Upper GI bleed/hematemesis
Definition:
Hematemesis is upper gastrointestinal bleeding. This means the bleeding site originates proximal to the ligament of Treitz (includes the esophagus, stomach, and duodenum).
Etiology:
**Esophageal Varices and Peptic ulcer disease (Hpylori, NSAIDs) are most common
Other causes: Esophagitis/gastritis, Mallory-Weiss tears, Arteriovenous malformations, tumors and erosions, Erosive esophagitis ( in HIV patients consider CMV, HSV, candida), Dieulafoy’s lesions (submucosal artery), gastric vascular ectasis. Aortic-enteric fistula.
Signs/Symptoms:
Acute upper GI bleed: Will see bright red bloody vomitus. With stasis of blood in stomach, patient will vomit coffee ground like material. As the blood passes through the GI tract, the patient will produce dark, tar like stool called melena and this often time suggest an upper GI source. R sided colonic lesions may also produce melena.
Hematochezia (bright red blood per rectum) is more often a lower GI source, however a very rapid upper GI source can produce this. Patients are often hemodynamically unstable.
Chronic slow upper GI bleed can present with hemoccult postive brown stool and chronic iron deficiety anema.
General: nausea, epigastric pain, syncope, lightheadedness, dizziness, fatigue
Evaluation:
-First determine if bleed is acute or chronic. If the bleed is acute, first evaluate hemodynamic stabiligy. Check blood pressure and heart rate. Ask about lightheadedness, syncope, dizziness. Check orthostatics, will be positive is patient with significant blood loss.
-ask about number of bleeding episodes, most recent episode, abdominal pain, weight loss, use of asa, NSAIDs, alcohol, cirrhosis, risk factors for schistosomiasis
-check full blood panel
-do rectal exam to look for bright red blood, melena or hemoccult positive brown stool
-check creatinine
-check PT/PTT/INR for coagulopathy
-may need to place nasogastric tube for localization: if you pull out fresh blood-> acute and active upper GI bleed, if you pull out coffee ground like material -> recent upper GI bleed,
if you pull out non bloody bilious material -> does not exclude upper gi bleed, may be lower
Management:
-establish IV access: 2 large bore IV’s or central line placement
-start IV fluids with normal saline if blood pressure is low (if you suspect esophageal variceal bleed, start normal saline cautiously)
-cross match blood and administer packed red blood cells if needed
-place foley catheter to closely moniter urine output, decrease urine output is sign of hypoperfusion, bleeding
-start PPI (proton pump inhibitor), omeprazole 40 mg bid
-correct any coagulopathies, consider giving vitamin K if signs of liver disease. For severe bleeding give vitamin K 1 mg IV
-upper endoscopy if available
Hematemesis Clinical Cases
Case 1
40 yo male with history of HTN presents with 3 episodes of bloody vomiting in one day. He describes the vomit as bright red and each time he vomits, about a cupful comes out. He also reports dizziness and lightheadedness. Before coming to the hospital, he almost passed out. He has not taken any of his blood pressure medications in the past few days. No abdominal pain or nausea reported.
1. What are the most important diagnostic tools you need to have right now?
a. Vitals are the most important tool, particularly BP and HR
2. Is this patient stable from the history?
a. NO!
You decided to take his vital signs first. His blood pressure lying down is 70/40 and his heart rate is 130. You are not able to perform orthostatics because as soon as you sit him up, he immediately feels dizzy and feels like he may pass out. He is afebrile.
1. At this point, what are your primary steps in stabilizing the patient?
a. Two large bore IVs, with fluid wide open, and ICU consult.
2. Do you want to order any laboratory tests or imaging tests at this time? If yes, what do you want and why?
a. FBP, T+C, Coags stat.
You are able to increase his blood pressure and lower his heart rate. The patient tells you he feels much better.
1. How are you going to find the underlying reason for his GI bleed?
a. EGD, f/u lab results, look for stigmata of liver disease.
2. What is in your differential for an upper GI bleed?
a. From above:
i. **Esophageal Varices and Peptic ulcer disease (Hpylori, NSAIDs) are most common, Other causes: Esophagitis/gastritis, Mallory-Weiss tears, Arteriovenous malformations, tumors and erosions, Erosive esophagitis ( in HIV patients consider CMV, HSV, candida), Dieulafoy’s lesions (submucosal artery), gastric vascular ectasis. Aortic-enteric fistula.
3. If you suspect peptic ulcer disease, what medication do you want to start this patient on now?
a. PPI
