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Upper Gastrointestinal Bleeding
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Upper Gastrointestinal Bleeding
, Upper GI Bleed
See Also
Gastrointestinal Bleeding Management
Esophageal Varices
Gastrointestinal Bleeding
Lower Gastrointestinal Bleeding
Peptic Ulcer Disease
Definitions
Upper Gastrointestinal Bleeding
Bleeding proximal to the ligament of treitz (suspends the distal duodenum) at the duodenojejunal flexure
Epidemiology
Incidence
: 48 to 160 cases per 100,000
Accounts for 300,000 to 400,000 hospitalizations in U.S. yearly
Risk factors
History of prior Upper Gastrointestinal Bleeding (
Relative Risk
13.5)
Anticoagulant
use (
Relative Risk
12.7)
Apixaban
(
Eliquis
) appears to have the lowest risk of bleeding compared with other
DOAC
s and
Warfarin
Helicobacter Pylori
infection (present in 64% of cases)
Upper Gastrointestinal Bleeding
Odds Ratio
: 1.7
Adheres to gastric epithelium, predisposing underlying mucosa to injury by toxins
Together,
Helicobacter Pylori
and/or
NSAID
use accounts for 80% of Upper GI Bleeding cases
Antiplatelet Agents
Aspirin
alone increases risk of
GI Bleed
ing by 37%
Clopidogrel
(
Plavix
) increases the
GI Bleed
ing risk
Monotherapy: 1.9% per patient year
With
Aspirin
(Dual Therapy): 3.1% per patient year
With
Aspirin
and
Warfarin
(Triple Therapy): 5.1% per patient year
Concurrent
Proton Pump Inhibitor
lowers the
GI Bleed
ing
Odds Ratio
PPI and
Aspirin
OR
Clopidogrel
monotherapy: 0.2
Odds Ratio
PPI and
Aspirin
AND
Clopidogrel
: 0.36
Odds Ratio
NSAID
use (most common cause)
See
NSAID Gastrointestinal Adverse Effects
for
Relative Risk
of specific
NSAID
s
Upper Gastrointestinal Bleeding
Odds Ratio
: 4.8 to 5.8
Upper Gastrointestinal Bleeding
Odds Ratio
: 6.1 if
Helicobacter Pylori
positive in addition to
NSAID
use
Celecoxib
(
Celebrex
) and
Naproxen
Sodium
(
Naprosyn
) are the lowest risk of Upper Gastrointestinal Bleeding
Elderly (especially over age 70 years) with
Relative Risk
5.6
Male gender (twice as common as women)
Acid suppression therapy does not reduce bleeding risk
End Stage Renal Disease
(esp. first year of
Dialysis
)
Selective Serotonin Reuptake Inhibitor
s
SSRI
s increase
GI Bleed
ing risk by 55%, especially when combined with
NSAID
s or antiplatelet agents
Causes
Adults
Adults with acute massive
GI Bleed
ing
Peptic Ulcer Disease
(62%)
Gastric Ulcer
(up to 55%)
Duodenal Ulcer
(30-38%)
Esophageal Varices
(6-10%)
Gastritis
or
Duodenitis
(5-10%)
Esophagitis or esophageal ulcer (5-10%)
Mallory-Weiss tear (3-7%)
Gastrointestinal malignancy (1-4%)
Arteriovenous malformation (10%)
Dieulafoy's Lesion (1%)
Artery at gastric fundus may bleed heavily
Difficult to identify on endoscopy
Gastric antral vascular ectasia (0.5 to 2%)
Longitudinal erythematous stripes on gastric mucosa
Known as Watermelon
Stomach
Conditions associated with angiodysplasia of
Stomach
or duodenum
Chronic Renal Failure
Aortic Stenosis
Cirrhosis
Von Willebrand's Disease
Chronic intermittent
GI Bleed
ing
Gastritis
(18 to 35%)
Esophagitis (18 to 35%)
Gastric Ulcer
(18 to 21%)
Duodenal Ulcer
(3 to 15%)
Angiodysplasia (5 to 23%)
Gastric Cancer
Most commonly missed upper GI sources
Large
Hiatal Hernia
erosions
Arteriovenous malformation
Peptic Ulcer Disease
Causes
Children
Esophagitis
Gastritis
Peptic Ulcer Disease
Esophageal Varices
Mallory-Weiss Tear
History
See
Gastrointestinal Bleeding
Symptoms
Abdominal Pain
Hematemesis
Coffee-ground Emesis
Black tarry stools or
Melena
Bright Red Blood Per Rectum
or
Hematochezia
