Upper gastrointestinal bleed: Difference between revisions
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− | == |
+ | ==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 |
− | ** pRBC to maintain |
+ | **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) |
[[Category:Gastroenterology]] |
[[Category:Gastroenterology]] |
Latest revision as of 10:40, 2 August 2020
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
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
- Pantoprazole 80 mg IV bolus then 8mg/h IV infusion x72h
- 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)