Approach to Upper Gastrointestinal Bleeding

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Upper GI bleeding is any GI bleeding originating proximal to the ligament of Treitz. 

Clinical Presentation 

Hematemesis and coffee-ground emesis suggest a UGI source. On physical examination, vital signs  may reveal obvious hypotension and tachycardia. Cool, clammy skin is an obvious sign of shock.  Abdominal examination may disclose tenderness, masses, ascites, or organomegaly. Perform rectal  examination  to  detect  the  presence  of  blood  and  its  appearance,  whether  bright  red,  maroon,  or  melanotic. Other findings include, the presence of spider angiomas, palmar erythema, jaundice, and  gynecomastia  which  may  suggest  liver  disease  while  petechiae  and  purpura  may  suggest  an  underlying coagulopathy.  

Differential diagnosis 

Peptic  ulcer  disease,  upper  GI  malignancy,  oesophageal  or  gastric  varices,  esophagitis,  Mallory- Weiss tear, Boerhaave syndrome and arteriovenous malformation 

Investigations 

ABO Grouping and cross-matching, Complete Blood Count, Hemoglobin Level, Blood Urea Nitrogen  and Creatinine, Electrolytes, (Sodium, Potassium, Calcium Chloride), PT, PTT, INR, Liver Function  Tests,  Lactate  levels,  Obtain  an  ECG  in  patients  with  underlying  coronary  artery  disease  and/or  Bedside Ultrasound 

Non Pharmacological treatment 
Maintain ABCs, give oxygen if needed 

Pharmacological Treatment 

Give blood If severe pallor, ongoing bleeding, Hb < 5g/dl and Hb < 7g/dl (with active bleeding) 

  • Adults 2 units within 1hour and Paediatric 20ml/kg 1hour (whole blood) or 10ml/kg (pRBC)
  • If  ongoing  indication  for  blood,  start  transfusion  in  the  following  ratio:    1unit  pRBCs (20ml/kg  in  Paediatric):  1unit  FFP  (20mls/kg  in  Paediatric):  1unit  PLT  (20ml/kg  in Paediatric)

Give 

A: 0.9% sodium chloride (IV) 

OR 

A: compound sodium lactate (IV); Adult 2000mls and Paediatrics 20ml/kg 

AND 

C:     pantoprazole      (IV);     Adult     80mg     stat,      then          infusion               8mg/hour          for           3days, 

Paediatrics1mg/kg stat (max 80mg) then infusion 1mg/kg/hour for 3days  

OR 

S: esomeprazole (IV) 40mg 24hourly for 3days 

For patients with suspected variceal bleeding give: 

S:    octreotide    (IV)    Adult    50mg    slow    bolus,    then         infusion        50mcg/hour for         5days;  Paediatrics1mcg/kg/hour (maximum 50mcg/hour) for 5days  

If features suggestive of cirrhosis; give 

C: ciprofloxacin (IV) 500mg 12hourly for 7days 

OR   

B: ceftriaxone (IV) 2g 24hourly for 7days 

DEFINITIVE  CARE: Early Endoscopy and Intensive care unit admission (Refer  Gastrointestinal  disease chapter)