Upper GI Bleeding

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 facemask, 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)

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.

Read More

ALiEM: Upper Gastrointestinal Bleeding: Evidence-Based Treatment

Life in the Fastlane: Gastrointestinal haemorrhage

Life in the Fastlane: Intubation in Upper Gastrointestinal Haemorrhage

Emergency Medicine Cases: Episode 101 GI Bleed Emergencies Part 1

Emergency Medicine Cases: Episode 101 GI Bleed Emergencies Part 2

EMRAP HD: Placement of a Blakemore Tube for Bleeding Varices

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