Presentation on theme: "Upper GI Bleeding Upper GI Hemorrhage Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D."— Presentation transcript:
Upper GI Bleeding Upper GI Hemorrhage Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D.
Upper GI Bleeding Definitions UGIH = proximal to ligament of Treitz Hematemesis = vomiting blood - bright red or coffee- ground (typically UGI source) Melena = black tarry stool (often UGI) –Enzymatic breakdown Hematochezia = bloody stool (LGI > UGI) –Blood as cathartic agent Occult blood = UGI or LGI source
Upper GI Bleeding DDx Peptic Ulcer Disease (PUD) >50% cases Gastritis / Duodenitis (15-30%) –Subset due to NSAID use Esophageal varices from portal hypertension (10-20%) Gastric varices Mallory-Weiss tears at GE junction (5%) Esophagitis (3-5%) Malignancy (3%) Dieulafoy’s lesion (1-3%) Nasopharyngeal bleed – swallowed blood Other- aortoenteric fistula, angiodysplasia, Crohn’s, hemobilia, hemosuccus pancreaticus, AVM, watermelon stomach LGI: diverticulosis, hemorrhoids, anal fissure, UC/Crohn’s, Meckel’s,
Upper GI Bleeding Initial Evaluation Evaluate ABCs/PE: –Can the pt protect his airway? –Is the pt hemodynamically unstable? –Does the pt have adequate IV access, Foley, NGT? Resuscitate as appropriate Orders: NPO, IVF, NGT to LCWS, Foley, HOB>30, continuous pulse oximetry & telemetry Labs: type & cross, CBC, INR/PT/PTT, BMP, LFTs Additional question to ask yourself: –Does the pt require a higher level of care?
Upper GI Bleeding H&P Risk factors: age, oral anticoagulant use, h/o prior GIB, PUD, NSAID use, alcohol/tobacco use, liver disease / portal HTN, burn/trauma, severe vomiting, h/o H. pylori, GI instrumentation, AAA repair History: OPQRST, PMHx, PSHx, Meds, ALL, SHx. –Symptoms: none postural hypotension, exertional dyspnea –Coffee ground emesis (UGI) PE: remember to examine for signs of cirrhosis & portal HTN (ascites, caput medusa, rectal varices) Tests: T&C, CBC, coags, BMP, LFT, CXR/KUB
Upper GI Bleeding Management Assess magnitude of hemorrhage Place 2 large-bore IV, volume resuscitation w/ isotonic IVF. Be prepared to transfuse blood. Place NGT & lavage, place Foley –NG lavage can identify UGI Monitor for continued blood loss Start proton pump inhibitor (PPI) infusion For varices: start octreotide infusion –Reduces portal pressure, vasoconstricts
Upper GI Bleeding Sengstaken-Blakemore Tube
Upper GI Bleeding Diagnostic/Therapeutic Procedures NGT EGD - 95% diagnostic accuracy if used w/in 24 hrs –Inject sclerosing agents, vasopressin/epinephrine, electrocautery –Repeat endoscopy if needed Angiography (Diagnostic & Therapeutic) Intra-arterial vasopressin Embolization Can detect bleeding rate > 30-50mL/hr Colonoscopy Technetium labeled RBC scan –Only diagnostic & usually for occult bleeding More sensitive than angiography Can detect bleeding rate > 3-10mL/hr
Upper GI Bleeding Indications for Surgical Intervention Spontaneous resolution in 80-90% Refractory or recurrent bleeding Inability to identify bleeding source
Upper GI Bleeding Long-Term Management Test for H. pylori. Treatment = amoxicillin, clarithromycin, and PPI Limit NSAID use H2B, PPI
Upper GI Bleeding Take Home Points Start with ABCs Remember: NPO, NGT, IVF via 2 large-bore IV Resuscitate prior to intervention Evaluate UGIH with EGD > angiography, tagged RBC scan