[Duodenitis]]
Line 24: Line 20:
* [[Variceal bleed]]
* [[Variceal bleed]]


==Initial Management==
==Management==
Shown below is an algorithm summarizing the approach to upper GI bleed.
===Initial Management===
Shown below is an algorithm depicting the initial approach to upper GI bleed.<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222  }} </ref><ref name="pmid20083829">{{cite journal| author=Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M et al.| title=International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. | journal=Ann Intern Med | year= 2010 | volume= 152 | issue= 2 | pages= 101-13 | pmid=20083829 | doi=10.7326/0003-4819-152-2-201001190-00009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20083829  }} </ref>


{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | | | | | | | | A01 |A01=<div style="float: left; text-align: left; height: 25em; width: 20em; padding:1em;">'''Characterize the symptoms:'''<br>❑ Blood in [[vomiting]]<br> ❑ Coffee ground emesis<br>❑ Black and tarry stools<br>❑ Frank blood in stools<br>❑ Maroon colored stool<br>❑ [[Abdominal pain]]<br>❑ [[Altered mental status]]<br>❑ [[Dizziness]]<br>❑ [[Syncope]]<br>❑ [[Palpitations]]<br>
{{familytree | | | | | | | | | | | | A01 |A01=<div style="float: left; text-align: left; height: 25em; width: 20em; padding:1em;">'''Characterize the symptoms:'''<br>❑ Blood in [[vomiting]]<br> ❑ Coffee ground emesis<br>❑ Black and tarry stools<br>❑ Frank blood in stools<br>❑ Maroon colored stool<br>❑ [[Abdominal pain]]<br>❑ [[Altered mental status]]<br>❑ [[Dizziness]]<br>❑ [[Syncope]]<br>❑ [[Palpitations]]<br>
----
----
'''Inquire about the past medical history:'''<br> ❑ Previous GI bleed <br>❑ [[Anticoagulants]] use <br> ❑ [[NSAIDs]] use <br> ❑ Alcohol intake <br> ❑ Other comorbities </div>}}
'''Obtain the past medical history:'''<br> ❑ Previous GI bleed <br>❑ [[Anticoagulants]] use <br> ❑ [[NSAIDs]] use <br> ❑ Alcohol intake <br> ❑ Other comorbidities </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | B01=<div style="float: left; text-align: left; height: 41em; width: 27em; padding:1em;">'''Examine the patient:'''<br>
{{familytree | | | | | | | | | | | | B01 | | | | | | | | | | | | | | | | | | | | | | | | B01=<div style="float: left; text-align: left; height: 45em; width: 27em; padding:1em;">'''Examine the patient:'''<br>
'''Abdominal examination'''
❑ [[Abdominal tenderness]]<br>❑ Involuntary [[guarding]]<br>
❑ [[Abdominal tenderness]]<br>❑ Involuntary [[guarding]]<br>
❑ Bowel sounds<br>
❑ Bowel sounds<br>
:❑ Hyperactive: Suggests UGIB<br>
:❑ Hyperactive (suggestive of upper GI bleed)<br>
:❑ Hypoactive: Suggests mesenteric ischemia or ileus<br>
:❑ Hypoactive (suggestive of [[mesenteric ischemia]] or [[ileus]])<br>
❑ [[Cirrhosis physical examination|Signs of liver failure]]<br>❑ [[Rectal exam]] to assess the stool color<br>❑ [[Guaiac test]]<br>❑ [[Blood pressure]]<br>❑ [[Pulse]]<br>
❑ [[Cirrhosis physical examination|Signs of liver failure]]<br>❑ [[Rectal exam]] to assess the stool color<br>❑ [[Guaiac test]]<br>
❑ Assess [[mental status]]<br> ❑ [[Blood pressure]]<br>❑ [[Pulse]]<br>
----
----
❑ '''Signs of hypovolemia:<ref name="pmid18387374">{{cite journal| author=Cappell MS, Friedel D| title=Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. | journal=Med Clin North Am | year= 2008 | volume= 92 | issue= 3 | pages= 491-509, xi | pmid=18387374 | doi=10.1016/j.mcna.2008.01.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18387374  }} </ref>'''<br>
❑ '''Assess the [[hemodynamic status]]:'''<ref name="pmid18387374">{{cite journal| author=Cappell MS, Friedel D| title=Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. | journal=Med Clin North Am | year= 2008 | volume= 92 | issue= 3 | pages= 491-509, xi | pmid=18387374 | doi=10.1016/j.mcna.2008.01.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18387374  }} </ref>'''<br>
