Upper Gastrointestinal Bleeding

Introduction

Upper gastrointestinal bleeding is any GI bleeding originating proximal to the ligament of Treitz.

Clinical Presentation of upper gastrointestinal bleeding

  1. Hematemesis and coffee-ground emesis suggest an upper Gastrointestinal bleeding source.
  2. On physical examination, vital signs may reveal obvious hypotension and tachycardia.
  3. Cool, clammy skin is an obvious sign of shock.
  4. Abdominal examination may disclose tenderness, masses, ascites, or organomegaly.
  5. Perform rectal examination to detect the presence of blood and its appearance, whether bright red, maroon, or melanotic.
  6. Other findings include, the presence of spider angiomas, paimar erythema, jaundice, and gynecomastia which may suggest liver disease while petechiae and purpura may suggest an underlying coagulopathy.

Differential diagnosis

  • Peptic ulcer disease, upper GI malignancy, oesophageal or gastric varices, esophagitis, Mallory Weiss tear, Boerhaave syndrome and arteriovenous malformation

Investigations

  • ABO Grouping and cross-matching,
  • Complete Blood Count
  • Hemoglobin Level
  • Blood Urea Nitrogen and Creatinine
  • Electrolytes, (Sodium, Potassium, Calcium Chloride)
  • PT
  • PTT
  • INR
  • Liver Function Tests
  • Lactate levels
  • Obtain an ECG in patients with underlying coronary artery disease and/or Bedside Ultrasound

Treatment for upper gastrointestinal bleeding

Non Pharmacological treatment

  • Maintain ABCs, give oxygen if needed

Pharmacological Treatment

Give blood if:

  1. severe pallor
  2. ongoing bleeding
  3. Hb < 5g/dl and Hb<7g/dl (with active bleeding)

Adults 2 units within 1hour and Paediatric 20ml/kg 1hour (whole blood) or 10ml/kg (pRBC)

  • If ongoing indication for blood, start transfusion in the following ratio: 1unit pRBCs (20ml/kg in Paediatric): 1unit FFP (20mls/kg in Paediatric): 1unit PLT (20ml/kg in Paediatric)

Give:
A: 0.9% sodium chloride (IV)

OR

A: compound sodium lactate (IV);
Adult 2000mls and Paediatrics 20ml/kg
AND
C: pantoprazole (IV);
Adult 80mg stat, then infusion 8mg/hour for 3days.
Paediatrics 1mg/kg stat (max 80mg) then infusion 1mg/kg/hour for 3days

OR

S: esomeprazole 40 mg  (IV) 24hourly for 3days.
For patients with suspected variceal bleeding give:
S: octreotide (IV)
Adult 50mg slow bolus, then infusion 50mcg/hour for 5days;
Paediatrics 1mcg/kg/hour (maximum 50mcg/hour) for 5days
If features suggestive of cirrhosis; give
C: ciprofloxacin (IV)

  • 500mg 12hourly for 7days

OR

B: ceftriaxone (IV)

  • 2g 24hourly for 7days

Definitive Care:

Early Endoscopy and Intensive care unit admission