Undifferentiated upper gastrointestinal bleeding
Background
- Bleeding originating proximal to ligament of Treitz
- In the acute setting, the hemoglobin/hematocrit may be normal until dilutional anemia appears after volume resuscitation
- Older patients -> peptic ulcer disease, esophagitis, gastritis; younger patients -> Mallory-Weiss tears, GI varices, gastropathy
Mortality[1]
- Peptic ulcer disease = 4%
- Variceal bleeding = 50%
Risk Factors
- Medications
- ASA, steroids, anticoagulants, chemotherapeutic agents
- NSAIDs[2]
- RR of bleeding for COX-1 inhibitors is 4.5 (3.82-5.31)
- RR of bleeding for COX-2 inhibitors is 1.88 (0.96-3.71)
- ETOH abuse
- Aortic graft = aortoenteric fistula
- Advanced age (>60 yr)
- Current smoker
Prehospital
- Airway: suction to prevent aspiration, provide oxygen as needed
- Breathing: maintain patient in position of comfort
- Circulation: monitor for early signs of shock and provide fluid resuscitation if hypotensive. Blood products should be individualized based on local protocols
- Antiemetics can be given to decrease nausea and vomiting
- Assume the patient is hepatitis positive and wear appropriate personal protective gear
Clinical Features
History
- Hematemesis
- Coffee-ground emesis
- Vomiting + retching followed by hematemesis is more likely Mallory-Weiss (esophageal)
- Melena
- Syncope or presyncope
- Dyspepsia, epigastric pain or heartburn
Physical Exam
- Tachycardia, hypotension
- Normal vital signs do not preclude the possibility of a severe bleed
- Altered mental status -> poor cerebral perfusion
- Pallor
- In the stable patient may indicate the anemia of a subacute/chronic bleed, in the unstable patient may indicate poor perfusion and massive blood loss
- Liver disease
- Spider angiomata, palmar erythema, jaundice, gynecomastia, hepatomegaly, ascites
- Coagulopathy
- ENT exam
- Swallowed blood may result in coffee-ground emesis or melena
- Rectal exam
- Only 20% of patients with a positive fecal occult have an identified upper GI bleed.[3]
Differential Diagnosis
Upper gastrointestinal bleeding
- Peptic ulcer disease (most common cause)
- Gastritis/esophagitis
- Gastric/esophageal varices
- Mallory-Weiss tear
- Malignancy
- Aortoenteric fisulta
- Boerhaave
- Dieulafoy's lesion
- Angiodysplasia
- Hemobilia
- Hemorrhagic gastritis, EtOH
- Celiac disease
- Dengue
- Other intrabdominal bleeds
- Lower GI bleeding
- Hemorrhagic pancreatitis
- Splenic rupture
- Subcapsular cavernous hemangiomas
- Peliosis hepatis
Mimics of GI Bleeding
- Hemoptysis
- Vaginal/Urethra bleeding
- ENT bleeding
- Dietary (Iron, bismuth, beets)
- Swallowed maternal blood (in neonate)
Evaluation
Workup
- 2 large bore IVs (or sheath introducer)
- Type and cross
- CBC & serial hemoglobin
- Chemistry
- BUN/creatinine >30 suggests UGI if no history of renal failure (increased absorption/digestion of hb)
- Coags
- LFTs
- Fibrinogen
- Guiac
- More useful for diagnosing chronic occult bleeding (it could be positive for up to 2 weeks after an acute bleed)
- False-positive: vitamin C, red meat, methylene blue, bromide preparations, turnips, horseradish
- ECG (if >40 yo or if suspicious for silent MI, especially from demand ischemia)
- CXR (if suspect perforation)
NG Lavage Controversy
- Pros[4]
- Positive aspirate proves strong evidence for an upper GI source of bleeding
- Can assess presence of ongoing active bleeding
- Can prepare patient for endoscopy
- Cons[4]
- Uncomfortable
- Negative aspirate does not conclusively exclude upper GI source
- Provides useful information in only minority of patients without hematemesis
- Erythromycin 200mg IV can provide equal endoscopy conditions as lavage[5]
Diagnosis
- Endoscopy frequently required for definitive diagnosis of underlying etiology
Management
Resuscitation
- Place 2 large bore IVs (or sheath introducer/rapid infusion catheter) and monitor airway status
- Crystalloid IVF can be used for initial resuscitation but should be limited due to the dilutional anemia and coagulopathy that can result (i.e. IV fluid use in non-compressible hemorrhage)
Medications
Proton pump inhibitor
- Pantoprazole or esomeprazole 80mg x 1; then 8mg/hr
Antibiotics
For short-term prophylaxis against SBP and bacteremia[10]
- Ceftriaxone 1gm daily x 7 days (first line)[11]
- OR ciprofloxacin IV or PO 500mg BID x7 days
- Indicated for:
- Patients with cirrhosis or history of ETOH abuse (regardless of whether bleeding is variceal or not)
- Prior to endoscopy or as soon as possible after endoscopy
Other Medications
- Consider octreotide (50 mcg IV bolus, then 50 mcg/hr continuous, maintained at 2-5 days in patients with concern for variceal bleeding)[12]
- Consider vasopressin
- 0.4 unit bolus, then infuse at 0.4 - 1 unit/min[13]
- Give with IV nitroglycerin at 10 - 50 mcg/min to bolster portal hypotension and reduce vasopressin systemic effects[14]
- Associated with many vasoconstrictive complications to include peripheral necrosis, dysrhythmias, myocardial ischemia [15]
- Terlipressin (analog of vasopressin, available outside U.S.)
