Dilemma: Upper GI Bleed

Author: Dr. Ryan Killian

Edited: Kevin Cao

Background and Differential:

Bleeding typically proximal to Ligament of Treitz

Causes: PUD, Gastritis, Varices, Mallory-Weiss Tear

Signs/Symptoms: Hematemesis, Melena, Pain, Cirrhosis

Mortality: 10-14%1

  1. Hemodynamics

  • IVx2, O2, monitor, fluids, transfusion

2. Assess ABC's


  • Intubation, suction x2

3. PPI bolus + drip (pantoprazole)

  • No improvement in clinical outcomes2-5

  • Improved visualization of lesion, rebleeding2-5

If Suspect Cirrhosis or Variceal Bleeding:

Octreotide:

  • Two metanalysis: No mortality benefit6-7

  • Reduction in transfusions, improved hemostasis w/ EGD vs EGD alone6-7



Ballon Tamponade:

  • Retrospective Analysis: N=34. 59% survived to discharge, 95% received TIPS.9

  • Recommendation: If unstable, try it but only bridge to TIPS.


Endoscopy:

  • Study 1: High Risk UGIB > no mortality benefit if <6hr compared 6-24hr 10

  • Study 2: HDS, ASA 3-5 > LOWER mortality associated w/ 12-36hr endoscopy 11

Hemodynamically unstable > LOWER mortality w/ 6-24hr endoscopy

Ceftriaxone:

  • Meta Analysisshowed beneficial effects on: All-cause mortality, Rebleeding, Days of hospitalization, Bacteremia, SBP 8


References

  • 1. Hearnshaw SA, Logan RF, Lowe D, Travis SP, Murphy MF, Palmer KR. Acute upper gastrointestinal bleeding in the UK: patient characteristics, diagnoses and outcomes in the 2007 UK audit. Gut. 2011 Oct;60(10):1327-35.

  • 2. Laine L, Jensen D. Practice Guidelines. Management of Patients With Ulcer Bleeding. Am J Gastroenterol 2012; 107:345–360.

  • 3. Rezaie, Salim. Upper Gastrointestinal Bleeding: Evidence-Based Treatment. Mar 12, 2014. https://www.aliem.com/upper-gastrointestinal-bleeding-treatment/

  • 4. Tintinalli's Emergency Medicine Manual, Chapter 39: Gastrointestinal Bleeding by Mitchell C. Sokolosky

  • 5. Rosen’s Chapter 27: Gastrointestinal Bleeding by David A. Meguerdichian & Eric Goralnick

  • 6. Bañares R, Albillos A, Rincón D, et al. Endoscopic treatment versus endoscopic plus pharmacologic treatment for acute variceal bleeding: a meta-analysis. Hepatology. 2002;35(3):609-615.

  • 7. Gøtzsche P, Hróbjartsson A. Somatostatin analogues for acute bleeding oesophageal varices. Cochrane Database Syst Rev. 2008;(3):CD000193.

  • 8. Chavez-Tapia N, Barrientos-Gutierrez T, Tellez-Avila F, et al. Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding – an updated Cochrane review. Aliment Pharmacol Ther. 2011;34(5):509-518.

  • 9. Morgan TG, Carlsson T, Loveday E, Collin N, Collin G, Mezes P, Pullyblank AM. Needle or knife? The role of interventional radiology in managing uncontrolled gastrointestinal bleeding. Int J Gastrointest Interv 2021;10:17-22.

  • 10. Lau J et al. 2020. Timing of Endoscopy for Acute Upper Gastrointestinal Bleeding. NEJM. 382(14):1299-1308.

  • 11. Laursen et al. 2016. Relationship between timing of endoscopy and mortality in patients with peptic ulcer bleeding: a nationwide cohort study. Gastrointest Endosc 2016:1-9.

  • Intubation image courtesy of Wikipedia


Key Terms: Proton Pump Inhibitor (PPI), Transjugular intrahepatic portosystemic shunt (TIPS), Esophagogastroduodenoscopy (EGD), Peptic Ulcer Disease (PUD), Hemodynamically Stable (HDS), American Society of Anesthesiology Physical Status Score (ASA)