<table class="wikitable">
<table class="wikitable">
<tr class="v-firstrow"><th>'''Severity of blood loss'''</th><th>'''Signs'''</th></tr>
<tr class="v-firstrow"><th>Severity of blood loss</th><th>Signs</th></tr>
<tr><td>Mild to moderate</td><td> Resting [[tachycardia]]</td></tr>
<tr><td>Mild to moderate</td><td> Resting [[tachycardia]]</td></tr>
<tr><td>15% blood loss</td><td>[[Orthostatic hypotension]]</td></tr>
<tr><td>15% blood loss</td><td>[[Orthostatic hypotension]]</td></tr>
<tr><td>40% blood loss</td><td>[[Hypotension]]</td></tr>
<tr><td>40% blood loss</td><td>[[Hypotension]]</td></tr>
<tr><td>[[Shock]]</td><td>Cold clammy extremities,<br> Weak and [[thready pulse]]</td></tr>
<tr><td>[[Shock]]</td><td>Cold clammy extremities<br> Weak and [[thready pulse]]</td></tr>
</table>
</table>
</div>}}
----
'''Initiate resuscitative measures if needed:'''<br>
❑ Ensure normal [[breathing]] and clear [[airway]]<br>
❑ Consider [[intubation]] in patients with ongoing massive bleeding<br>
❑ [[Cardiac monitoring]]<br></div>}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; height: 21em; width: 20em; padding:1em;">'''Order tests:'''<br>
{{familytree | | | | | | | | | | | | C01 | | | | | | | | | | | | | | | | | | | | | | | |C01=<div style="float: left; text-align: left; height: 18em; width: 20em; padding:1em;">'''Order labs and tests:'''<br>
❑ [[Blood type]] and [[cross-match]]<br>❑ [[CBC]]<br>❑ [[Platelet count]]<br>❑ [[Prothrombin time]] and [[INR]]<br> ❑ [[Liver enzymes]]<br>❑ [[BUN]]<br>❑ [[Creatinine]]<br>❑ [[Electrolytes]]<br>❑ Order [[EKG]] and [[cardiac enzymes]] to rule out [[myocardial infarction]] in elderly patients </div>}}
❑ [[Blood type]] and [[cross-match]]<br>❑ [[CBC]]<br>❑ [[Platelet count]]<br>❑ [[Prothrombin time]] and [[INR]]<br> ❑ [[Liver enzymes]]<br>❑ [[BUN]]<br>❑ [[Creatinine]]<br>❑ [[Electrolytes]]<br>❑ Order [[EKG]] and [[cardiac enzymes]] to rule out [[myocardial infarction]] in elderly patients </div>}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | D01 | | | | | | | | | | | | | | | | | | | |D01=<div style="float: left; text-align: left; height: 16em; width: 20em; padding:1em;">'''Initiate initial supportive measures:'''<br>
{{familytree | | | | | | | | | | | | F01 | | | | | | | | | | | | | | | | | | | | F01= '''Stratify the patient by their hemodynamic status'''}}
❑ Ensure normal [[breathing]] and clear [[airway]]<br>
:❑ Consider [[intubation]] in patients with ongoing massive bleeding<br>
❑ '''Assess the [[hemodynamic status]]'''<br> ❑ Monitor [[vital signs]]<br>❑ [[Cardiac monitoring]]<br>❑ Assess [[mental status]]<br></div>}}
{{familytree | | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | F01 | | | | | | | | | | | | | | | | | | | | F01= '''Risk assessment'''}}
{{familytree | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | G01 | | G02 | | | | | | | | | | | | | | | | | | G01='''Unstable patient and/or massive active bleeding<br>and/or altered mental status'''|G02='''Stable patient'''}}
{{familytree | | | | | | | | | | G01 | | G02 | | | | | | | | | | | | | | | | | | G01='''Unstable patient and/or massive active bleeding<br>and/or altered mental status'''|G02='''Stable patient'''}}
{{familytree | | | | | | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | H01 | | H02 | | | | | | | | | | | | | | | | | | H01= <div style="float: left; text-align: left; height: 32em; width: 20em; padding:1em;"> '''Resuscitate the patient:<ref name="pmid18387374">{{cite journal| author=Cappell MS, Friedel D| title=Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. | journal=Med Clin North Am | year= 2008 | volume= 92 | issue= 3 | pages= 491-509, xi | pmid=18387374 | doi=10.1016/j.mcna.2008.01.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18387374  }} </ref>''' <br>❑ Keep patient [[NPO]]<br>❑ Insert 2 large bore IV lines<br>❑ Administer supplemental oxygen<br> ❑ Ensure fluid resuscitation<br>
