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Upper GI Bleeding

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...

Give antibiotics to patients with confirmed or suspected cirrhosis with UGIB. Prophylactic antibiotics shown to reduce risk of SBP and mortality.

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 Critical Pearls for Acute Upper GI Bleeds

The dose of vasopressin for massive upper GI bleeding is NOT the same as the vasopressin replacement dosing used in sepsis. Use an infusion rate of 0.2 – 0.4 units/min IV, and titrate by doubling the dose q 30 min until bleeding stops of MAP > 65.

 No Reason Not to Use TXA for Critical GI Bleeds

Curiously, one medication has remained inexplicably absent from our routine resuscitation of the critically ill GI bleeder. Tranexamic acid, or TXA, recently championed in trauma and publicized for every bleeding source from epistaxis (EMN 2018;40[4]:1; http://bit.ly/2Qq5Iux) to abnormal uterine bleeding (EMN 2018;40[3]:5; http://bit.ly/2N7MAmW), often sits unused in the pharmacy as the blood bank is emptied and our patients deteriorate. Despite strong physiologic justification for its use and a level of clinical evidence that should sate even the strictest of EBM evangelists, TXA has yet to find permanent purchase in the GI bleed armamentarium.

 Tranexamic Acid for Upper Gastrointestinal Bleeding

1 in 30 were helped (death prevented) when compared to placebo; no one was helped when compared against antiulcer therapy. No one was harmed.

 Upper Gastro Intestinal Bleeding at St.Emlyn’s.

Peptic ulcer disease accounts for the majority of bleeds – around 40-50% of cases. This could be in the form of either a gastric ulcer or duodenal ulcer. In peptic ulcer disease, haemorrhage results from erosion into a blood vessel at the ulcer base . In patients with liver cirrhosis, increased blood flow through the portal venous system causes submucosal vessels in the oesophagus and stomach to become dilated and tortuous.

 Upper Gastrointestinal Bleeding: Evaluation, Management, and Disposition

Non-variceal UGIBs are the most common type of acute UGIB and includes peptic ulcer disease, gastroduodenal erosions, Mallory-Weiss tears, erosive esophagitis, arterio-venous malformations, Dieulafoy lesions, tumors, and malignancies.2

Articles of Interest

Management of acute upper gastrointestinal bleeding

Upper gastrointestinal bleeding is a common medical emergency worldwide and refers to bleeding from the esophagus, stomach, or duodenum. Patients present with hematemesis (bloody or coffee ground emesis) or melena, although hematochezia can occur in the context of a major bleed and is typically associated with hemodynamic instability.

Management of upper gastrointestinal bleeding emergencies: evidence-based medicine and practical considerations

Acute upper gastrointestinal (GI) bleeding remains one of the most common encounters in emergency medicine. The increased use of non-steroid anti-inflammatory drugs by the general population and the increased prescription of anti-platelet agents and anti-coagulants after cardiovascular interventions and for prevention of cerebral vascular accidents may have aggravated the situation.

Treatment of upper gastrointestinal bleeding mnemonic

The mnemonic is, "UPPER" U: Upper gi bleed P: Proton pump inhibitors like pantoprazole (And medical therapy) E: Endoscopic therapy (Banding, Tamponade, Sclerotherapy, Laser, Hemoclip, etc.) Embolization (CT angiography guided transcatheter embolization of artery) R: Resuscitation (with fluids) Ryles tube

Upper GI Bleeding in Children

Pediatricians and pediatric gastroenterologists see this problem quite regularly. It is estimated that GI bleeding accounts for 1% of all pediatric hospitalizations.

Death from GI bleeding decreased in United States in past two decades

The number of patients dying from upper gastrointestinal bleeding has decreased over the past two decades, a result researchers attribute to the advances in medical and endoscopic therapies introduced over the past 20 years.