(if bleeding is brisk)
Lightheadedness,
Dizziness
or
Syncope
Signs
Vital Sign
s
Do not be reassured by normal
Vital Sign
s
In contrast, abnormal
Vital Sign
s mandate emergent management
Tachycardia
Initially normal
Hypotension
or
Orthostasis
Late finding, requires 20% loss of
Blood Volume
Respiratory Exam
Exclude
Epistaxis
source
Exclude
Hemoptysis
source
Abdominal exam
Hyperactive
Bowel
Sounds
Hematemesis
Large volume, coffee ground or brownish
Emesis
Contrast with
Hemoptysis
(cough with smaller volume, bright red, frothy
Sputum
)
Rebound Tenderness
Consider viscus perforation with
Acute Abdomen
Nasogastric aspirate bloody
False Negative Rate
is at least 15% and likely higher (negative aspirate does not exclude
GI Bleed
)
Fresh blood suggests persistant bleeding and suggests a high risk lesion
Lavage offers higher
Test Sensitivity
but increases risk of aspiration and is controversial
Lavage does not mortality, surgery or transfusion requirements
Huang (2011) Gastrointest Endosc 74(5):971-80 [PubMed]
Lavage positive for coffee ground material or bright red blood confirms upper gastrointestinal source
However a negative lavage does not exclude Upper Gastrointestinal Bleeding
Gastric Lavage
may also help clear the
Stomach
of blood prior to endoscopy and improve the evaluation
Allows for monitoring of ongoing upper gastrointestinal
GI Bleed
ing
Labs
Complete Blood Count
Baseline
Hemoglobin
(trails bleeding by 8 to 24 hours)
Blood Type and Cross-match
Coagulation Factor
s
Prothrombin Time
(INR)
Partial Thromboplastin Time
(PTT)
Platelet Count
Comprehensive metabolic panel
Liver Function Test
s
Renal Function
s tests
Blood Urea Nitrogen
(BUN)
Serum Creatinine
BUN to
Creatinine
ratio
Does not reliably distinguish upper GI source
However some studies show ratio >36 has
Test Sensitivity
90%
Evaluation
See
Upper GI Bleeding Score
See
Rockall Risk Score
See
Upper Endoscopy Evaluation of GI Bleeding
Management
Stabilization of the actively bleeding patient
Gene
ral measures
See
Acute Gastrointestinal Bleeding Management
ABC Management
Supportive care
Oxygen
Two large bore IVs (14-18 gauge)
Fluid
Resuscitation
Consider intubation (for airway protection)
Monitor
Vital Sign
s including
Blood Pressure
,
Heart Rate
and
Oxygen Saturation
Intensive Care
Unit admission for significant bleeding or hemodynamically unstable
Replace blood and
Coagulation Factor
s if needed
Consider
pRBC
,
PCC4
,
Fresh Frozen Plasma
,
Platelet Transfusion
,
Vitamin K
pRBC
transfusion for
Hemoglobin
<7 g/dl (or <8 g/dl with significant comorbidity)
Platelet Transfusion
for
Platelet Count
<50,000
Correct INR >2.5 before endoscopy (e.g.
PCC4
or FFP and
Vitamin K
)
See
Gastrointestinal Bleeding Management
for indications
Upper endoscopy urgently to emergently
Notify GI or surgery on patient presentation to ready for upper endoscopy
Performed in first 24 hours after fluid
Resuscitation
and stabilization
See
Upper Endoscopy Evaluation of GI Bleeding
See
Glasgow-Blatchford Bleeding Score
May forego upper endoscopy if score <1
See protocols below
Medications
Intravenous
Proton Pump Inhibitor
(e.g.
Protonix
IV) - see below
Prokinetic Agents (e.g.
Erythromycin
IV before endoscopy)
Controversial, but may improve endoscopy efficacy
Esophageal Varices
See
Bleeding Esophageal Varices
Upper Endoscopy emergently for banding
Vasoactive agents (e.g.
Octreotide
50 mcg IV bolus)
Non-selective
Beta Blocker
(e.g.
Propranolol
, Nadalol,
Timolol
)
Prophylactic Antibiotics (e.g.
Norfloxacin
,
Ciprofloxacin
,
Ceftriaxone
)
Consider Balloon tamponade (e.g.
