UGIB Flashcards
Arteries of the GI tract that protrude through the submucosa
Dieulafoy lesions
- most commonly found in the lesser curvature of the stomach but may be found anywhere in the GI tract
- 80% to 9% are found within 6 cm of the gastroesophageal junction
Dieulafoy lesions are difficult to diagnose endoscopically, and sometimes patients report multipole previous diagnostic maneuvers with negative results
Remarks on aortoenteric fistula
Seocondary to a preexisting aortic graft.
Classically, this presents as a self-limited “herald” bleed with hematemesis or hematochezia, which preceds massive hemorrhage and exsanguination
Most reliable way to diagnose upper GI bleeding in the ED
Visual inspection of the vomitus for a bloody, maroon, or coffee-ground appearance
Single most important laboratory test for patients with significant UGIB
bloot type and crossmatch
BUN in UGIB
UGIB will elevated BUN levels through digestion and absorption of hemoglobin
A BUN:creatinine ratio ≥30 suggests an upper GI source of bleeding.
Remarks on nasogastric lavage
A negative nasogastric aspiration does not conclusively exclude an upper GI source.
Intermitting bleeding, pyloric spasm, or edema preventing reflux of duodenal blood can cause false-negative results.
[As of this writing], there is no evidence to support concerns that nasogastric tube passage may provoke bleeding in patients with varices.
Remarks on intubating a patient with UGIB
Intubating a patient with an upper GI bleed how is hemodynamically unstable can be a perilous procedure.
Aggressively resuscitate prior to intubation, and consider using smaller doses of induction agent to minimize peri-intubation hypotension or arrest
Blood transfusion cutoffs in UGIB
Transfuse if ≤7 g/dL in most (“restrictive transfusion”)
≤9 g/dL in older patients or patients with comorbidities
Remarks on blood transfusion in UGIB
- When UGIB is severe, blood transfusion can be lifesaving.
- If a large amount of blood product is anticipated, use massive transfusion protocols.
Coagulopathy and platelets in UGIB
Reverse coagulopathy with INR ≥1.5 and transfuse platelets for counts <50,000/uL
“Tranexamic acid, in a small systematic review study, has been shown to reduce the risk of death in patients with UGIB, but a much larger randomized controlled trial is due to be published soon.”
PPIs
When PPIs are given at high dose, the gastric pH remains neutral.
Clot formation from platelet aggregation is dependent on a pH >6.0
Octreotide
Somatostatin analogue
It inhibits the secretion of gastric acid, reduced blood flow to the gastroduodenal mucosa, and causes splanchnic vasoconstriction.
Begin at a lower dose for elderly (25mcg bolus and 25 mcg/h infusion)
Octreotide does not appear to provide a clear benefit on mortality, but when combined with early endoscopy, it may reduce bleeding.
Starting antibiotics in UGIB
- Patients with cirrhosis have an impaired immune system and have an increased risk of gut bacterial translocation during an acute bleeding episode
- Prophylactic antibiotics (e.g., cipro 400 or ceftri 1 gram) reduce infectious complications, rebleeding, days of hospitalization, mortality from bacterial infections, and all-cause mortality
- should be started as soon as possible
Promotility agents in UGIB
- Erythromycin and metoclopramide are examples of promotility agents used to enhance endoscopic visualization
- Consider administration if the patient is undergoing endoscopy in the ED and the patient is suspected to have large amounts of blood in the upper GI tract
Diagnostic study of choice in UGIB
Upper GI endoscopy
