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Managing Upper GI Bleeds

Managing Upper GI Bleeds. Prepared by Shane Barclay MD. What the endoscopist sees. What we see. Objectives. 1. Learn causes and various characteristics of upper GI bleeds. 2. Learn appropriate workup and treatment of upper GI bleeds.

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Managing Upper GI Bleeds

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  1. Managing Upper GI Bleeds Prepared by Shane Barclay MD

  2. What the endoscopist sees

  3. What we see

  4. Objectives • 1. Learn causes and various characteristics of upper GI bleeds. • 2. Learn appropriate workup and treatment of upper GI bleeds. • 3. Review intubating the unstable upper GI bleed.

  5. Outline • Definition and causes • Clinical characteristics • Laboratory investigations • Treatment • Intubating the unstable upper GI bleed

  6. Definition of Upper GI Bleeding • Bleeding that originates from the GI tract proximal to the Ligament of Treitz.

  7. Outline • Causes of upper GI bleeding • Clinical characteristics/Evaluation • Laboratory investigations • Treatment • Intubating the unstable upper GI bleed

  8. Causes • Peptic ulcer 35-50% • Esophagitis 20-30% • Esophageal varices 5-10% • Arteriovenous malformations 2-3% • Tumor 2-5% • Esophageal Tear 2-5%

  9. Mortality • 10 – 14% • This figure has not changed in over 50 years! • Majority of these are over 60 years of age.

  10. Outline • Definition and causes • Clinical characteristics/Evaluation • Laboratory investigations • Treatment • Intubating the unstable upper GI bleed

  11. Initial Evaluation • Most patients will present with hematemesis and/or melena. • The history and physical exam may give clues as to the source. • However the first priority is to assess the severity of the bleed and co-morbidities that may affect management and outcome.

  12. Initial Evaluation • The presence of hematemesis (red blood) suggests acute upper GI bleeding. • Coffee ground emesis only suggests more limited bleeding. • Melena can be seen with as little as 50 ml blood loss from anywhere in the GI tract. • Therefore melena is not a major predictor of bleeding severity (nor specific site).

  13. Initial Evaluation • Hematochezia is usually due to lower GI bleeding. • However if it is present from a known upper GI bleed, it usually indicates a massive upper GI bleed and is often associated with cardiovascular deterioration.

  14. Initial Evaluation • Pertinent Past Medical History: • Liver disease – varices or portal hypertension • History of AAA or aortic graft – Aorto-enteric fistula • Renal disease, aortic stenosis – angiodysplasia • History of NASIDS, H pylori – peptic ulcer

  15. Initial Evaluation • Comorbid conditions that affect management: • CAD, pulmonary disease – may need earlier transfusions. • Renal disease, heart failure – may need less fluids and close monitoring. • Coagulopathies, hepatic disease – may need Fresh Frozen plasma or platelets. • Dementia, hepatic encephalopathies – may aspirate. May need to be intubated.

  16. Outline • Define causes • Clinical characteristics • Laboratory investigations • Treatment • Intubating the unstable upper GI bleed

  17. Laboratory Evaluation • Initial Hg may not be that low. Do serial Hg. • With time however, influx of extravascular fluid will dilute the Hg. This also occurs with IV fluid administration. • Patients should have CBC, full electrolytes, troponin, BUN, Creat, INR, Type X-M , ECGs.

  18. Laboratory Evaluation • Blood is absorbed in the small bowel, causing an elevated BUN and increased BUN-to-Creatinine ratio. (> 100:1) • Causes of increased BUN/Creat ratio • Upper GI bleed • Dehydration/Prerenal failure • Corticosteroids • Protein rich diet • Severe catabolic state

  19. Outline • Define causes • Clinical characteristics • Laboratory investigations • Treatment/Management • Intubating the unstable upper GI bleed

  20. Management • 1. Oxygen. • 2. Large bore IV x 2. • 3. Vitals, monitors. • 4. Treat hypotension with normal saline. • 5. NG tubes – only indicated for clearing the stomach prior to endoscopy OR if trying to establish if bleeding is upper or lower GI, OR prior to intubation. • Are not contraindicated in upper GI bleeding.

