Upper GI Bleeds

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Stable UGIB

DDx:

1. PUD: most common cause. Associated with NSAID use and H.Pylori, smoking. 
2. Erosive gastritis/esophagitis: Associated with alcohol, salicylates/NSAIDs, infectious, stress from severe illness (cushings)
3. Varices: Portal HTN 
4. Mallory- Weiss Syndrome: Repetitive vomiting
5. Dieulafoy Lesion:
   1. Arteries that protrude through the GI submucosa and can cause intermittent bleeding with negative endoscopic findings. 
   2. NSAIDs and liver disease can predispose to this
6. AVMs
7. Malignancy
8. Aortoenteric fisula
9. Ischemia/perforation
10. Epistaxis/Upper airway bleed
11. Ingestions

Hx:

1. Is this really a GI bleed? 
   1. Nosebleed
   2. Ingestions (guiac card) 

1. Timing/amount
2. H/o GIB

1. If so h/o scope

1. EtoH, NSAID, Smoking hx
2. Anti-platlet /anti-coagulation history
3. Good ROS

PE: 

1. Vital signs
2. Abdominal Exam
3. Rectal Exam (guiaic)
4. S/s Liver failure
   1. Jaundice
   2. Ascites
   3. Palmar erythema
   4. Spider nevi
   5. Caput medusa
   6. Hepatomegaly/splenomegaly

Labs:

1. Hb/hct
2. CBC
3. Basic Chemistry
   1. BUN: Cr ?30 suggestive of bleed

1. Coags
2. Type and screen

Treatment:

1.  PPIs 
   1. oral (omeprazole, pantoprazole, lansoprazole) vs IV therapy. No difference
   2. Continuous vs intermittent IV PPI boluses
      1. JAMA systematic review that showed 13 different RCTs revealing no difference between gtt vs bolus in mortality, rebleeding, LOS, PRBC transfusion  
   3. PPI vs placebo
      1. No difference in mortality
      2. Reduced surgical intervention
      3. Reduced Rebleeding (NNT = 15)

1. Somatostatin (Octreotide-long acting somatostatin): 
   1. ​Decrease gastric acid, decrease blood flow to stomach/duodenum, splanchnic vasoconstriction
      
   2. 50 mcg bolus
2. Antibiotics
   1. Cirrhotic patients are innately immunocompromised -> increased risk of gut bacterial translocation
   2. 1 g Rocephin
   3. ONLY Tx that has mortality benefit with NNT = 4 to prevent an infection NNT = 22 to save a life!
3. Pro-motility agents
   1. Ertyhromycin/Azithromycin (500mg)
   2. Decreases need for second EGD
4. Transfusion     
   
   1. Threshold use to be Hbg < 9, yet theres mortality benefit with transfusion of Hbg < 7
   2. If thrombocytopenia <50k with active GIB, transfuse platelets 

Disposition:

Risk scoring systems to help risk stratify

1. Glasgow Blatchford Scale: 
   1. NPV of a GBS score of <1 for the outcome of transfusion, death or need for intervention was 99% 
   2. Approximately 20% of patients’ presenting with upper GI hemorrhage have a Blatchford score of zero

1. Rockall Score
2. AIM65 Score

Unstable UGIB

1. Airway/breathing
   1. Preoxygenate
      1. Limit BVM
      2. Hbg dissociation curve shift right in anemia
   2. Upright
   3. RSI vs DSI
2. Circulation
   1. MTP 1:1:1 Resuscitation
   2. Reverse Coagulopathy
      1. Cirrhotics —> Vit K IV, FFP, ? 4 factor FFP
      2. NOAC reversal: praxibind, kcentra
      3. Thrombocytopenia —> Plts
      4. ESRD/ASA —> DDAVP 0.3mcg/kg
   3. Permissive Hypotension —> MAP goal 60-65
   4. TXA —> HALT-IT data to come in May 2019.
3. Medications
   1. PPI
   2. Octreotide
   3. Antibiotics
   4. Pressor of choice? Vasopressin
4. Treatment/Consultants
   
   1. Ballon Tamponade 
      1. Call for xray
      2. 3 ports: Esophagus balloon, Gastric ballon, Suction
      3. Measure out your E and G with NGT at 50 cm mark on Blakemore 
      4. Insert it with lube
      5. Insufflate 50 ccs of air into gastric lavage port
      6. Insufflate 50 ccs of air into gastric port
      7. Xray, make sure ballon bubble below diaphragm
      8. Put another 200 ccs of air in gastric port for total 250 ccs
      9. Place on traction
      10. Insert your NGT to esophageal port
      11. Blakemore holds approximately 50-100ccs of air 
      12. Get manometer
      13. Goal manomatry for esophagus 30-45 mmHg
          
   2. Endoscopy
      
   3. IR for embodied vs emergent TIPs (Transjugular Intrahepatic Portosystemic Shunts)
      
   4. Surgery

Core Concepts:

• Keep your DDx broad for UGIB and perform a focused H&P and PE
• Use risk stratification tools like GBS, Rockall, and AIMS 65 to help with your disposition
• Remember that the most important intervention that affects mortality is antibiotics in your cirrhotic UGIBs as well as restrictive transfusion with only those with Hbg < 7
• Other treatment remedies include PPIs (no difference between IV vs oral or gtt vs bolus), somatostatin (or somatostatin analogs like octreotide), and promotility agents 
• In a hemodynamically unstable UGIB, remember your ABCs. Secure your airway early, resuscitate with blood products, consider reversal of coagulopathies. 
• Know how to place your hail mary Blakemore while making early consultations to your ICU, GI, IR and surgical colleagues.