Chapter 214. Upper Gastrointestinal Bleeding

80% ulcer, gastric >duodenal.

15% esophageal varices.

5% Mallory–Weiss or angiodysplasia.

Presentation:

• Hematemesis 75%
• Melena in 20%
• Hematochezia (red blood per rectum) 5%

Differential diagnosis: hemoptysis, bleeding from mouth.

In case of hypovolemic shock without exteriorized bleeding, remember to insert a nasogastric tube.

Markers of severity—BLEED:

• Ongoing bleeding
• Low SBP
• Elevated PT
• Erratic mental status
• Comorbid disease

See Figure 214-1.

• Resuscitation goals:
  • MAP 60 mm Hg and SpO2 ≥95%:
    • Administer crystalloids (LR)
    • Start norepinephrine (2–5 μg/min infusion) if BP goal not reached after 1,000 mL LR
  • Transfuse RBC if Hct <24% (or 30 if h/o CAD [or high likelihood: elderly, long-standing DM, etc.]):
    • Use clinical judgment to transfuse RBC without waiting for labs if obviously massive bleed or poorly tolerated
  • Transfuse FFP if RBC given. Start with 1 U FFP/3 U RBC, but if >10 U RBC, give 1 U FFP/1 U RBC
• EGD:
  • Insert NGT/OGT; perform irrigation with saline, GT to gravity
  • EGD performed when the patient is stabilized:
    • In the first 6 hours if active bleeding
    • Otherwise in the first 12 hours
  • Erythromycin 250 mg IV in 20 minutes, 30 minutes before EGD, to promote gastric emptying (controversial)
  • Intubate if refractory shock or altered consciousness
• Ulcer/gastritis:
  • During EGD: ulcer sclerosis, epinephrine injection, clips if needed
  • The Forrest score assesses the prognosis and the recurrence risk of bleeding in gastric ulcer case
  • If Forrest IIa or Ia, start PPI infusion: for example, omeprazole 80 mg IV bolus, and then 8 mg/h infusion × 48 hours
  • Consider surgery if:
    • Unable to stop bleeding on EGD
    • Diameter >2 cm
    • Posterior bulb location
  • Consider embolization if unable to stop bleeding on EGD and focal (not diffuse) bleeding
  • If H. pylori on biopsies, treat with two antibiotics + PPI (consult GI)
• Esophageal varices rupture:
  • Treat bleeding:
    • Banding or sclerotherapy during EGD (give cefazolin 1–2 g IV)
    • Octreotide 25 μg/h (no bolus) to be continued for 2–5 days
    • Antibiotics: norfloxacine 400 mg PO BID × 7 days
    • If unsuccessful, consider repeat EGD
    • If bleeding still persists: TIPS
    • Blakemore/Linton balloon: rarely used nowadays
  • Once bleeding stopped:
    • Prevent hepatic encephalopathy (lactulose, neomycin, or rifamixin)
    • Consider evacuating ascites
    • Prevent rebleeding: propranolol 80–160 mg per day (goal: limit HR increase to 25%)