upper gi bleeding tad kim, m.d. connie lee, m.d
TRANSCRIPT
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Upper GI Bleeding
Upper GI Bleeding
Tad Kim, M.D.Connie Lee, M.D.
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Upper GI Bleeding
GIB: Definitions
• UGIB = proximal to ligament of Treitz
• Hematemesis = vomiting blood - bright red or coffee-ground (typically UGI source)
• Melena = black tarry stool (often UGI)
• Hematochezia = bloody stool (LGI > UGI)
• Occult blood = UGI or LGI source
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Upper GI Bleeding
UGIB: DDx• Peptic Ulcer Disease (PUD) >50% cases• Gastritis / Duodenitis (15-30%)
– Subset due to NSAID use• Esophageal varices from portal hypertension (10-20%)• Gastric varices• Mallory-Weiss tears at GE junction (5%)• Esophagitis (3-5%)• Malignancy (3%)• Dieulafoy’s lesion (1-3%)• Nasopharyngeal bleed – swallowed blood• Other- aortoenteric fistula, angiodysplasia, Crohn’s, hemobilia,
hemosuccus pancreaticus, AVM, watermelon stomach
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Upper GI Bleeding
Examples
QuickTime™ and a decompressor
are needed to see this picture.
Dieulafoy’s lesion
QuickTime™ and a decompressor
are needed to see this picture.
Gastric varices
QuickTime™ and a decompressor
are needed to see this picture.QuickTime™ and a
decompressorare needed to see this picture.
Watermelon stomach
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Upper GI Bleeding
UGIB: Initial Evaluation• Evaluate ABCs/PE:
– Can the pt protect his airway?– Is the pt hemodynamically unstable?– Does the pt have adequate IV access, Foley, NGT?
• Resuscitate as appropriate• Orders: NPO, IVF, NGT to LCWS, Foley, HOB>30,
continuous pulse oximetry & telemetry• Labs: type & cross, CBC, INR/PT/PTT, BMP, LFTs
• Additional question to ask yourself: – Does the pt require a higher level of care?
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Upper GI Bleeding
UGIB: H&P• Risk factors: older age, male, cardiovascular
disease, renal disease, DM, oral anticoagulant use, h/o prior GIB, PUD, NSAID use, tobacco use, liver disease, splenic vein thrombosis, sepsis, burn injury, severe vomiting, h/o H. pylori, GI instrumentation, trauma
• History: OPQRST, PMHx, PSHx, Meds, ALL, SHx.• PE: remember to examine for signs of cirrhosis &
portal HTN• Tests: T&C, CBC, coags, BMP, LFT, CXR/KUB
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Upper GI Bleeding
UGIB: Management
• Assess magnitude of hemorrhage
• Place 2 large-bore IV, volume resuscitation w/ isotonic IVF. Be prepared to transfuse blood.
• Place NGT & lavage, place Foley
• Monitor for continued blood loss
• Start proton pump inhibitor (PPI) infusion
• For varices: start octreotide infusion
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Upper GI Bleeding
UGIB: Diagnostic Procedures• NGT• EGD - 95% diagnostic accuracy if used w/in 24 hrs
Angiography (Diagnostic & Therapeutic)• Intra-arterial vasopressin• Embolization• Can detect bleeding rate > 0.5 mL/min
• Technetium labeled RBC scan – Only diagnostic & usually for occult bleeding
• More sensitive than angiography• Can detect bleeding rate > 0.1 mL/min
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Upper GI Bleeding
UGIB: Indications for Surgical Intervention
• Refractory or recurrent bleeding
• Inability to identify bleeding source
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Upper GI Bleeding
UGIB: Long-Term Management
• Test for H. pylori. Treatment = amoxicillin, clarithromycin, and PPI
• Limit NSAID use
• H2B, PPI
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Upper GI Bleeding
UGIB: Take Home Points
• Start with ABCs• Remember: NPO, NGT, IVF via 2 large-bore IV• Resuscitate prior to intervention • Evaluate UGIB with EGD > angiography, tagged
RBC scan