Linton Tube
,
Sengstaken-Blakemore Tube
)
Indicated for stabilization until endoscopy
Non-variceal persistent bleeding
Transcatheter Arterial Embolization (via Angiography) Indications for Persistent Bleeding
Endoscopy not available
Biliary bleeding
Pancreatic bleeding
Gastric Ulcer
Mallory-Weiss Tear
Gene
ral Surgery Indications
Acute Abdomen
(peritonitis)
Continued massive bleeding without known source
Failed medical therapy, endoscopy and angiography
Lower risk of rebleeding compared with transcatheter ablation
Beggs (2014) Clin Exp Gastroenterol 7:93-104 [PubMed]
Management
Acid reduction
Proton Pump Inhibitor
(preferred)
Start Intravenous
Proton Pump Inhibitor
in all Upper Gastrointestinal Bleeding cases
Better outcomes with use, although mixed results (see below)
Dosing
Massive Hemorrhage
Protonix
80 mg IV, then 8 mg/h
Typical dosing
Protonix
40 mg IV
Effects
Full protection (achlorhydria) is delayed for the 5-7 days required to deactivate the proton pump
Consider
H2 Blocker
initially (see below)
Not proven in-vivo to aid clotting
Omeprazole
may heal peptic ulcer if near-achlorhydria
No proven benefit in mortality
No benefit or harm seen when PPI given at Upper GI Bleeding presentation
Dorward (2006) Cochrane Database Syst Rev (4): CD005415 [PubMed]
Cochrane study suggested PPI benefit in specific measures when given in endoscopy suite
May reduce
Incidence
of re-bleeding (NNT 15)
May reduce
Incidence
of
Gastrointestinal Bleeding
requiring surgery (NNT 30)
Peptic ulcer related bleeding appears to benefit from PPI in China and Japan (but possible associated worse outcomes in U.S.)
Leontiadis (2006) Cochrane Database Syst Rev (1): CD002094 [PubMed]
References
Newman in Herbert (2014) EM:Rap 14(1): 4
Daneshmend (1992) BMJ 304:143-47 [PubMed]
Sreedharan (2010) Cochrane Database Syst Rev (2): CD005415 [PubMed]
Sung (2009) Ann Intern Med 150(7): 455-64 [PubMed]
H2 Blocker
Use is controversial in
Acute Gastrointestinal Hemorrhage
Consider starting initially concurrently with
Proton Pump Inhibitor
to bridge the delay in full PPI activity
Ranitidine
Intermittent: 50 mg IV or IM every 6-8 hours
Continuous: 6.25 mg/hour IV
Management
Very low risk patients
Indications
Hemodynamically stable with normal lab testing
No evidence of significant bleeding in last 48 hours
Nasogastric Tube
aspirate without blood
Upper GI Bleeding Score
(
Glasgow-Blatchford Bleeding Score
) <1
Mustafa (2015) Eur J Gastroenterol Hepatol 27(5):512-5 +PMID:25822859 [PubMed]
Protocol
Home with follow-up within days
Gene
ral measures as above
Management
Low risk patients
Indications
Hemodynamically stable within 1 hour of
Resuscitation
Minimal
Blood Product
s required (2 PRBC or less)
No evidence of active bleeding
Nasogastric Tube
aspirate without blood
No active comorbid medical conditions
Protocol
Consider for rapid protocol
Immediate
Upper Endoscopy Evaluation of GI Bleeding
Discharge to home if low-risk endoscopy results
Admit if rapid protocol not available
Follow moderate risk patient protocol below
Gene
ral measures as above
Management
Moderate risk patients
Indications
Tachycardia
persists despite
Resuscitation
Blood Product
s required >2 PRBC
Active comorbid condition
Protocol
Gene
ral measures as above
Admit to regular medical bed
Upper endoscopy when patient stabilized (<24 hours)
See
Upper Endoscopy Evaluation of GI Bleeding
Disposition based on Upper Endoscopy results
Low risk endoscopy: Observe for 24 hours
Moderate risk endoscopy: Observe for 48-72 hours
High risk endoscopy
Initially observe in ICU for at least 24 hours
Observe in hospital for 72 hours total or more
Management
High risk patients
Indications
Active ongoing bleeding
Hypotension
persists despite
Resuscitation
Severe active comorbid condition exascerbation
Liver
disease exascerbation
Endotracheal Intubation
for airway protection
Protocol
Gene
ral measures as above
