Upper gastrointestinal bleeding resident survival guide: Difference between revisions

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{{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 endocopy<br> ❑ Discharge after 3 days if no re-bleeding occurs</div>}}
{{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>}}
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{{familytree | | | | | | | F01 | | | | | | | | | | | | | | | | | | | | | | | | |F01=If '''re-bleeding''' occurs clinically}}
{{familytree | | | | | | | F01 | | | | | | | | | | | | | | | | | | | | | | | | |F01=If '''re-bleeding''' occurs clinically}}
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{{familytree | | | | | I01 | | I02 | | | | | | | | | | | | | | | | | | | | | | |I01=Surgery<br>[[Arterial embolization]]|I02= IV PPI therapy for 72 hours<br> Oral therapy thereafter }}
{{familytree | | | | | I01 | | I02 | | | | | | | | | | | | | | | | | | | | | | |I01=Surgery<br>[[Arterial embolization]]|I02= IV PPI therapy for 72 hours<br> Oral therapy thereafter }}
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==Long Term Prevention of UGIB Recurrence==
==Long Term Prevention of UGIB Recurrence==
{{familytree/start |summary=PE diagnosis Algorithm.}}
{{familytree | | A01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |A01= Patient treated for UGIB }}
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{{familytree | | B01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |B01=<div style="float: left; text-align: left; height: 10em; width: 20em; padding:1em;"> ❑ Test for [[H. Pylori]]<br>
: * Endoscopic biopsy based test for H. Pylori<br>
: * If biopsy is negative, confirm with a non endoscopic [[H. Pylori]] test<br> </div> }}
{{familytree | | |!| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | }}
{{familytree | | C01 | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |C01= Treat with [[Helicobacter pylori#Treatment of infection|H. Pylori eradication therapy]]}}
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==References==
==References==

Revision as of 18:34, 27 January 2014


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

Definition

Upper GI bleed refers to any bleeding occurring from 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.

Any cause leading to severe gastrointestinal bleeding can be life threatening without immediate appropriate management.

Common Causes

Initial Assessment and Management

Shown below is an algorithm summarizing the approach to [[disease name]].

 
 
 
 
 
 
 
 
 
 
 
Characterize the symptoms:

❑ Blood in vomiting
❑ Coffee ground emesis
❑ Black, tarry stools
❑ Frank blood in stools
❑ Maroon colored stool
Abdominal pain
Altered mental status
Dizziness
Syncope
Palpitations

Elicit past medical history about previous GI bleed, anticoagulants, NSAIDs, alcohol intake and other comorbities
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Physical examination

Abdominal examination


Abdominal tenderness
❑ Involuntary guarding
❑ Bowel sounds

Hyperactive: Suggests UGIB
Hypoactive: Suggests mesenteric ischemia or ileus

Signs of liver failure
Rectal exam to assess stool color
Guaiac test


Signs of hypovolemia:


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

❑ Ensure normal breathing and clear airway

Consider intubation in patients with ongoing massive bleeding
❑ Assess hemodynamic status
❑ Monitor vital signs
Cardiac monitoring
❑ Assess mental status
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Risk assessment
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Patient is unstable and/or massive active bleeding
and/or altered mental status
 
Patient is stable
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Consider admission to ICU after urgent initial resuscitation

Initial resuscitative measures


Nil per oral
❑ 2 large bore IV lines
❑ Supplemental oxygen
❑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 in patients with Hb < 7 g/dL
❑ Cardiac monitoring in ICU
Pulse oximetry
❑ Monitor urine output


❑ Order a surgical consult
 

❑ Initial fluid resuscitation

Blatchford score = 0 ?


Blatchford Score = 0 if:


Urea Nitrogen < 18.2 mg/dl
Hemoglobin < 13.2 g/dL (12 g/dL for women)
Systolic blood pressure > 110 mmHg
Pulse <100/min
❑ Absence of melena, cardiac failure, syncope and liver disease

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
No
 
Yes
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Discharge from emergency room without endoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Prepare patient for early endoscopy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Endoscopic Management

 
 
 
 
 
 
Pre-endoscopic medications:

❑ Administer IV infusion of erythromycin (250 mg for 30 min)
❑ Consider IV PPI therapy (80 mg bolus followed by 8 mg/h infusion


Patients with suspected varices
❑ Refer Varices and variceal bleed resident survival guide

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
EGD
 
 
Variceal bleed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non variceal bleed
 
 
Refer variceal bleed
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ 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)
* Epinephrin injection PLUS thermal therapy or sclerotherapy or clips
* Clips

❑IV PPI therapy

* 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
 
❑ No endoscopic therapy
❑ Oral PPI therapy (once daily)
❑ Regular diet after endoscopy

Early prompt discharge after endoscopy in following patients:


❑ Hemodynamic stability
❑ No other comorbdity
❑ Easy access to hospital
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Hospital admission for 3 days
❑ Clear liquids can be fed soon after endoscopy
❑ Discharge after 3 days if no re-bleeding occurs
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
If re-bleeding occurs clinically
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Repeat endoscopy with hemostatic therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bleeding could not be controlled?
 
Bleeding controlled
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Surgery
Arterial embolization
 
IV PPI therapy for 72 hours
Oral therapy thereafter
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Long Term Prevention of UGIB Recurrence

 
Patient treated for UGIB
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
❑ Test for H. Pylori
* Endoscopic biopsy based test for H. Pylori
* If biopsy is negative, confirm with a non endoscopic H. Pylori test
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Treat with H. Pylori eradication therapy
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

References


Template:WikiDoc Sources