{{familytree | | | | | | | | | | H01 | | H02 | | | | | | | | | | | | | | | | | | H01= <div style="float: left; text-align: left; height: 28em; width: 20em; padding:1em;"> '''Resuscitate the patient:<ref name="pmid18387374">{{cite journal| author=Cappell MS, Friedel D| title=Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. | journal=Med Clin North Am | year= 2008 | volume= 92 | issue= 3 | pages= 491-509, xi | pmid=18387374 | doi=10.1016/j.mcna.2008.01.005 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18387374  }} </ref>''' <br>❑ Keep patient [[NPO]]<br>❑ Insert 2 large bore IV lines<br>❑ Administer supplemental oxygen<br> ❑ Ensure fluid resuscitation<br>
:❑  Administer 500 ml of NS during first 30 min and simultaneously send blood sample for [[cross-matching]]<br>
:❑  Administer 500 ml of NS during first 30 min and simultaneously send blood sample for [[cross-matching]]<br>
:❑  Consider increasing fluid administration if blood pressure fails to rise<br>
:❑  Consider increasing fluid administration if blood pressure fails to rise<br>
❑ Consider [[blood transfusion]] in patients with Hb < 7 g/dL<br>❑ Admit to [[ICU]]and monitor:<br>
❑ Consider [[blood transfusion]] to target Hb 7 g/dL (higher target in case of [[CAD]] or intravascular volume depletion)<br>❑ Admit to [[ICU]]<br>❑ Monitor the [[urine output]]<br>
:❑ [[Pulse oximetry]]<br>
❑ Request a '''surgical consult'''</div>| H02=<div style="float: left; text-align: left; height:30em; width: 20em; padding:1em;">
:❑ [[Urine output]]<br>
❑ Request a '''surgical consult'''</div>| H02=<div style="float: left; text-align: left; height:32em; width: 20em; padding:1em;">
❑ Ensure fluid resuscitation<br>
❑ Ensure fluid resuscitation<br>
----
----
'''Asess Blatchford score'''<br>
'''Assess if Blatchford score is 0:'''<br>
----
(Score is zero if the following criteria are fulfilled)
❑ [[Urea Nitrogen]] < 18.2 mg/dl<br>❑ [[Hemoglobin]] < 13.2 g/dL (12 g/dL for women)<br>❑ [[Systolic blood pressure]] > 110 mmHg<br>❑ [[Pulse]] <100/min<br>❑ Absence of [[melena]], [[cardiac failure]], [[syncope]] and [[liver disease]]
:❑ [[Urea Nitrogen]] < 18.2 mg/dl<br>
</div>}}
:❑ [[Hemoglobin]] 13 g/dL (12 g/dL for women)<br>
:❑ [[Systolic blood pressure]] 110 mmHg<br>
:❑ [[Pulse]] <100/min<br>
:❑ Absence of [[melena]], [[cardiac failure]], [[syncope]] and [[liver disease]]</div>}}
{{familytree | | | | | | | | | | |!| |,|-|^|-|.| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | |!| |,|-|^|-|.| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | |!| I01 | | I02 | | | | | | | | | | | | | | I01=>0|I02=0}}
{{familytree | | | | | | | | | | |!| I01 | | I02 | | | | | | | | | | | | | | I01=> 0|I02=0}}
{{familytree | | | | | | | | | | |!| |!| | | |!| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | |!| |!| | | |!| | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | |`|v|'| | | J01 | | | | | | | | | | | | | | | |J01= ❑ Discharge from emergency room without [[endoscopy]]}}
{{familytree | | | | | | | | | | |`|v|'| | | J01 | | | | | | | | | | | | | | | |J01= ❑ Discharge from the emergency room without [[endoscopy]]}}
{{familytree | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | K01 | | | | | | | | | | | | | | | | | | | | |K01=❑ Prepare patient for early [[endoscopy]]}}
{{familytree | | | | | | | | | | | K01 | | | | | | | | | | | | | | | | | | | | |K01=❑ Prepare patient for early [[endoscopy]]}}
{{familytree/end}}
{{familytree/end}}


