Upper gastrointestinal bleeding resident survival guide
Upper gastrointestinal (GI) bleed refers to any bleeding originating from the gastrointestinal tract proximal to ligament of Treitz.
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.
- Aorto-enteric fistula
- Duodenal ulcer
- Gastric ulcer
- Mallory-Weiss tear
- Variceal bleed
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
Obtain the past medical history:
❑ Previous GI bleed
❑ Anticoagulants use
❑ NSAIDs use
❑ Alcohol intake
❑ Other comorbidities
Examine the patient:
|Stratify the patient by their hemodynamic status|
|Unstable patient and/or massive active bleeding|
and/or altered mental status
Resuscitate the patient:
❑ Keep patient NPO
❑ Insert 2 large bore IV lines
❑ Administer supplemental oxygen
❑ Ensure fluid resuscitation
❑ Ensure fluid resuscitation
❑ Assess if Blatchford score is 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
Shown below is algorithm depicting the endoscopic management of upper GI bleeding based on the guidelines issued by the American College of Gastroenterology (ACG).
|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
❑ 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
|❑ 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).
|❑ Determine the etiology of the upper GI bleed|
❑ 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
❑ Stop aspirin
❑ Resume aspirin as soon as possible
❑ Start PPI
NSAIDs: Non steroidal anti-inflammatory drugs; PPI: Proton pump inhibitor
- 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.
- 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.
- 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.
- Do not administer nasogastric lavage in patients with upper GI bleed for diagnosis, prognostic evaluation, visualization or therapeutic effect.
- 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.
- 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.
- 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.
- 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.