UGIB Therapy
These are your first 3 initial Mx priorities (steps) given: a 51y M, currently vomiting blood, has vomited approx 1L blood with EMS
VS: 125 HR, BP 88/57
A: Maintaining
B: AEBE
C: Vomiting blood as above
Brisk UGIB MX:
1. Protection - gowns, gloves, faceshield
2. Monitors, 2 IV, O2
3. Start Fluids
3 risk factors for poor outcome in UGIB
R/F for poor outcome in UGIB:
Age >60
coagulopathy
liver failure
cardiac dz
severe bleeding
Investigations you order for patient with brisk UGIB
CBC for Hb
U/E for BUN
ECG if age and CAD
CXR, AXR
EGD
3 R/F for ischemic colitis
Painful Rectal Bleeding
R/F for ischemic Colitis:
CAD
Dysrhythmia
Heart Failure
Prolonged Hypotension
Marathon Running
Top three medications u might order for a patient with UGIB
1. Gastric Acid Suppression
PPI 80mg IV f/b 8mg/hr infusion
2. Somastatin analog
Octreotride 50ug IV then 50mg/hr infusion
3. Abx
Ceftriaxone 1g IV
The 3 of these are responsible for 75% of all UGIB
Duodenal Ulcer 25%
Gastric Ulcer 20%
Gastroduodenal erosions 25%
Mallory weiss - 5%
Varices - 10%
3 consults? other than ICU
HELP!
GI for scoping
IR for TIPS or Angio
GS
Anyone else?
Vasc
2 potential future diagnostic modalities for GIB
CT/MRI reconstruction endoscopy
Indication for using vasopressin in UGIB, & its Mechanism of action
VASOPRESSIN
20U IV over 20min then 0.2 - 0.4U/min
Constricts mesentric arterioles
No mortality benefit (?incr mortality)
Complication rate: 9% major (bowel, limb, myocardial, brain ischemia); 3% fatal
Indication:
Can try it in exsanguinating patient with ?variceal bleeding if EGD not available
The 2 of these are responsible for 80% of LGIB
Diverticula 22-56%
AVM/Angiodysplasia/Vascular Ectasia - 2.5 - 30%
Polyps - 1.7 - 22%
This is the likely source of bleeding (UGIB vs LGIB) in the following patient:
72y M, PMH: HTN, OA, AFib, Multiple meds
C/O hematochezia x 5 episodes over 90min
VS: 112, 80/40, 22, 37'
Hematochezia + Shock = UGIB
Rapid Transit
These are GIB patients you can send home from ED
DISPOSITION
VERY LOW RISK(D/C HOME):
No comorbidities
Normal V/S
NG aspirate -ve if done
Home support in place
Understand the S/S of GIB
Easy Access to ED
F/up in 24hr
TIPS is acronym for?
Indication:?
Transjugular Intrahepatic Portosystemic Shunt
IR Radiology
Connection between hepatic vein, intrahepatic portion of portal vein
Indication?
Continued bleeding despite Rx/EGD
4 Causes of dark stools
DDx MELENA:
UGIB
High LGIB
Swallowed blood (epistaxis, etc)
Iron
Bismuth
Food Products
What is the utility of NG tube insertion in patient with bleeding PR
NGT in bleeding PR?
IF +blood:
UGIB
LGIB + nasal/oral mucosal bleed
If -ve blood:
UGIB +bleeding stopped; duodenal bleed
(10% of UGIB have negative NG aspirate)
LGIB
Bottom line ....
NOT DIAGNOSTIC ! NOT HELPFUL
DAILY DOUBLE:!!!!
2 potential causes of elevated BUN in GIB patient
Elevated BUN
Prerenal Azotemia
Digested Blood
The rate of major complications from this procedure is 15%, rate of fatal complications is 3%
LINTON TUBE
Major Complications:
Mucosal Ulceration, tracheal compression, asphyxiation, asp. PNA, esophageal/gastric rupture
Consider with exsanguinating patient with ?variceal bleeding and EGD not immediately available
TEMPORISING MEASURE!!! until EGD/TIPS/Sx
Anything you need to do before u put it in?
Secure Airway
The utility of postural vital signs & cap refill in predicting hypovolemia in GIB? Which one?
Phys Exam:
Postural Signs:
Incr HR by 20 (sustained) - 98% Sp for significant blood loss in GIB
Decr SBP by 20 - 97% Sp or significant blood loss in GIB
CR>2-3s:
10% Sn for significant hypovolemia
This is the expected rise in Hb & Hct with 2U PRBC
Transfusion facts
1U PRBC (if no ongoing bleeding)
HB incr by 10mmol/l
Hct incr byb 3%
It is much more likely to be your Dx in hematochezia & hx of cirrhosis (&its not a risk for UGIB)
Liver Dz & LGIB
Anorectal Variceal bleed (hemorrhoidal veins)