Core Topic

Learning Objectives
 Review the major causes of upper GI bleeding and
important elements of the history
 Know the important elements of the physical exam
and diagnostic evaluation
 Understand acute management of upper GI bleeding
Clinical Scenario
 67 yo M with history of HTN and osteoarthritis who
presents to the ED with 3 episodes of coffee –ground
emesis today.
 No abdominal pain, melena or hematochezia. No history
of liver disease or coagulopathy, +occasional ETOH use.
 Medications include HCTZ, Lisinopril, and Ibuprofen PRN
for joint pain
 VS on arrival: T 37, HR 102, BP 108/72, similar BP standing ,
Pox 99% RA
 Examination: AOx3. No scleral icterus. Abdomen soft, non-
tender, no HSM. Rectal with dark brown stool, guiac +.
 Labs: Hgb 9.8, Plt 245, INR 1, LFTs nl, BUN 28/Cr 1.4.
Initial Evaluation
 Major causes
 Peptic ulcer, esophagogastric varices, arteriovenous
malformation, tumor, esophageal (Mallory-Weiss) tear
 Characteristics of bleeding
 Hematemesis – coffee ground vs bright red blood
 Melena
 Hematochezia
 History
 Liver disease, alcoholism, coagulopathy
 NSAID, antiplatelet or anticoagulant use
 Abdominal Surgeries
 Examination
 Vitals
 Tachycardia, hypotension
 Abdominal examination
 Significant tenderness, organomegaly, ascites
 Rectal examination
 Skin examination
 NG lavage - if source of bleeding unclear
 Diagnostic Evaluation
 Hgb/Hct, plt count, coag studies
 LFTs, albumin, BUN and creatinine
 Type and screen /type and cross
Emergent Management
 Closely monitor airway, clinical status, vital signs,
cardiac rhythm
 two large bore IV lines (16 gauge or larger)
 bolus infusions of isotonic crystalloid
 Transfusion
 pRBCs – Hgb <7, hemodynamic instability
 FFP, platelets – coagulopathy, plt <50 or plt dysfunction
 Triage – ICU vs Wards
 Hemodynamic instability or active bleeding > ICU
 Immediate GI consult
Medications
 Acid Suppression
 PPI
 Protonix 80mg IV bolus, then 8mg/hr infusion
 Esomeprazole at the same dose
 Somatostatin analogues
 Suspected variceal bleeding/cirrhosis
 Octreotide 50mcg IV bolus, then 50mcg/hr infusion
 Antibiotics
 Suspected variceal bleeding/cirrhosis
 Most common regimen is Ceftriaxone (1 g/day) for seven days
 Can switch to Norfloxacin PO upon discharge
Clinical Scenario Conclusion
 67yo M on NSAIDS with 3 episodes of coffee –ground
emesis, anemia, and tachycardia
 What is the likely etiology of the bleeding?
 What is the appropriate acute management?
Clinical Scenario Conclusion
 67yo M on NSAIDS with 3 episodes of coffee –ground
emesis, anemia, and tachycardia
 What is the likely etiology of the bleeding?
 Suspect peptic ulcer disease or gastritis

 What is the appropriate acute management?

 Airway stable, cardiac monitoring
 Two 16 gauge IVs, immediately given 1L NS bolus and
tachycardia improved
 Type and cross sent
 Protonix 80mg IV x 1, then continuous infusion of 8mg/hr
 GI consult called
 Admitted to Medicine Wards
Take Home Points
 Obtain a good history to identify potential sources of the
upper GI bleed and assess the severity of the bleed
 Exam and diagnostic data should focus on signs that
indicate the severity of blood loss, help localize the source
of the bleeding, and suggest complications (ie perforation)
 Emergent management includes ABCs, two large caliber
IVs, fluid resuscitation, possible transfusion
 All patients should be treated initially with PPI. If you
suspect variceal bleed, add somatostatin analogue and
empiric antibiotics
 Triage appropriately to ICU vs Wards, and contact GI
immediately