Upper GI Bleed

The Common Internal Medicine posts continue. I have two patients with upper GI bleeds (UGIB) on my census this week. One patient has a large antral ulcer and another patient has a varicele bleed from cirrhosis of the liver.

Introduction - An upper gastrointestinal bleeding includes hemorrhage originating from the esophagus to the ligament of Treitz. Peptic ulcer bleeding causes more than 60 percent of cases of upper gastrointestinal bleeding, whereas esophageal varices cause approximately 6 percent. Other etiologies of upper gastrointestinal bleeding include arteriovenous malformations, Mallory-Weiss tear, gastritis and duodenitis, and malignancy.

Management 

Triage the patient - Patients with acute upper gastrointestinal (GI) bleeding commonly present with hematemesis or melena. The very first thing you should do when evaluating a patient with an UGIB is ask if they are hemodynamically stable and order a type and cross in case the patient will need a transfusion.

General Support - The patient recieve supplemental oxygen and be kept NPO for 24 hours or as long as an active bleed is occuring. If hemodynamic instability is occurring or suspected, the patient should have two large bore IV catheters or a central line for rapid fluid resuscitation.

Fluid Resuscitation - Patients with active bleeding should receive intravenous fluids, about 500 mL of normal saline or lactated Ringer's solution over 30 minutes, while being typed and cross-matched for blood transfusion.

Blood Transfusion - The decision on whether to transfuse or not depends on the patient's medical history. Do they have and co-morbid condition such as unstable angina that make them more susceptible to hypoxemia. Up to Date recommends that you should try to keep the patient's hemoglobin > 7, including patients with stable CAD. In patients with unstable CAD, the recommendation is > 9. However, patients with active bleeding and hypovolemia may require blood transfusion despite an apparently normal hemoglobin. In one of my patients, he became tachycardiac with a HR of 120 and so we transfused two PRBC eventhough his hemoglobin was >7. One should also avoid over transfusing (Hg>10) the patient as it may precipitate the bleeding.

Medications 

Acid suppression - Patients admitted to the hospital with acute upper GI bleeding are typically treated with a proton pump inhibitor (PPI). We started my patients on IV Protonix for 72 hours. PPIs may also promote hemostasis in patients with lesions other than ulcers secondary to the neutralization of gastric acid which leads to the stabilization of blood clots.

Prokinetics - The goal of using a prokinetic agent (erythromycin and metoclopramide) is to improve gastric visualization at the time of endoscopy by clearing the stomach of blood, clots, and food residue. We suggest that erythromycin be considered in patients who are likely to have a large amount of blood in their stomach, such as those with severe bleeding.  Erythromycin is a motilin agonist and will promote gastric motility. My patient with an antral ulcer may have benefited from this as the endoscope report read that "stomach difficult to fully visualize due to the large amount of blood".

Octreotide - Somatostatin, or its analog octreotide, is used in the treatment of variceal bleeding and may also reduce the risk of bleeding due to nonvariceal causes. In patients with suspected variceal bleeding, octreotide is given as an intravenous bolus of 20 to 50 mcg, followed by a continuous infusion at a rate of 25 to 50 mcg per hour. My patient with a varicele bleed and cirrhosis is on octreotide.
Octreotide is not recommended for routine use in patients with acute nonvariceal upper GI bleeding, but it can be used as adjunctive therapy in some cases, such as when the patient needs to be stabilized before an endoscopy. My patient with an antral ulcer is currently not on octreotide.

Antibiotics - Antibiotics are considered in the patient with an UGIB and cirrhosis. Bacterial infections are present in up to 20 percent of patients with cirrhosis who are hospitalized with gastrointestinal bleeding and up to an additional 50 percent develop an infection while hospitalized. The most common infections include spontaneous bacterial peritonitis, UTI, respiratory infections and septicemia. Studies have shown that by giving patients with a varicele bleed and cirrhosis prophylactic antibiotics, you will decrease mortality, hospital stay and recurrence of bleeding. The most common antibiotics used are the fluoroquinolones and ceftriaxone. Ceftriaxone is used on patients with severe cirrhosis or if the patient is in a hospital setting where there is a high resistance to the flouroquinolones. My patient with a varicele bleed and cirrhosis is on 1 gm/day of IV ceftriaxone X 5 days.

Anticoagulants - hold any anticoagulant medication (plavix, aspirin or coumadin) that the patient may be on.

Procedures - upper endoscopy is diagnostic test of choice for patients with UGIB.