Upper GI Bleed

Kumar R, Mills AM. Gastrointestinal Bleeding. EM Clin N Am. 2011; 29:239-52.

Mortality from UGIB:

• Peptic ulcer disease (PUD) = 4%
• Esophageal varices = 50%

Common causes: PUD (55%) > esophageal varices, gastritis, Mallory-Weiss tears

Risk factors:
• Medications
- ASA use (<100 mg/d), anticoagulation agents, antiplatelet agents = 3x risk
- NSAIDs
- Glucocorticoids
• Coagulopathies, HIV infection, Liver disease, Prior GI bleed, Prior irradiation for
prostate/pelvic cancer, Tobacco use, Alcohol use, Vascular Disease

Exam:
• Iron or bismuth ingestion can result in melanotic stool --> fecal occult blood negative
• Beets ingestion can result in red stool --> fecal occult blood negative

Diagnostic Testing:
• BUN/Cr
• Hematocrit and platelet count
• Liver function test
• PT/PTT
• Type and screen (or cross)
• EKG, if significant bleed and/or risk for ACS

Tip:
• BUN-Cr ratio ≥ 36 predicts UGIB (sensitivity 90-95%), assuming no h/o renal failure

Transfusions:
• pRBC - Target hematocrit for…
- Variceal bleed: Goal = 27 (conservative transfusion b/c risk of rebleed)
- Young patient without CV risk: Goal = 25-27
• FFP: Should also be given for patients with coagulopathy and for every 4 pRBC units
(add 1 unit FFP per 4 units pRBC).
- Dose: 10-15 cc/kg with 1 unit of FFP containing 200 cc. (per Rosen text)
- Typical adult dose = 3-4 units FFP
• Platelets: Indicated for platelets < 50K in setting of active bleed
- Dose: 1 unit platelets/10 kg. Typical adult dose = 6 units (“6 pack”). 1 unit
raises platelet count 5K-10K. (per Roberts/Hedges text)

Medications:
• H2 blockers: No benefit.
• Proton pump inhibitor (PPI): Reduces risk of rebleeding, need for surgical
intervention and transfusion. Questionable if mortality reduction.
• Octreotide: Decreases risk for persistent and recurrent bleeding from variceal and
nonvariceal bleeding. Decreases need for transfusion. No mortality reduction. Dose:
50 mcg IV bolus and then 50 mcg/hr IV drip.