Definition: bleeding from the gastrointestinal tract that is proximal to the ligament of Treitz

Presentation

  • Hematemesis
  • Coffee-ground emesis
  • Melena
  • Hematochezia (14% cases from UGIB)
  • Anemia
  • Hypovolemic shock

Important Historical Features

  • History of GI bleeds (rebleed at same site is common)
  • Peptic ulcer disease most common cause (Overton 2011)
  • Esophageal or Gastric Variceal Bleed
    • Heavy alcohol use (consider diagnosis of esophageal/gastric variceal bleeding)
    • Cirrhosis and known varices
  • Aspirin or NSAID use: consider esophagitis/gastritis/duodenitis
  • Extreme valsalva maneuvers: consider Mallory-Weiss Syndrome
  • Aortic or GI tract surgeries: consider aortoenteric fistulas vs. post-surgical anastomotic ulcers
  • GI neoplasms

Physical Examination:

  • Review vital signs looking for hemodynamic compromise (tachycardia, hypotension, tachypnea)
  • Look for evidence of shock: confusion, peripheral vasoconstriction
  • Hematemesis
  • Evidence of liver disease
    • Jaundice, ascites, spider angiomas, caput medusae
    • Increases risk of variceal bleeding

ED Management

  • Initial Resuscitation
    • Evaluate for evidence of hemodynamic instability
      • Clinical signs most useful
      • Hemoglobin inaccurate in acutely bleeding patient
    • Obtain large bore IV access
      • 18 gauge IV or larger at/above antecubital fossae
      • Consider placement of introducer central line
    • Replace blood loss with blood products
      • Can start with crystalloid fluids if blood not immediately available
      • Consider massive transfusion protocol as needed
    • Airway
      • Actively bleeding patients may require intubation to facilitate endoscopy or balloon tamponade
      • Patients often confused at increased aspiration risk
      • Intubation often complicated by blood airway and tenuous hemodynamics
      • Airway Considerations
        • Aggressively resuscitate prior to intubation as induction agents can cause worsening hemodynamics and apnea can cause worsening hypoxia
        • Personal protection equipment including facemark, gown, gloves
        • Pre-oxygenation
          • Positioning: Head of bed >45 degrees to increase oxygenation and decrease vomiting risk
          • Consider ketamine (1-2mg/kg IV) to facilitate cooperation with pre-oxygenation
          • Avoid BiPAP or CPAP if actively vomiting or high-risk for vomiting
        • RSI medication considerations
          • Lower dose of induction agent if patient in shock
          • Increase dose of paralytic if patient in shock (increased circulation time)
        • Have push-dose (i.e. epinephrine) and infusion vasopressors (norepinephrine) available
        • Redundant large bore suction to clear blood (see SALAD technique)
        • Consider gastric emptying
          • Nasogastric tube
          • Metoclopramide 10-20 mg IV (delayed onset)
        • Mentally prepare and low threshold for surgical airway
          • Evaluate and consider marking landmarks
    • Reverse coagulopathy + thrombocytopenia
      • Reverse coagulopathy + thrombocytopenia
        • FFP or PCCs for INR >1.6
        • Platelet goal is >50,000 if actively bleeding
      • Maintain normal body temperature to prevent worsening coagulopathy
      • If HD stable, transfuse to Hb of 7 or higher depending of evidence of end-organ dysfunction; do not over transfuse (Villaneuva, 2013)
  • Specific considerations
    • Peptic ulcer bleeding
      • Call consultants early for definitive treatment
        • Gastroenterology – endoscopy with epinephrine injection, sclerotherapy, or clipping
        • General Surgery – surgical resection and vessel ligation
        • Interventional Radiology – transarterial embolization
      • Proton Pump Inhibitor (PPI)
        • Omeprazole or esomeprazole 40 mg IV twice daily
        • Use BID doses as no added utility in infusion (Sachar 2014)
        • No effect mortality benefit but reduce stigmata of PUD during initial endoscopy
    • Variceal bleeding
      • Call consultants early for definitive treatment
        • Gastroenterology – endoscopy with banding/clipping
        • Interventional Radiology – TIPS procedure (see below)
          • Reduces portal systemic pressures shunting blood away from varices
          • Effective but often results in hepatic encephalopathy
        • General Surgery – surgical shunts, i.e. Warren distal splenorenal shunt
      • Prophylactic antibiotics:
        • 1g Ceftriazone or a fluoroquinolone (I.e. Cipro 400mg BID if cephalosporin allergy)
        • Reduces bacterial infections, mortality, and hospitalization length (Chavez-Tapia, 2011)
        • NNT = 4 for bacterial infections
        • NNT = 22 for mortality
      • Octreotide
        • 50mcg IV bolus and then drip at 50mcg/hr
        • Shunts blood away from varices by reducing splanic blood flow
      • If intubated with persistent bleeding and no immediate definitive treatment available, can try ballon tamponade (see videos for placement of Blakemore and Minnesota tubes)

Sengstaken-Blakemore Tube (www.derangedphysiology.com)

Take Home Points

  • Resuscitate early with blood and blood products to address hemodynamic instability. Remember hemoglobin will not reflect actual blood volume in acutely bleeding patient.
  • Intubate early with back-up and lots of suction after first resuscitating. Have push-dose or infusion vasopressors nearby for peri- or intra-intubation hypotension
  • Contact your consults early for definitive diagnosis and treatment as it will take time to prepare. Consultants provide definitive therapy after adequate ED resuscitation.
  • Give antibiotics to patients with confirmed or suspected cirrhosis with UGIB. Prophylactic antibiotics shown to reduce risk of SBP and mortality.

References

Chavez-Tapia NC, Barrientos-gutierrez T, Tellez-avila F, et al. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding – an updated Cochrane review. Aliment Pharmacol Ther. 2011;34(5):509-18. PMID: 21707680

Overton DT: Upper Gastrointestinal Bleeding in Tintinalli JE, Stapczynski JS, Ma OJ, Cline DM, Cydulka RK, Meckler GD, et al (eds): Tintinalli’s Emergency Medicine: A Comprehensive Guide, ed 7. McGraw Hill Companies, Inc., 2011, (Ch) 78: p 543-545.

Sachar H et al. 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 – 62. PMID: 25201154

Villanueva C, et al. Transfusion Strategies for Acute Upper Gastrointestinal Bleeding. NEJM. 368 (1): 11-21. 2013. PMID: 23281973