Ver el código de «Undifferentiated upper gastrointestinal bleeding»

==Background==
*Bleeding originating proximal to ligament of Treitz
*In the acute setting, the hemoglobin/hematocrit may be normal until dilutional anemia appears after volume resuscitation

==Prehospital==
*'''Airway:''' suction to prevent aspiration, provide oxygen as needed
*'''Breathing''': maintain patient is position of comfort
*'''Circulation:''' monitor for early signs of shock, and provide fluid resuscitation if hypotensive. Blood products should be individualized based on local protocols
*[[Antiemetics]] can be given to decrease nausea and vomitting
*Assume the patient is hepatitis positive and wear appropriate personal protective gear

==Clinical Features==
===History===
*Hematemesis
*Coffee-ground emesis
*Melena + age <50 suggests upper GI bleed
*[[Vomiting]] + retching followed by hematemesis = Mallory-Weiss
*Aortic graft = aortoenteric fistula
*Meds
**[[ASA]], steroids, [[NSAIDs]], anticoagulants
*ETOH abuse
**Peptic ulcer disease, gastritis, varices

===Physical Exam===
*Tachycardia, hypotension
*Liver disease
**Spider angiomata, palmar erythema, jaundice, gynecomastia
*Coagulopathy
**Petechiae/purpura
*ENT exam
**Swallowed blood may result in coffee-ground emesis or melena
*Rectal exam
**Only 20% of patients with a positive fecal occult have an identified upper GI bleed. UGI Bleed should not be ruled out based on a negative test<ref>Allard J  et al. Gastroscopy following a positive fecal occult blood test and negative colonoscopy: systematic review and guideline. Can J Gastroenterol.2010;24(2):113-120.</ref>

==Differential Diagnosis==
*[[Peptic ulcer disease]] (most common cause)
*[[Gastritis]]/[[esophagitis]]
*Gastric/esophageal varices
*[[Mallory-Weiss tear]]
*Malignancy
*[[Aortoenteric fisulta]]
*[[Boerhaave]]
*Dieulafoy's lesion
*Angiodysplasia
*Hemobilia
*Hemorrhagic gastritis, EtOH
*Celiac
*Dengue
*Other intrabdominal bleeds
**Hemorrhagic pancreatitis
**Splenic rupture 
**Subcapsular cavernous hemangiomas
**Peliosis hepatis 

===Mimics of GI Bleeding===
*[[Hemoptysis]]
*[[Vaginal Bleeding (Main)|Vaginal]]/[[Hematuria|Urethra]] bleeding
*ENT bleeding
*Dietary (Iron, bismuth, beets)

==Diagnosis==
[[File:Sengstaken-Blakemore_scheme_EN.png|thumbnail|Sengstaken-Blakemore Tubel]][[File:Sengstaken-Blakemore_tube_EN-2.png|thumbnail|Sengstaken-Blakemore Tube Placement]]
===Workup===
*2 large bore IVs
*Type and cross
*CBC & serial Hb
*Chemistry
**BUN/Cr >30 suggests UGI if no hx of renal failure (incr absorption/digestion of hb)
*Coags 
*LFTs
*Guiac
*?ECG (if >50 yo or if suspicious for silent MI)
*?CXR (if suspect perforation)

===NG Lavage Controversy===
*'''Pros'''<ref name="ali">Aljebreen AM et al. Nasogastric aspirate predicts high-risk endoscopic lesions in patients with acute upper-GI bleeding. Gastrointest Endosc. 2004;59(2):172-178.</ref>
**Positive aspirate proves strong evidence for an UGI source of bleeding
**Can assess presence of ongoing active bleeding
**Can prepare patient for endoscopy
*'''Cons'''<ref name="ali"></ref>
**Uncomfortable
**Negative aspirate does not conclusively exclude UGI source
**Provides useful information in only minority of patients without hematemesis
**[[Erythromycin]] 200mg IV can provide equal endoscopy conditions as lavage<ref>Huang ES et al. Impact of nasogastric lavage on outcomes in acute GI bleeding. Gastrointest Endosc. 2011;74(5):971-980.</ref>

