Rapid overview: Emergency management of severe upper GI bleeding in adults
Going to try to keep this one simple and present two items:
- Table with subsections such as pathogensis, diagnosis, and treatment
- An algorithmic approach to dealing with a patient suffering from GI bleed.
- This is not medical advice. If you need help, please seek a medical professional. This is purely educational and nothing more.
Link to image above so you can zoom in if needed.
| Major causes* |
| • Peptic ulcer, esophagogastric varices, arteriovenous malformation, tumor, esophageal (Mallory-Weiss) tear |
| Clinical features |
| • Use of: NSAIDs, aspirin, anticoagulants, antiplatelet agents |
| • Alcohol abuse; previous GI bleed; liver disease; coagulopathy |
| • Symptoms and signs: Abdominal pain; hematemesis or “coffee ground” emesis; passing melena/tarry stool (stool may be frankly bloody or maroon with massive or brisk upper GI bleeding) |
| Examination |
| • Tachycardia, orthostatic blood pressure changes suggest moderate to severe blood loss; hypotension suggests life-threatening blood loss (hypotension may be late finding in healthy younger adult) |
| • Rectal examination is performed to assess stool color (melena versus hematochezia versus brown) |
| • Significant abdominal tenderness accompanied by signs of peritoneal irritation (eg, involuntary guarding) suggests perforation |
| Diagnostic testing |
| • Obtain type and screen (or type and crossmatch for hemodynamic instability, severe bleeding, or high-risk patient) |
| • Obtain hemoglobin concentration (normal measurement may be inaccurate with acute severe hemorrhage), platelet count, coagulation studies (prothrombin time with INR), liver enzymes (AST, ALT), albumin, BUN and creatinine |
| • Nasogastric lavage may be helpful if the source of bleeding is unclear (upper or lower GI tract) or to clean the stomach prior to endoscopy |
| Treatment |
| • Closely monitor airway, clinical status, vital signs, cardiac rhythm, urine output, nasogastric output (if nasogastric tube in place) |
| • Do NOT give patient anything by mouth |
| • Establish two large bore IV lines (16 gauge or larger) |
| • Provide supplemental oxygen |
| • Treat hypotension initially with rapid, bolus infusions of isotonic crystalloid |
| Transfuse for: |
| • Hemodynamic instability despite crystalloid resuscitation |
| • Hemoglobin <9 g/dL (90 g/L) in high-risk patients (eg, elderly, coronary artery disease) |
| • Hemoglobin <7 g/dL (70 g/L) in low-risk patients |
| • Avoid over-transfusion with possible variceal bleeding |
| • Give fresh frozen plasma for coagulopathy; give platelets for thrombocytopenia (platelets <50,000) or platelet dysfunction (eg, chronic aspirin therapy) |
| • Obtain immediate consultation with gastroenterologist; obtain surgical and interventional radiology consultation for any large-scale bleeding¶ |
| Pharmacotherapy for all patients with suspected or known severe bleeding: |
| • Give a proton pump inhibitor (eg, esomeprazole 40 mg IV twice daily or pantoprazole 40 mg IV twice daily) |
| Pharmacotherapy for known or suspected esophagogastric variceal bleeding and/or cirrhosis: |
| • Give somatostatin or an analogue (eg, octreotide 50 mcg IV bolus, followed by 50 mcg/hour continuous IV infusion) |
| • Give an IV antibiotic (eg, ceftriaxone or fluoroquinolone) |
| • Balloon tamponade may be performed as a temporizing measure for patients with uncontrollable hemorrhage likely due to varices using any of several devices (eg, Sengstaken-Blakemore tube, Minnesota tube); tracheal intubation is necessary if such a device is to be placed; ensure proper device placement prior to inflation to avoid esophageal rupture |
Footnotes:
GI: gastrointestinal; INR: international normalized ratio; AST: aspartate aminotransferase; ALT: alanine aminotransferase; BUN: blood urea nitrogen; IV: intravenous.
*An important but uncommon cause of gastrointestinal hemorrhage is vascular-enteric fistula, typically aortoduodenal fistula related to erosion of a prosthetic aortic graft.
¶Minimally invasive techniques to control bleeding include sclerotherapy, embolization and other vascular occlusion techniques. For patients with massive hemorrhage, resuscitative endovascular balloon occlusion of the aorta (REBOA) can be used to limit blood loss and support perfusion of vital organs until the sites of bleeding can be directly controlled.
