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Core Topic

UCI Internal Medicine Residency 2012

Learning Objectives
Review the major causes of upper GI bleeding

and important elements of the history


Know the important elements of the physical
exam and diagnostic evaluation
Understand acute management of upper GI
bleeding

Clinical Scenario
67 yo M with history of HTN and osteoarthritis who

presents to the ED with 3 episodes of coffee ground


emesis today.
No abdominal pain, melena or hematochezia. No
history of liver disease or coagulopathy, +occasional
ETOH use.
Medications include HCTZ, Lisinopril, and Ibuprofen
PRN for joint pain
VS on arrival: T 37, HR 102, BP 108/72, similar BP
standing , Pox 99% RA
Examination: AOx3. No scleral icterus. Abdomen soft,
non-tender, no HSM. Rectal with dark brown stool,
guiac +.
Labs: Hgb 9.8, Plt 245, INR 1, LFTs nl, BUN 28/Cr 1.4.

Initial Evaluation
Major causes
Peptic ulcer, esophagogastric varices, arteriovenous
malformation, tumor, esophageal (Mallory-Weiss) tear
Characteristics of bleeding
Hematemesis coffee ground vs bright red blood
Melena
Hematochezia
History
Liver disease, alcoholism, coagulopathy
NSAID, antiplatelet or anticoagulant use
Abdominal Surgeries

Examination
Vitals

Tachycardia, hypotension

Abdominal examination
Significant tenderness, organomegaly, ascites
Rectal examination
Skin examination
NG lavage - if source of bleeding unclear

Diagnostic Evaluation
Hgb/Hct, plt count, coag studies
LFTs, albumin, BUN and creatinine
Type and screen /type and cross

Emergent Management
Closely monitor airway, clinical status, vital

signs, cardiac rhythm


two large bore IV lines (16 gauge or larger)
bolus infusions of isotonic crystalloid
Transfusion
pRBCs Hgb <7, hemodynamic instability
FFP, platelets coagulopathy, plt <50 or plt

dysfunction

Triage ICU vs Wards


Hemodynamic instability or active bleeding > ICU
Immediate GI consult

Medications
Acid Suppression
PPI

Protonix 80mg IV bolus, then 8mg/hr infusion


Esomeprazole at the same dose

Somatostatin analogues
Suspected variceal bleeding/cirrhosis
Octreotide 50mcg IV bolus, then 50mcg/hr infusion
Antibiotics
Suspected variceal bleeding/cirrhosis
Most common regimen is Ceftriaxone (1 g/day) for seven

days

Can switch to Norfloxacin PO upon discharge

Clinical Scenario
Conclusion
67yo M on NSAIDS with 3 episodes of coffee
ground emesis, anemia, and tachycardia
What is the likely etiology of the bleeding?
What is the appropriate acute management?

Clinical Scenario
Conclusion
67yo M on NSAIDS with 3 episodes of coffee
ground emesis, anemia, and tachycardia

What is the likely etiology of the bleeding?


Suspect peptic ulcer disease or gastritis
What is the appropriate acute management?

Airway stable, cardiac monitoring


Two 16 gauge IVs, immediately given 1L NS bolus and
tachycardia improved
Type and cross sent
Protonix 80mg IV x 1, then continuous infusion of 8mg/hr
GI consult called
Admitted to Medicine Wards

Take Home Points


Obtain a good history to identify potential sources of

the upper GI bleed and assess the severity of the bleed


Exam and diagnostic data should focus on signs that
indicate the severity of blood loss, help localize the
source of the bleeding, and suggest complications (ie
perforation)
Emergent management includes ABCs, two large
caliber IVs, fluid resuscitation, possible transfusion
All patients should be treated initially with PPI. If you
suspect variceal bleed, add somatostatin analogue and
empiric antibiotics
Triage appropriately to ICU vs Wards, and contact GI
immediately