==Management==
{{Upper GI bleed treatment}}
===Special Circumstances===
*Acute variceal bleeding
**[[Octreotide]] (50 mcg IV bolus, then 50 mcg/hr continuous, maintained at 2-5 days)<ref>Augustin S et al. Acute esophageal variceal bleeding: Current strategies and new perspectives. World J Hepatol. 2010 Jul 27; 2(7): 261–274.</ref>
**Judicious IVF and blood products
**Emergency endoscopy for ligation, banding, and/or sclerotherapy
**Antibiotics
***For short-term prophylaxis against SBP and bacteremia<ref>Lee YY et al. Role of prophylactic antibiotics in cirrhotic patients with variceal bleeding. World J Gastroenterol. 2014 Feb 21; 20(7): 1790–1796. </ref>
***Recommend administering antibiotics prior to endoscopy or as soon as possible after endoscopy
***[[Ciprofloxacin]] IV or PO 500 mg BID x7 days
***OR [[ceftriaxone]] 1gm daily x 7 days
****Indicated for patients with cirrhosis or history of [[ETOH abuse]] (regardless of whether bleeding is variceal or not)
****More effective than [[quinolones]]<ref>Fernandez J, Ruiz dA, Gomez C, et al. Norfloxacin vs ceftriaxone in the prophylaxis of infections in patients with advanced cirrhosis and hemorrhage. Gastroenterology. 2006;131:1049–1056.</ref>
*Vasopressin associated with many vasoconstrictive complications to include peripheral necrosis, dysrhythmias, myocardial ischemia <ref>GI Bleeding: An Evidence-Based ED Approach. EB Medicine. http://www.ebmedicine.net/topics.php?paction=showTopicSeg&topic_id=75&seg_id=1507</ref>
**0.4 unit bolus, then infuse at 0.4 - 1 unit/min<ref>Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.</ref>
**Give with IV nitroglycerin at 10 - 50 mcg/min to bolster portal hypotension and reduce vasopressin systemic effects<ref>Tsai YT, Lay CS, Lai KH, et al. Controlled trial of vasopressin plus nitroglycerin vs. vasopressin alone in the treatment of bleeding esophageal varices. Hepatology 1986; 6:406.</ref>
**Terlipressin (analog of [[vasopressin]], available outside U.S.)
***Alternative to [[vasopressin]] with mortality benefit
***Given as 2 mg IV q4 hrs, then decrease to 1 mg IV q4 hrs until bleeding stops<ref>Ioannou G, Doust J, Rockey DC. Terlipressin for acute esophageal variceal hemorrhage. Cochrane Database Syst Rev 2003:CD002147.</ref>
*No evidence for [[tranexamic acid]] (TXA); HALT-IT trial RCT underway<ref>Roberts I et al. HALT-IT - tranexamic acid for the treatment of gastrointestinal bleeding: study protocol for a randomised controlled trial. Trials. 2014; 15: 450.</ref>

===[[Intubation]]===
*Protection of airway from massive aspiration, especially prior to endoscopy
*Does not seem to protect against pneumonia or cardiopulmonary events<ref>Rudolph SJ et al. Endotracheal intubation for airway protection during endoscopy for severe upper GI hemorrhage. Gastrointest Endosc. 2003 Jan;57(1):58-61.</ref>
*Have bed-side [[Push-dose pressors|push-dose pressors]] on hand
*'''NO CHRISTMAS'''<ref>Weingart S. EMCrit Podcast 5 – Intubating the Critical GI Bleeder. June 2009. http://emcrit.org/podcasts/intubating-gi-bleeds/</ref>
**'''N'''GT (salem sump to remove stomach contents)
***Varices not contraindication to NGT
***Consider metoclopramide 10 mg IV
**Good pre-'''O'''xygenation critical
**'''C'''hest and '''H'''OB elevation to 45 degrees - consider intubating from 45 degrees to prevent gastric contents coming up
**'''R'''SI - consider halving dosages for lost blood volume
***Etomidate or ketamine for sedation
***Succinylcholine and vecuronium increases LES tone
**'''I'''ntubation with strong chance for first pass
**'''S'''low and gentle BVM breathes at 10 breathes/min if first pass fails
**'''T'''rendelenberg if vomiting, keeping emesis out of lungs (have many suctions available before this happens)
**'''M'''econium aspirator may be hooked up to ETT for large bore suction
**'''A'''ntibiotics not needed in early phase of aspiration
***Chemical pneumonitis in first 24 hours, no bacterial pneumonia
***Early antibiotics may predispose patient to resistant bacterial superinfection
**'''S'''IRS-like response often occurs from aspiration, but otherwise not sepsis if there is no other concerning source or suspicion
***May require pressors and fluids
***Consider withholding early antibiotics, but doing the rest of the sepsis treatments

==Disposition==
===Admission===
*Age >60yr
*Transfusion required
*Initial Sys BP < 100
*Red blood in NG lavage
*History of cirrhosis or ascites on exam
*History of vomiting red blood

===Consider Discharge===
''If [[Glasgow-Blatchford Bleeding Score]] of 0 (<1% chance of requiring intervention):<ref>Tacke F, Fiedler K, Trautwein C. A simple clinical score pre- dicts high risk for upper gastrointestinal hemorrhages from varices in patients with chronic liver disease. Scand J Gastro- enterol. 2007;42(3):374-382.</ref>.  Must meet ALL of the following:''
*BUN <18
*Hb >13 (men), Hb >12 (women)
*Sys BP >110
*HR <100
*Patient did NOT present with melena
*Patient did NOT present with syncope
*No hepatic disease
*No cardiac failure

==See Also==
*[[Lower GI Bleeding]]
*[[Upper GI Bleed Guidelines]]
*[[Balloon tamponade]]
*[[EBQ:Omeprazole in Bleeding Peptic Ulcers]]

==References==
{{Reflist|2}}

[[Category:GI]]