1. Upper GI Bleed Leigh Vaughan, MD Division of Hospital Medicine
General Internal Medicine and Geriatrics, MUSC

2. Objectives
Identify common causes for acute gastrointestinal bleeding in the hospitalized patient
Describe clinical presentation and appropriate evaluation of patients with an acute upper GI bleed
Outline appropriate resuscitative measures for the patient with consideration given to co- morbid illnesses
Delineate high risk patients who may need more aggressive intervention or level of care

3. Key Messages
The history and physical are essential to identifying the cause of an acute GI bleed
Physical exam and laboratory data can assess the severity of illness and the likelihood of clinical decompensation
Initial and rapid stabilization with IV fluids and blood products followed by intensive monitoring are the mainstays of resuscitation efforts

4. Causes Upper GI Bleed Peptic ulcer disease Gastritis
Esophagogastric varices
Arteriovenous malformation
Tumor
Mallory-Weiss (esophageal) tears

5. Initial evaluation History Physical examination Laboratory tests
Assess the severity of the bleed
Identify potential sources of the bleed

6. History – Pertinent points
HPI
Inquire about hematemesis
Coffee ground emesis suggests limited bleed
BRBPR  suggests faster bleed
Melena- tarry black stools*
Clots in stool less likely upper GI bleed
PMHx
Prior GI bleed- 60 % patients with a history of prior GI bleed, rebleed from same cause
H. pylori status
Relevant comorbidities
Prior surgeries that may have affected anatomy
Social history
Prior smoking
Alcohol use
*Only takes a small amount of blood to get melena (50cc)
Coffee ground emesis & melena- both suggest bleed is proximal to ligament of Treitz.

7. History -continued Family history Medications Coagulopathy
Congenital disorders with AV malformation
Medications
ASA, NSAID
Pill esophagitis- bisphosphonates, doxycycline, KCl, quinidine, iron
Anticoagulants
Bismuth, iron- darken stool

8. Physical Exam – Pertinent findings
Assessing clinical stability
Resting tachycardia suggests mild to moderate volume loss
Orthostatic hypotension  suggests blood volume loss of at least 15%
Supine hypotension  indicates blood volume loss of at least 40%
Involuntary guarding consider perforation
Stigmata of liver disease
Skin manifestations of systemic disorders (such as petechiae or telangiectasia) that may predispose to gastrointestinal bleeding
Rectal exam

9. Finding that may correlate with etiology
RUQ pain, epigastric discomfortPUD
Dysphagia, odynophagia, GERD esophageal ulcer
Retching, cough that precedes emesis Mallory Weiss tear
Weight loss, early satiety, cachexia cancer

10. Workup & laboratory, Nasogastric lavage- not uniformly recommended
Assess ongoing bleeding
Confirm upper GI bleed as source
Identify those who might benefit from an early endoscopy
Type and cross
CBC, serum chemistries, liver tests, and coagulation studies
Elevated BUN: linear correlation with likelihood of source of bleed being upper GI
Other labs depending on clinical scenario (LFT, alb)
Serial EKG’s and cardiac enzymes
Once stable, all patients should undergo H. Pylori testing

11. Interpretation of data
Initial Hgb in acute bleed- likely reflects baseline (no time to drop)
Check Hgb q 2-8 depending on clinical scenario
Over resuscitation can falsely dilute Hgb
Normocytic anemia most expected type in acute GI bleed; microcytic anemia suggests chronic bleed

12. Risk stratification tools
Multiple validated models -Blatchford and Rockall
Many include endoscopic data (which not available at presentation)
Poor prognostic indicators: age, shock, comorbidities, Hgb, need for blood, sepsis, BUN, Cr., AST, high APACHE score
AIM 65 - each risk factor gets a point, endpoints mortality & hospital stay
Album <3.0, INR >1.5, altered mental status, SBP < 90mmHg, age > 65
Zero risk factors conveys 0.3% chance of death during hospitalization. 5 risk factors 31.8 % chance of death during hospitalization
Saltzman JR, Tabak YP,. Gastrointest Endosc. 2011;74(6):1215.
Always look at tools’ endpoints and purpose. Is it to establish who could safely be discharged? Likelihood of mortality? Who needs higher level of care?