==Endoscopic Management==
<span style="font-size:85%">'''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</span>
<br>
 
===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).<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222  }} </ref>
 
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; height: 16em; width: 20em; padding:1em;">'''Medications before endoscopy:'''<br>
{{familytree | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; height: 10em; width: 20em; padding:1em;">'''Medications before endoscopy:'''<br>
----
Consider IV infusion of [[erythromycin]] (250 mg 30 minutes prior to the endoscopy)<br>❑ Consider IV [[PPI]] therapy (80 mg bolus followed by 8 mg/hour infusion)<br> </div> }}
Administer IV infusion of [[erythromycin]] (250 mg 30 minutes prior to the endoscopy)<br>❑ Consider IV [[PPI]] therapy (80 mg bolus followed by 8 mg/hour infusion)<br> </div> }}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | Z01 | | | | | | | | | |Z01=<div style="float: left; text-align: left; width: 20em; padding:1em;">'''Request endoscopy:''' <br>❑ As soon as possible for stable patients, OR <br> ❑ Within 24 hours for hemodynamically unstable patients, OR <br>❑ Within 12 hours for patients with [[tachycardia]], [[hypotension]], or bloody emesis</div>}}
{{familytree | | | | | Z01 | | | | | | | | | |Z01='''[[EGD]]''' <br> ❑ Within 24 hours for hemodynamically unstable patients, OR <br> ❑ ASAP for stable patients}}
{{familytree | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | X01 | | X02 | | | | | | | | | | | | | | | | | |X01= '''Non variceal bleed'''| X02='''Variceal bleed''' <br> Click '''[[Varices and variceal bleed resident survival guide|here]]''' for the detailed management}}
{{familytree | | | X01 | | X02 | | | | | | | | | | | | | | | | | | | | | |X01='''Variceal bleed''' <br> Click [[Varices and variceal bleed resident survival guide|here]] for the detailed management| X02= '''Non variceal bleed'''}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | X03 | | X03= Assess stigmata of recent hemorrhage }}
{{familytree | | | | | | | X03 | | X03=Assess stigmata of recent hemorrhage }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |,|-|^|-|v|-|-|-|.| | | | | | | | | | | | | | | | }}
{{familytree | | | | | |,|-|^|-|v|-|-|-|.| | | | | | | | | | | | | | | | }}
{{familytree | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | C01 | | C02 | | C03 | | | | | | | | |C01=<div style="float: left; text-align: left; height: 10em; width: 20em; padding:1em;">❑ Active spurting<br>❑ Oozing blood<br>❑ Non-bleeding visible vessel</div>|C02= Adherent Clot|C03=<div style="float: left; text-align: left; height: 10em; width: 20em; padding:1em;">❑ Clean base ulcer<br>❑ Flat pigmented spot</div>}}
{{familytree | | | | | C01 | | C02 | | C03 | | | | | | | | |C01=<div style="float: left; text-align: left; height: 4em; width: 20em; padding:1em;">❑ Active spurting<br>❑ Oozing blood<br>❑ Non-bleeding visible vessel</div>|C02=<div style="float: left; text-align: left; height: 4em; width: 20em; padding:1em;"> ❑ Adherent clot</div>|C03=<div style="float: left; text-align: left; height: 4em; width: 20em; padding:1em;">❑ Clean base ulcer<br>❑ Flat pigmented spot</div>}}
{{familytree | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | D01 | | D02 | | D03 | | | | | | | | | | | | | | | | | | |D01=<div style="float: left; text-align: left; height: 20em; width: 20em; padding:1em;"> ❑ [[Endoscopic therapy]]:<br>
{{familytree | | | | | D01 | | D02 | | D03 | | | | | | | | | | | | | | | | | | |D01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> ❑ [[Endoscopic therapy]]:<br>
:❑  Thermal therapy with bipolar electrocoagulation PLUS [[sclerosant]] injection (e.g absolute alcohol)<br>
:❑  Thermal therapy with bipolar electrocoagulation PLUS [[sclerosant]] injection (e.g absolute alcohol)<br>
:❑  Epinephrine injection PLUS another modality (thermal therapy or [[sclerotherapy]] or clips)<br>
:❑  Epinephrine injection PLUS another modality (thermal therapy or [[sclerotherapy]] or clips)<br>
:❑ Clips<br>
:❑ Clips<br>