- Alternative to vasopressin with mortality benefit
- Given as 2mg IV q4 hrs, then decrease to 1mg IV q4 hrs until bleeding stops[16]
- tranexamic acid (TXA) initially thought to help, NNT = 30, no one harmed[17]; but HALT-IT trial RCT[18] found it did not reduce death from GI bleeding[19]
Blood products
Packed red blood cell transfusion
Indications:
- Hemoglobin <7 g/dl
- In hemodynamically stable patients, the goal transfusion threshold should be 7 g/dl; NICE guidelines recommend avoidance of over-transfusion[20]
- Continued active bleeding
- Failure to improve perfusion and vital signs after infusion of 2L NS
- Known varicele bleeding[21]
Other Blood Products
Consider initiating massive transfusion protocol
- Prothrombin complex concentrates[22]
- Cryoprecipitate to raise fibrinogen (goal >120mg/dL)
- Platelets (goal >50-100k/μL)
- FFP can be used to correct anticoagulated patients, but is not indicated in cirrhotics with variceal bleeding[23]
- Monitor for hypocalcemia
Other Interventions
Balloon tamponade (e.g., Sengstaken-Blakemore or Minnesota Tubes)
For life-threatening hemorrhage if endoscopy is not available
- Adverse reactions are frequent:
- Mucosal ulceration
- Esophageal/gastric rupture
- Tracheal compression (consider intubation prior to balloon insertion)
Endoscopy
Should be performed at the discretion of the gastroenterologist; within 12 hrs for variceal bleeding[24]
- Early endoscopy does not necessarily improve clinical outcomes[25]
- Consider erythromycin 3mg/kg IV over 20-30min, 30-90min prior to endoscopy
- Achieves endoscopy conditions equal to lavage[26]
Intubation
Protection of airway from massive aspiration, especially prior to endoscopy; does not protect against pneumonia or cardiopulmonary events[27]
- NO CHRISTMAS[28]
Have bed-side push-dose pressors on hand
- NGT (salem sump to remove stomach contents)
- Varices not contraindication to NGT
- Consider metoclopramide 10mg IV
- Increases tone of lower esophageal sphincter[29]
- Good pre-Oxygenation critical
- Chest and HOB elevation to 45 degrees - consider intubating from 45 degrees to prevent gastric contents coming up
- RSI - consider halving sedation dosages for lost blood volume
- Etomidate or ketamine for sedation
- Succinylcholine and vecuronium increases LES tone
- Intubation with strong chance for first pass
- Slow and gentle BVM breaths at 10 breaths/min if first pass fails
- Trendelenberg if vomiting, keeping emesis out of lungs (have many suctions available before this happens)
- Meconium aspirator may be hooked up to ETT for large bore suction
- Antibiotics not needed in early phase of aspiration
- Chemical pneumonitis in first 24 hours, not bacterial pneumonia
- Early antibiotics may predispose patient to resistant bacterial superinfection
- SIRS-like response often occurs from aspiration, but otherwise not sepsis if there is no other concerning source or suspicion
- May require pressors and fluids
- Consider withholding early antibiotics, but doing the rest of the sepsis treatments
Disposition
Admission
- Anyone with a Glasgow-Blatchford Bleeding Score above 0 (see discharge section below); consider the clinical Rockall risk score too[30]
- Age >60yr
- Transfusion required
Consider Discharge
If Glasgow-Blatchford Bleeding Score of 0 (<1% chance of requiring intervention):[31]. Must meet ALL of the following:
- BUN <18
- hemoglobin >13 (men), hemoglobin >12 (women)
- Systemic BP >110
- Heart rate <100
- Patient did NOT present with melena
- Patient did NOT present with syncope
- No hepatic disease
- No cardiac failure
See Also
Gastrointestinal Bleeding Pages
- Adults
- Pediatrics
References
- ↑ Kumar R, Mills AM. GI Bleeding. EM Clin N Am. 2011; 29:239-52.