  21. Management • 6. Transfuse if: • Hemodynamically unstable despite N/S • Hg < 90 in high risk (CAD, elderly) • Hg < 70 low risk • 7. PPI • pantoprazole 40 mg IV bid

  22. Management • 8. If Variceal bleed or cirrhosis • Octreotide 50 mcg IV bolus. • Then 50 mcg/hour IV infusion. • Ceftriaxone 2 gm • Note: Octreotide is NOT recommended for routine upper GI bleeding. May be of value with variceal bleeds or cirrhosis. Consult gastroenterologist.

  23. Management • 9. Active bleeding and low platelets and/or an INR > 1.2 should ideally receive platelets and Fresh Frozen Plasma respectively. • However often in small rural hospitals, neither of these is available so this is rather academic.

  24. Management • 10. Tranexamic acid: NO benefit has been found with regard to bleeding, need for surgery or transfusion UNLESS endoscopy is not available. • Again, consult gastroenterologist on call.

  25. Outline • Define causes • Clinical characteristics • Laboratory investigations • Treatment • Intubating the unstable upper GI bleed

  26. Intubating the Unstable Upper GI Bleed But I’m off call in 10 minutes!

  27. Intubating the Unstable Upper GI Bleed Patient • 1. Goggles or better yet, full face mask. • 2. Place NG tube to empty stomach • 3. Consider Metoclopramide 10 mg IV • 4. Elevate head of bed 45 degrees • 5. If they vomit place in Trendelenburg • 6. Pre-oxygenate with mask x 3 min. Do not bag.

  28. Intubating the Unstable Upper GI Bleed Patient • 7. Have all your RSI equipment ready (use RSI checklist) • 8. Meds – use ketamine 1 mg/kg (1/2 dose) • Rocuronium (1.2 mg/kg) (may help increase lower esophageal sphincter tone) • 9. If patient does aspirate, no need for antibiotics. However if bleed cause was varices, the patient may already have gotten an antibiotic.

  29. Intubating the Unstable Upper GI Bleed Patient • 10. If patient does aspirate, beware of sepsis - like hypotension. Have pressors ready. • 11. Try to intubate the first time! Use video laryngoscope • 12. Good Luck!

  30. Scenario • 61 year old male with known alcoholism and history of CAD (stent x 2 2013). Smokes 1ppd. • Presents with 3-4 hour history of vomiting bright red blood. • He states he hasn’t been drinking for a week now, due to nausea and feeling ‘flu like’. • Meds: • Ramipril 5 mg (hasn’t taken for a week) • Metoprolol 25 mg bid (stopped a month ago) • Atorvastatin 20 mg (hasn’t taken for – can’t remember) • ASA 81 mg (takes occasionally)

  31. Scenario • Patient looks pale and unwell. • Front of shirt is blood stained. • BP 105/55 (normal 145/85), HR 130 • Sats 92% RA • Exam: • Chest is clear, skin has stigmata of alcoholism. • Heart sounds normal. • Abdomen is diffusely tender. • Rectal exam is negative for occult blood.

  32. Scenario • RN has tried 3 IV sites with no success. • He has oxygen nasal prongs on at 5 l/m. • What are you going to do? Besides that!

  33. Summary Managing Upper GI Bleed • 1. ABCDE • 2. Labs – CBC, Na, K, Ca, Mg, troponin, BUN, Creat, ECG, CXR, INR, Type X-M. • 3. Normal Saline • 4. NG tube IF clearing stomach for Intubation or endoscopy, OR if trying to determine if bleeding is upper or lower site. • 5. Transfuse if Hg < 90 in high risk (CAD, elderly) • Hg < 70 in low risk • 6. Pantoprazole 40 mg IV • 7. If Variceal bleed or Cirrhosis • Octreotide 50 mcg IV bolus then 50 mcg/hr infusion • Ceftriaxone 2 gm IV

  34. Summary Managing Upper GI Bleed • If need for Intubation: • Eye protection • Place NG tube • Metoclopramide 10 mg IV • Elevate head of bed 30-45 degrees • Pre-oxygenate with mask at 15 L/m x 3 minutes • RSI checklist • Ketamine 1 mg/Kg • Rocuronium 1.2 mg/Kg • Have push dose pressor ready

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