❑IV PPI therapy with 80 mg bolus followed by 8 mg/hr infusion for 72 hours</div> |D02=<div style="float: left; text-align: left; height: 20em; width: 20em; padding:1em;"> ❑ Consider endoscopic therapy in patients with clot resistant to irrigation<br>
❑ IV PPI therapy with 80 mg bolus followed by 8 mg/hr infusion for 72 hours</div> |D02=<div style="float: left; text-align: left; width: 20em; padding:1em;"> ❑ Consider endoscopic therapy in patients with clot resistant to irrigation<br>
❑ IV PPI therapy with 80 mg bolus followed by 8 mg/hr infusion for 72 hours</div>|D03=<div style="float: left; text-align: left; height: 20em; width: 20em; padding:1em;"> ❑ No endoscopic therapy<br>❑ Oral [[PPI]] therapy (once daily)<br> ❑ Regular diet after endoscopy<br>❑ Discharge hemodynamically stable patients who have no comorbdities</div>}}
❑ IV PPI therapy with 80 mg bolus followed by 8 mg/hr infusion for 72 hours</div>|D03=<div style="float: left; text-align: left; width: 20em; padding:1em;"> ❑ No endoscopic therapy<br>❑ Oral [[PPI]] therapy (once daily)<br> ❑ Regular diet after endoscopy<br>❑ Discharge hemodynamically stable patients who have no comorbidities</div>}}
{{familytree | | | | | |`|-|v|-|'| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |`|-|v|-|'| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | E01 | | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; height: 20em; width: 20em; padding:1em;"> ❑ Hospital admission for 3 days<br> ❑ Clear liquids can be fed soon after endoscopy<br> ❑ Discharge after 3 days if no re-bleeding occurs</div>}}
{{familytree | | | | | | | E01 | | | | | | | | | | | | | | | | | | | | | | | | |E01=<div style="float: left; text-align: left; width: 20em; padding:1em;"> ❑ Hospital admission for 3 days<br> ❑ Clear liquids can be fed soon after endoscopy</div>}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | F01 | | | | | | | | | | | | | | | | | | | | | | | | |F01=If '''re-bleeding''' occurs clinically}}
{{familytree | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | G01 | | | | | | | | | | | | | | | | | | | | | | | | |G01= Repeat endoscopy with hemostatic therapy }}
{{familytree | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | F01 | | F02 | | | | | | | | | | | | | | | | | | | | | | | | |F01= '''No re-bleeding''' | F02= '''Re-bleeding'''}}
{{familytree | | | | | H01 | | H02 | | | | | | | | | | | | | | | | | | | | | | |H01= Bleeding could not be controlled?|H02=Bleeding controlled }}
{{familytree | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | G01 | | G02 | | | | | | | | | | | | | | | | | | | | | | | G01= ❑ Discharge after 3 days| G02=❑ Repeat endoscopy with hemostatic therapy}}
{{familytree | | | | | I01 | | I02 | | | | | | | | | | | | | | | | | | | | | | |I01=Surgery<br>[[Arterial embolization]]|I02= IV PPI therapy for 72 hours<br> Oral therapy thereafter }}
{{familytree | | | | | | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | H01 | | H02 | | | | | | | | | | | | | | | | | | | | | | |H01= '''Bleeding is not controlled?'''|H02='''Bleeding is controlled''' }}
{{familytree | | | | | | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | I01 | | I02 | | | | | | | | | | | | | | | | | | | | | | |I01=<div style="float: left; text-align: left; width: 20em; padding:1em;">❑ Consider surgery, or<br>❑ Consider [[arterial embolization]] </div>|I02= <div style="float: left; text-align: left; width: 20em; padding:1em;">❑ Administer IV PPI therapy for 72 hours<br> ❑ Prescribe oral PPI therapy thereafter </div>}}
{{familytree/end}}
{{familytree/end}}
Above algorithm is adapted from guidelines issued by American College of Gastroenterology (ACG) and International consensus.<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222  }} </ref><ref name="pmid20083829">{{cite journal| author=Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M et al.| title=International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. | journal=Ann Intern Med | year= 2010 | volume= 152 | issue= 2 | pages= 101-13 | pmid=20083829 | doi=10.7326/0003-4819-152-2-201001190-00009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20083829  }} </ref>
<span style="font-size:85%">'''IV''': Intravenous; '''PPI''': Proton pump inhibitor</span>
<br>


