UGIB Flashcards
define UGIB
bleeding proximal to the ligament of Tretiz (fourth part of the duodenum)
what causes UGIB
duodenal ulcer 25%
gastric ulcer 20%
acute gastric erosions 20%
esophageal varices 20%–> 30% mortality
mallory weiss tear 10%
Boerhaave’s syndrome (spontaneous rupture of the lower esophagus… high mortality)
aortoenteric fistula (high mortality)
gastric carcinoma
AV malformations
what factors are important to ask on history for UGIB
quantify bleeding
constipation or diarrhea?
associated symptoms–pain, N/V, fevers, chills, dizziness, urgency, weight loss, fevers, night sweats?
symptoms of anemia–weakness, headache, lightheadedness, palpitations
diet
recent trauma, colonoscopy, gastroscopy
PMHx
how do you quantify the bleeding in UGIB
how much blood? frequency?
tarry stools/melena? bright red blood/hematochezia? mixed into or surrounding stool?
hematemesis? bright red or coffee ground?
diet should you ask about with UGIB
pepto bismol
iron supplements
beets
licorice
what should you ask on PMHx for UGIB
previous bleeds and their cause
PUD
H pylori infection
unstable angina
dysphagia, heartburn
AAA
abdominal aortic graft
stomach ca
clotting disorder
alcohol use
liver disease
previous varices
what meds to ask about for UGIB
NSAIDs
warfarin
ASA
clopidogrel
what should you pay attention to on physical exam for UGIB
vitals and assessment of volume status general appearance pallor postural vitals LOC
cool extremities for peripheral shut down
cardiac and resp failure
DRE with occult blood testing if unsure
abdominal exam
signs of chronic liver disease
what are signs of chronic liver disease
palmar erythema spider nevi caput medusae gynaecomastic clubbing testicular atrophy jaundice ascites leukonychia peripheral edema bruising Dupuytrens contracture fetor hepaticus
what investigations should you order for UGIB
CBC, lytes
type and screen–>order up 2-6 units
BUN, Cr
PT/PTT, INR
- remember that HgB remains normal until 6 hours later following fluid shifts causing hemodilution
- expect elevated BUN due to digestion of blood with urea absorption
what imaging should you do for UGIB
abdo xray
cxr
diagnostic endoscopy
angiography vs rbc scan to detect active bleeding
when should you use an NG tube in UGIB
if diagnosis is uncertain
how should you manage an UGIB
2 large bore IVs in moderate to severe cases
IV NS or ringers and/or tranfuse to stabilize hemodynamics
- -IV pumps if necessary to force in large amounts of crystalloid
- -non crossmatched O- blood
therapeutic endoscopy for all significant bleeds
–80% of bleeds stop spontaneously
ranitidine
IV octreotide for bleeding varices
IV pantoloc infusion
treat H pylori infection
what should you use for bleeding varices
IV octreotide
what meds are used in the management of UGIB
octreotide
pantoloc infusion
ranitidine
how do you treat H pylori infection
“PAC”
PPI + amoxicillen + clarithromycin
omeprazole 20 mg PO BID
amoxicillen 1 g PO BID
clarithromycin 500 mg PO BID
all for 7 days followed by repeat testing to confirm success
what are clinical predictors of poor UGIB outcome/high risk of re-bleed
hematemesis (especially bright red vs coffee ground)
hypotension
age above 60
comorbidity
bleed recurring during hospitalization
more than 10 units of blood transfused
what are endoscopic predictors of poor UGIB outcome/high risk of re-bleed
high gastric ulcer
large or posterior duodenal ulcer
presence of adherent clot or oozing blood
non bleeding visible vessel
actively bleeding vessel
when should you suspect perforated duodenal ulcer
intense pain radiating to the back
elevated amylase
possibly shock
suspicious if xrays reveal pneumoperitoneum
management of perforated duodenal ulcer
requires emergent surgery as has high mortality
what are two possible complications of UGIB
perforated duodenal ulcer
hepatic encephalopathy
why might you develop hepatic encephalopathy in UGIB
precipitated in cirrhotics by increased urea from digested blood
endoscopic treatment of varices–sclerotherapy and banding
how do you prevent recurrent peptic ulceration
dx H pylori by biopsy during endoscopy or urea breath test
of H pylori +, requires eradication therapy
discontinue NSAIDs until bleeding stops
–if NSAIDs must be restarted, then offer cytoprotection with misoprostol (200mg PO BID)
omeprazole 20 mg PO BID may be offered in short term (2 weeks) to enable complete healing
