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Upper Gastrointestinal BleedingAka: Upper GI Bleed
- Epidemiology
- Accounts for 350,000 hospitalizations in U.S. yearly
- Risk factors
- Aspirin or NSAID use (most common cause)
- Helicobacter Pylori infection
- Elderly (especially over age 70 years)
- Acid suppression therapy does not reduce bleeding risk
- Causes: Adults with acute massive GI Bleeding
- Duodenal Ulcer (30-37%)
- Gastric Ulcer (19-24%)
- Esophageal Varices (6-10%)
- Gastritis or Duodenitis (5-10%)
- Esophagitis or esophageal ulcer (5-10%)
- Mallory-Weiss tear (3-7%)
- Gastrointestinal malignancy (1-4%)
- Dieulafoy's Lesion (1%)
- Artery at gastric fundus may bleed heavily
- Difficult to identify on endoscopy
- Gastric antral vascular ectasia (0.5 to 2%)
- Longitudinal erythematous stripes on gastric mucosa
- Known as Watermelon stomach
- Arteriovenous malformation
- Angiodysplasia of stomach or duodenum, associated with
- Causes: Adults with chronic intermittent GI Bleeding
- Gastritis (18 to 35%)
- Esophagitis (18 to 35%)
- Gastric Ulcer (18 to 21%)
- Duodenal Ulcer (3 to 15%)
- Angiodysplasia (5 to 23%)
- Gastric Cancer
- Causes: Adults - most commonly missed upper GI sources
- Large Hiatal Hernia Erosions
- Arteriovenous malformation
- Peptic Ulcer Disease
- Causes: Children
- Esophagitis
- Gastritis
- Peptic Ulcer Disease
- Esophageal Varices
- Mallory-Weiss Tear
- Signs
- Hematemesis
- Coffee-ground Emesis
- Melena
- Hematochezia (if bleeding is brisk)
- Nasogastric aspirate bloody (15% false negative)
- Elevated Renal Function tests (BUN, Serum Creatinine)
- Hyperactive Bowel Sounds
- Labs
- BUN to Creatinine ratio
- Does not reliably distinguish upper GI source
- BUN to Creatinine ratio
- Evaluation
- Management: Initial
- See Acute Gastrointestinal Bleeding Management
- Nasogastric Tube with aspirate
- Fresh blood suggests persistant bleeding
- Avoid lavage due to aspiration risk
- If severe bleeding and suspected variceal source
- See Esophageal Varices
- Octreotide 50 ug bolus, then 50 ug/hour
- Avgerinos (1995) J Hepatol 22(2):247
- Management: General Measures
- Helicobacter Pylori management
- Empiric acid reduction (Proton Pump Inhibitor)
- Not proven in-vivo to aid clotting
- No proven benefit in mortality and other outcomes
- Does not lower overall Incidence of re-bleeding
- Omeprazole may heal ulcer if near-achlorhydria
- Daneshmend (1992) BMJ 304:143
- Management: Very low risk patients
- Indications
- Hemodynamically stable with normal lab testing
- No evidence of significant bleeding in last 48 hours
- Nasogastric Tube aspirate without blood
- Protocol
- Home with follow-up within days
- General measures as above
- Indications
- Management: Low risk patients
- Indications
- Hemodynamically stable within 1 hour of Resuscitation
- Minimal Blood Products required (2 PRBC or less)
- No evidence of active bleeding
- Nasogastric Tube aspirate without blood
- No active comorbid medical conditions
- Protocol
- Consider for rapid protocol
- Immediate Upper Endoscopy Evaluation of GI Bleeding
- Discharge to home if low-risk endoscopy results
- Admit if rapid protocol not available
- Follow moderate risk patient protocol below
- General measures as above
- Consider for rapid protocol
- Indications
- Management: Moderate risk patients
- Indications
- Tachycardia persists despite Resuscitation
- Blood Products required >2 PRBC
- Active comorbid condition
- Protocol
- General measures as above
- Admit to regular medical bed
- Upper endoscopy when patient stabilized (<24 hours)
- See Upper Endoscopy Evaluation of GI Bleeding
- Disposition based on Upper Endoscopy results
- Low risk endoscopy: Observe for 24 hours
- Moderate risk endoscopy: Observe for 48-72 hours
- High risk endoscopy
- Initially observe in ICU for at least 24 hours
- Observe in hospital for 72 hours total or more
- Indications
- Management: High risk patients
- Indications
- Active ongoing bleeding
- Hypotension persists despite Resuscitation
- Severe active comorbid condition exascerbation
- Liver disease exascerbation
- Endotracheal Intubation for airway protection
- Protocol
- General measures as above
- Admit to intensive care unit for first 24 hours
- Observe in hospital for 48 to 72 hours or more
- Urgent upper endoscopy when stabilized
- Consider arteriography if source not evident
- Indications
- Management: Refractory and Recurrent Bleeding
- Indications
- Persistent or recurrent bleeding despite EGD
- See Upper Endoscopy Evaluation of GI Bleeding
- Protocol
- Surgical Intervention (e.g. gastroduodenotomy, vagotomy, ulcer resection)
- Consider embolization for non-surgical patient
- Indications
- Prognosis: Outcomes
- Overall Mortality: 2-15% (often related to comorbidity)
- Bleeding stops and does not recur: 70% (<2% Mortality)
- Bleeding after initially stopped: 25% (10% Mortality)
- Continued active bleed: 5% (30% Mortality)
- Prognosis: Predictors
- Bleeding characteristic predictors of poor outcome
- See Upper GI Bleeding Score
- Emesis or nasogastric aspirate contains red blood
- Low initial Hematocrit
- Coagulopathy (low platelets or high INR)
- Comorbid condition predictors of poor outcome
- Active Coronary Artery Disease
- Congestive Heart Failure
- Active lung disease
- Renal Failure
- Sepsis
- Metastatic cancer
- Advanced liver disease
- Advanced age
- Bleeding characteristic predictors of poor outcome
- References