- ↑ Gonzalez ELM et al. Variability among NSAIDs in risk of upper GI bleeding. Arthritis & Rheumatism. 2010; 62(6): 1592-1601.
- ↑ Allard J et al. Gastroscopy following a positive fecal occult blood test and negative colonoscopy: systematic review and guideline. Can J Gastroenterol.2010;24(2):113-120.
- ↑ 4.0 4.1 Aljebreen AM et al. Nasogastric aspirate predicts high-risk endoscopic lesions in patients with acute upper-GI bleeding. Gastrointest Endosc. 2004;59(2):172-178.
- ↑ Huang ES et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc. 2011;74(5):971-980.
- ↑ Sachar H, Vaidya K, Laine L. Intermittent vs continuous proton pump inhibitor therapy for high-risk bleeding ulcers: a systematic review and meta-analysis. JAMA Intern Med. 2014;174(11):1755.
- ↑ Leontiadis GI et al. Proton pump inhibitor treatment for acute peptic ulcer bleeding. Cochrane Database Syst Rev. 2004(3):CD002094.
- ↑ Sreedharan A et al. Proton Pump Inhibitor Treatment Initiated Prior to Endoscopic Diagnosis in Upper Gastrointestinal Bleeding (Review). Cochrane Database Syst Rev 2010; (7): CD005415. PMID: 20614440
- ↑ Singh M. Proton pump inhibitors (PPIs) given for acute peptic ulcer bleeding 2013; bleeding/
- ↑ Lee YY et al. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol. 2014 Feb 21; 20(7): 1790–1796.
- ↑ Fernandez J, Ruiz dA, Gomez C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology. 2006;131:1049–1056.
- ↑ Augustin S et al. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol. 2010 Jul 27; 2(7): 261–274.
- ↑ Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.
- ↑ Tsai YT, Lay CS, Lai KH, et al. Controlled trial of vasopressin plus nitroglycerin vs. vasopressin alone in the treatment of bleeding esophageal varices. Hepatology 1986; 6:406.
- ↑ GI Bleeding: An Evidence-Based ED Approach. EB Medicine. http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=75&seg_id=1507
- ↑ Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.
- ↑ Beyda, R., & Johari, D. (2019). Tranexamic acid for upper gastrointestinal bleeding. Academic Emergency Medicine. 2019 Oct;26(10):1181-1182
- ↑ Roberts I et al. HALT-IT - tranexamic acid for the treatment of gastrointestinal bleeding: study protocol for a randomised controlled trial. Trials. 2014; 15: 450.
- ↑ The HALT-IT Trial Collaborators. (2020). Effects of a high-dose 24-h infusion of transexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020; 395:1927-36
- ↑ Dworzynski K et al. Management of acute upper gastrointestinal bleeding: summary of NICE guidance. BMJ. 2012;344:e3412.
- ↑ Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
- ↑ Makris M, et al. Warfarin anticoagulation reversal: management of the asymptomatic and bleeding patient. J Thromb Thrombolysis. 2010; 28:171–181.
- ↑ Intagliata NM, et al. Management of disordered hemostasis and coagulation in patients with cirrhosis. Clinical Liver Disease. 2014; 3(6):114-117.
- ↑ Kim YD. Management of acute variceal bleeding. Clin Endosc. 2014; 47(4):308–314.
- ↑ Sarin N et al. Time to endoscopy and out- comes in upper gastrointestinal bleeding. Can J Gastroenterol. 2009;23(7):489-493.
- ↑ Pateron D, et al. Erythromycin infusion or gastric lavage for upper gastrointestinal bleeding: a multicenter randomized controlled trial. Ann Emerg Med. 2011; 57(6):582-589.
- ↑ Rudolph SJ et al. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest Endosc. 2003 Jan;57(1):58-61.
- ↑ Weingart S. EMCrit Podcast 5 – Intubating the Critical GI Bleeder. June 2009. http://emcrit.org/podcasts/intubating-gi-bleeds/
- ↑ Mikami H, Ishimura N, Fukazawa K, et al. Effects of Metoclopramide on Esophageal Motor Activity and Esophagogastric Junction Compliance in Healthy Volunteers. J Neurogastroenterol Motil. 2016;22(1):112-117. doi:10.5056/jnm15130
- ↑ Tacke F, Fiedler K, Trautwein C. A simple clinical score pre- dicts high risk for upper gastrointestinal hemorrhages from varices in patients with chronic liver disease. Scand J Gastro- enterol. 2007;42(3):374-382.
- ↑ Tacke F, Fiedler K, Trautwein C. A simple clinical score pre- dicts high risk for upper gastrointestinal hemorrhages from varices in patients with chronic liver disease. Scand J Gastro- enterol. 2007;42(3):374-382.