Upper gastrointestinal bleed

Etiology

• Bleeding peptic ulcer
  • Duodenal ulcer (20-30%)
  • Gastric ulcer (10-20%)
• Gastric or duodenal erosion (20-30%)
• Bleeding esophageal varices (15-20%)
• Other
  • Mallory-Weiss tear (5-10%)
  • Erosive esophagitis (5-10%)
  • Angioma (5-10%)
  • Arteriovenous malformation (<5%)
• Very rare
  • GIST
  • Dieulafoy lesion
  • Cancer

Clinical Manifestations

History

• Hematemesis
• Melena stools
• Nausea, abdominal pain

Signs & Symptoms

• Hematemesis
• Melena stools (50-100mL blood loss)
• Hematochezia (500-1000mL blood loss)
• Signs of hypovolemia or shock
• Signs of liver disease and portal hypertension, if variceal bleed

Risk Stratification

• Rockall score (requires endoscopy)
• Blatchford score
  • >12 suggests need for endoscopy
• Forrest classification of ulcers on endoscopy
  • 1a active spurting and 1b oozing have a 55% rebleed rate
  • 2a visible vessel and 2b adherent clot
  • 3 flat spot or clean-based ulcer

Investigations

• Other
  • FOBT + with 10-20mL blood loss in UGIB (0.5mL in LGIB)
  • Upper endoscopy within 24 hours

Management

• Fluid resuscitation
  • Transfuse pRBC to maintain hemoglobin over 70
• Bleeding ulcer
  • Pantoprazole 80 mg IV bolus then 8mg/h IV infusion x72h
    • Reduces rebleeding of ulcers but not mortality
    • Alternate: Pantoprazole 40 mg IV bid x72h
    • Step down to oral therapy bid x28d then to once daily
  • OGD within 24 hours
• Variceal bleed
  • Ceftriaxone 1 g IV daily for 7 days
  • Octreotide 50 mcg IV bolus then 50mcg/h IV infusion
  • If bleeding continues, Blakemore tube (deflate within 12h for OGD)
  • OGD within 12h
• For both, endoscopy within 24h if Blatchford score >12 (urgent endoscopy not required)