Episode 102 GI Bleed Emergencies Part 2

In Part 2 of our two part podcast on GI Bleed Emergencies Anand Swaminathan and Salim Rezaie kick off with a discussion on the evidence for benefit of various medications in ED patients with upper GI bleed. PPIs, somatostatin analogues such as Octreotide, antibiotic prophylaxis and prokinetics have varying degrees of benefit, and we should know which ones to prioritize.

Proton pump inhibitor co-therapy reduces gastrointestinal bleeding risk of oral anticoagulants

In this cohort, rivaroxaban had the highest and apixaban had the lowest upper gastrointestinal bleeding (UGIB) risk. With PPI co-therapy, the risk of UGIB was reduced for each oral anticoagulant that was tested.

UGIB in the ED: Fresh Grounds

90% of melena (dark tarry stool due to digested blood) originates from the upper GI tract (above the ligament of Treitz). However, hematochezia (bright red or maroon blood that is fresh) can come from an upper GI source if there is a massive bleed and blood is transiting the GI tract quickly. Of course, these patients would likely present hemodynamically unstable from the rapid blood loss.

Undifferentiated upper gastrointestinal bleeding

Older patients -> peptic ulcer disease, esophagitis, gastritis; younger patients -> Mallory-Weiss tears, GI varices, gastropathy.

Upper Gastrointestinal Bleeding | Acute Management | ABCDE

This guide provides an overview of the recognition and immediate management of upper gastrointestinal bleeding (UGIB) using an ABCDE approach.

Upper Gastrointestinal Bleeding: Evidence-Based Treatment

NG lavage DOES NOT change 30 day mortality and transfusion requirements; a clear aspirate can still miss almost 15% of high risk lesions.

Upper GI Bleed with Walter Himmel

Dr. Himmel takes us through the resuscitation of a sick patient with an UGIB and the management priorities including blood products, antibiotics, TXA, octreotide, pantoprazole and endoscopy.

Weekends May Be Worse for GI Bleeding Death

A lack of endoscopy services on the weekend may be linked to a significant increase in mortality in patients with non-variceal upper gastrointestinal hemorrhage, a researcher reported...

Why Was This Teenager Bleeding So Excessively?

Usually, profuse bleeding from the mouth comes from the upper gastrointestinal tract. But when a scope was passed through her mouth and esophagus into her stomach, it did not show anything that would have caused significant bleeding.

Resources

Glasgow-Blatchford Bleeding Score (GBS)

Stratifies Upper GI bleeding patients who are 'low-risk' and candidates for outpatient management.

AlmostaDoctor

Upper GI bleeding is a major complication of Peptic ulcer disease. It occurs in 1/2000 people each year, of which ½ of these cases are due to PUD. Also remember that patients who take long term aspirin not only have increased risk of ulcer, but that they have a reduced platelet count, so if their ulcer bleeds, they are likely to lose more blood.

NICE

This clinical guideline offers evidence-based advice on the effective management of upper gastrointestinal bleeding in adults and young people aged 16 years and older.

Patient

Acute upper gastrointestinal bleeding (UGIB) is a gastroenterological emergency with a mortality of 6%-13%. Despite changes in management, mortality has not significantly improved over a period of 50 years. Bleeding from the upper gastrointestinal tract (GIT) is about four times as common as bleeding from the lower GIT.

StatPearls

For upper GI bleeds, in-hospital mortality rates are approximately 10% based on observational studies. This rate holds steady up to 1-month post-hospitalization for GI bleed. Long-term follow-up of patients with UGIB shows that at three years after admission mortality rates from all causes approach 37%.

UpToDate

Patients with acute upper gastrointestinal (GI) bleeding commonly present with hematemesis (vomiting of blood or coffee-ground-like material) and/or melena (black, tarry stools). The initial evaluation of patients with acute upper GI bleeding involves an assessment of hemodynamic stability and resuscitation if necessary. Diagnostic studies (usually endoscopy) follow, with the goal of both diagnosis, and when possible, treatment of the specific disorder.