Admit to
Intensive Care
unit for first 24 hours
Observe in hospital for 48 to 72 hours or more
Urgent upper endoscopy when stabilized
See
Upper Endoscopy Evaluation of GI Bleeding
Consider repeat routine recheck upper endoscopy in 24 hours for high risk lesions
Consider arteriography if source not evident
Management
Refractory and Recurrent Bleeding
Indications
Persistent or recurrent bleeding despite EGD
See
Upper Endoscopy Evaluation of GI Bleeding
Procedures
Consider arteriography with embolization
First-line study
Equivalent efficacy to surgical intervention
Surgical Intervention
Gastroduodenotomy
Vagotomy
Peptic ulcer resection
Management
Disposition
See prevention measures below
See
Helicobacter Pylori
management
Proton Pump Inhibitor
once daily for 4-8 weeks
Increase to twice daily for first 2 weeks for high risk lesions
Repeat Upper Endoscopy
Perform at 8-12 weeks after initial endoscopy
Indications
Gastric Ulcer
(Confirm healing and exclude cancer)
Severe esophagitis (exclude
Barrett's Esophagus
)
Iron Deficiency Anemia
Transfused blood will keep
Hemoglobin
increased only 2-3 weeks
Ferrous Sulfate
325 mg daily to three times daily
Continue until
Serum Ferritin
and
Hemoglobin
return to normal
Management
Cause Specific Approaches
Erosive Disorders (Esophagitis,
Gastritis
or
Duodenitis
)
Good prognosis and therapeutic endoscopy is not required
Early discharge on
Proton Pump Inhibitor
for 8 weeks
Mallory Weiss Tear
Most spontaneously heal
However, bleeding related mortality approaches that of Peptic Ulcer Bleeding
Management
Restarting
Anticoagulant
s and Antiplatelet agents after Upper GI Bleed
Warfarin
Restart 7-15 days after bleeding (7 days if high thromboembolic risk)
Non-Vitamin K Antagonist Oral Anticoagulant
(e.g
DOAC
s,
Apixaban
)
Change to
Apixaban
from other
DOAC
s
If already taking
Apixaban
, decrease dose
Aspirin
May restart in 3 days (immediately at 0 days, if low bleeding risk )
Dual Antiplatelet agents
First start
Aspirin
AND
After 5-7 days, may add back
Clopidogrel
or other antiplatelet agent in high risk patients (e.g. cardiac stents)
Prevention
See
Helicobacter Pylori
management
Avoid
NSAID
s
Consider longterm
Proton Pump Inhibitor
if
Aspirin
or
Clopidogrel
(
Plavix
) cannot be stopped
See
Clopidogrel
(
Plavix
) for potential
Proton Pump Inhibitor
interactions
Proton Pump Inhibitor
s reduce antiplatelet efficacy (increased cardiovascular events)
Tobacco Cessation
Avoid
Alcohol
Prognosis
Outcomes
Mortality: 2-15% overall (often related to comorbidity)
In hospital mortality: 13%
Duodenal Ulcer
: 3.7%
Higher risk of erosions into larger vessels
Gastric Ulcer
: 2.1%
Course
Bleeding stops and does not recur: 85% (<2% Mortality)
Re-bleeding after initially stopped: 15% (10% Mortality)
Continued active bleed: 5% (30% Mortality)
Prognosis
Predictors
Bleeding characteristic predictors of poor outcome
See
Upper GI Bleeding Score
Emesis
or nasogastric aspirate contains red blood
Low initial
Hematocrit
Coagulopathy
(
Low Platelets
or high INR)
Comorbid condition predictors of poor outcome
Active
Coronary Artery Disease
Congestive Heart Failure
Active lung disease
Renal Failure
Sepsis
Metastatic cancer
Advanced liver disease
Advanced age
References
Spangler, Swadron, Mason and Herbert (2016) EM:Rap C3, p. 1-11
Gupta (1993) Med Clin North Am 77(5):973-92 [PubMed]
Fallah (2000) Med Clin North Am 84(5):1183-208 [PubMed]
Longstreth (1995) Am J Gastroenterol 90(2):206-10 [PubMed]
Peter (1999) Emerg Med Clin North Am 17(1):239-61 [PubMed]
Stanley (2019) BMJ 364:1536 +PMID:30910853 [PubMed]
Terdiman (1998) Postgrad Med 103(6):43-64 [PubMed]
Wang (2010) Ann Surg 215(1):51-8 [PubMed]
Wilkins (2012) Am Fam Physician 85(5): 469-76 [PubMed]
Wilkins (2020) Am Fam Physician 101(5):294-300 [PubMed]
Zuckerman (2000) Gastroenterology 118:201-21 [PubMed]
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