==Long Term Prevention of Recurrent Ulcer Bleed==
===Long Term Prevention of Recurrent Ulcer Bleed===
{{familytree/start |summary=PE diagnosis Algorithm.}}
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).<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222 }}</ref>
{{familytree | | | | | | | | | | A01 | | | | | | | | | | | | | | | | | | | | | |A01=<div style="float: left; text-align: left; height:1em; width: 20em; padding:1em;"> Patient treated for UGIB</div>}}
 
{{familytree | | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree/start}}
{{familytree | | | | | | | | | | Z01 | | | | | | | | | | | | | | | | | | | |Z01=Approach to long term treatment based on different etiologies}}
{{familytree | | | | | | | | A01 | | | | | | | | | | | |A01=❑ '''Determine the etiology of the upper GI bleed'''}}
{{familytree | | | | |,|-|-|-|-|-|+|-|-|-|.| | | | | | | | | | | | | | | | | | | }}
{{familytree | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | }}
{{familytree | | | | Y01 | | | | Y02 | | Y03 | | | | | | | | | | | | | | | | Y01=[[H. Pylori]] and NSAIDs|Y02=Aspirin|Y03=<div style="float: left; text-align: left; height:1em; width: 20em; padding:1em;">Idiopathic</div>}}
{{familytree | | B01 | | B02 | | B03 | | B04 | | | B01='''[[H. Pylori]]'''|B02='''NSAIDs'''|B03='''[[Aspirin]]'''|B04='''Idiopathic'''}}
{{familytree | | | | |!| | | | | |!| | | |!| | | | | | | | | | | | | | | | | }}
{{familytree | | |!| | | |!| | | |!| | | |!| | | | }}
{{familytree | | | | B01 | | | | B02 | | B03 | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; height: 10em; width: 20em; padding:1em;"> ❑ Test for [[H. Pylori]]<br>
{{familytree | | C01 | | C02 | | C03 | | C04 | | | C01= <div style="float: left; text-align: left; height: 7em; width: 20em; padding:1em;"> ❑ Test for [[H. Pylori]]<br>
: * Endoscopic biopsy based test for H. Pylori<br>
❑ Treat with [[Helicobacter pylori#Treatment of infection|H. Pylori eradication therapy]]<br>❑ Document cure of [[H. Pylori]] at > 1 month after eradication therapy is stopped</div>
: * If biopsy is negative, confirm with a non endoscopic [[H. Pylori]] test<br> </div>|B02= Is patient taking aspirin?|B03= Continue daily [[PPI]] therapy}}
|C02=<div style="float: left; text-align: left; height: 7em; width: 20em; padding:1em;">❑ Stop NSAIDs <br> ❑ If NSAIDs have to be resumed, use celecoxib plus PPI therapy <br> ❑ In patients on antithrombotics, continue PPI therapy </div>
{{familytree | | | | |!| | | | | |!| | | | | | | | | | | | | | | | | | | | | | | }}
| C03=<div style="float: left; text-align: left; height: 7em; width: 20em; padding:1em;">❑ Assess the indication for aspirin</div>
{{familytree | | | | C01 | | | | C02 | | | | | | | | | | | | | | | | | | | | | |C01= Treat with [[Helicobacter pylori#Treatment of infection|H. Pylori eradication therapy]]|C02=Assess the indication of aspirin}}
| C04=<div style="float: left; text-align: left; height: 7em; width: 20em; padding:1em;">❑ Continue daily PPI therapy </div>}}
{{familytree | | | | |!| | | | | |!| | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | |,|-|^|-|.| | | | | | }}
{{familytree | | | | D01 | | E02 |^| E03 | | | | | | | | | | | | | | | | | | | | D01=<div style="float: left; text-align: left; height: 10em; width: 20em; padding:1em;">Document cure of H. Pylori at > 1 month after eradication therapy is stopped with following tests:<br>
{{familytree | | | | | | | | D01 | | D02 | | | | | D01= '''Primary prevention'''<br>❑ Stop aspirin| D02= '''Secondary prevention'''<br><div style="float: left; text-align: left; padding:1em;">❑ Resume aspirin as soon as possible<br>❑ Start PPI </div>}}
: * [[Endoscopy]] (if done for some other reason)<br>
: * [[Urea breath test]]<br>
: * [[Stool antigen test]]<br>
</div>||E02= Aspirin is being given for an established cardiovascular disease (for secondary prevention)?|E03=Aspirin is being given for primary prevention?}}
{{familytree | | | | |!| | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | E01 | | F03 | | F04 | | | | | | | | | | | | | | | | | | | |E01= Is patient on [[NSAID]] or antithrombotics?|F03= Resume aspirin as soon as possible and also start [[PPI]] therapy|F04=Stop aspirin}}
{{familytree | | | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | |,|-|^|-|.| | | | | | | | | | | | | | | | | | | | | | | | |}}
{{familytree | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | F01 | | F02 | | | | | | | | | | | | | | | | | | | | F01= No|F02=Yes}}
{{familytree | | |!| | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | G01 | | G02 | | | | | | | | | | | | | | | | | | | | | | | | | |G01=Stop [[PPI]] therapy|G02=<div style="float: left; text-align: left; height: 10em; width: 20em; padding:1em;">❑ Stop NSAIDs.<br>
If NSAIDs have to be resumed, use [[celecoxib]] plus [[PPI]] therapy.<br>
❑ In patients on antithrombotics, continue PPI therapy</div>}}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree/end}}
{{familytree/end}}
Above algorithm is adapted from guidelines issued by American College of Gastroenterology (ACG).<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222 }}</ref>
<span style="font-size:85%">'''NSAIDs''': Non steroidal anti-inflammatory drugs; '''PPI''': Proton pump inhibitor</span>
 