13. Who needs ICU? & Why?
 All patients with hemodynamic instability (shock, orthostatic hypotension)
All patients with active bleeding (hematemesis, BRB per nasogastric tube, or hematochezia)
Resuscitation and close observation
Monitoring blood pressure, pulse oximetry, urine output
Electrocardiogram monitoring

14. Management – volume resuscitation
Fluid resuscitation with 2 large bore IVs
Bolus (not only hourly drip) of isotonic crystalloid
Consideration for invasive hemodynamic monitoring
Packed RBCs – revised transfusion criteria:
Hemodynamic instability, despite fluid resuscitation
Hgb < 8 high risk patient, intolerant to anemia (CAD, Pulmonary HTN, Pulmonary disease)
Hgb < 7 in low risk patient
Overall data supportive of restrictive transfusion if early endoscopy available
Every 4 u PRBC’s necessitates unit of FFP
Barkun AN, Bardou M, Kuipers EJ, et al., Ann Intern Med. 2010; 152(2):101
Carson JL, et al., Ann Intern Med 2012;157:49-58

15. Management NPO O2 supplement Correction of coagulopathy
INR > 1.5  FFP (not vit K acutely)
Platelets < 50,000 transfusion
Recent use of ASA/ antiplatelet agent- indication for platelet transfusion in massive bleed 2/2 induced platelet dysfunction
Empiric IV PPI (Omeprazole IV 80 bolus, plus hourly infusion)- until etiology established
Provide appropriate nutritional support
Assess aspiration risk, need for intubation
Early GI/ IR/ surgery involvement

16. Confounding variables
Beware of over zealous fluid resuscitation in CHF, renal disease
Avoid over transfusion in variceal bleed- do not exceed Hgb >10g/dL
Esophageal varices, cirrhosis
IV somatostatin bolus, followed by hourly infusion
Broad spectrum antibiotics* - 20% patients have concurrent infection, 50% develop infection during hospital course
Various studies using flouroquinolones, cephalosporins. No consensus on duration or spectrum of pathogens covered.

17. Anticoagulation & active bleed
Do NOT delay endoscopy-moderately anticoagulated (INRs of ) success rates are comparable to those not anticoagulated
INR > 3.0 urgent reversal prior to endoscopy
Attempt to lower below when possible
No reversal agent for direct thrombin inhibitors or Factor Xa inhibitors

18. Invasive tests, studies
Endoscopy- #1 tool, used early (24 hr)
Can locate bleed
Can achieve hemostasis
Can prevent rebleed
Requires hemodynamic stability
Patients likely get erythromycin (as prokinetic) prior to procedure in severe bleed
Tagged red cell
Angiography
NO GI barium- contraindicated

19. Who can be discharged quickly & safely?
Reliable patient with good follow-up Favorable factors Few comorbidities Negative NG aspirate Hemodynamic stablility Normal labs (Hgb, BUN, Cr.) Likely source of bleed identified (from endoscopy or other modality) Absence of factors associated with rebleed (variceal bleeding, active bleeding, bleeding from a Dieulafoy's lesion, or ulcer bleeding with high-risk stigmata)

20. Discharge medications
All decisions predicated on favorable risk benefit analysis
Resumption of warfarin after bleed
Many risk stratification tools (HAS-BLED, ATRIA)
If risk/benefit ratio favors resuming, wait 4 days after bleed
Patients who require NSAIDS - PPI with a cyclooxygenase-2 inhibitor can reduce, not prevent, rebleed
Discharge in cardiac patients requiring ASA- ASA +PPI may be resumed in 7 days
Most patients should receive a single Rx for daily dosing of PPI; duration should be determined by cause of bleed

21. References
Barkun AN, Bardou M, Kuipers EJ. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152(2):101.
The role of endoscopy in the management of acute non- variceal upper GI bleeding. Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy. Gastrointest Endosc. 2012;75(6):1132.
Laine L, Jensen DM. Management of patients with ulcer bleeding. Am J Gastroenterol Mar;107(3):345-60; quiz 361. Epub 2012 Feb 07.
Carson JL, Grossman BJ, Kleinman S, et al. Red blood cell transfusion: a clinical practice guideline from the AABB. Ann Intern Med 2012;157:49-58