<br>


==Do's==
==Do's==
* Assess the hemodynamic status immediately upon presentation and start the appropriate resuscitation measures.
* 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.
* 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.
* 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]], [[heart failure|cardiac failure]] and liver disease can be discharged without endoscopy.<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222  }} </ref>
* 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]], [[heart failure|cardiac failure]] and liver disease can be discharged without endoscopy.<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222  }} </ref>
* Considered endoscopy among patients with upper GI bleed within 24 hours of presentation, however in patients with tachycardia, hypotension, bloody emesis should be done with in 12 hrs after presentation.
 
* For actively bleeding patents, thermal therapy or epinephrin therapy plus a second modality endoscopic therapy are recommended over clips and sclerosant therapy alone.
* 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.<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222  }} </ref>
* For active bleeding on endoscopy, thermal therapy or epinephrine plus a second modality are preferred over clips or sclerosant alone.<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222  }} </ref>
* 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.
 
* 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]].<ref name="pmid22310222">{{cite journal| author=Laine L, Jensen DM| title=Management of patients with ulcer bleeding. | journal=Am J Gastroenterol | year= 2012 | volume= 107 | issue= 3 | pages= 345-60; quiz 361 | pmid=22310222 | doi=10.1038/ajg.2011.480 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=22310222  }} </ref><ref name="pmid20083829">{{cite journal| author=Barkun AN, Bardou M, Kuipers EJ, Sung J, Hunt RH, Martel M et al.| title=International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. | journal=Ann Intern Med | year= 2010 | volume= 152 | issue= 2 | pages= 101-13 | pmid=20083829 | doi=10.7326/0003-4819-152-2-201001190-00009 | pmc= | url=http://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=20083829  }} </ref>


==Dont's==
==Dont's==

Latest revision as of 18:25, 20 March 2018

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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