The Upper GI Bleeder

By Kane Guthrie FCENA

Upper GI Bleeds

• Understand the causes• Goals of resuscitation• Pharmacological resuscitation• Procedural resuscitation

Upper GI Bleeds in ED

• Its challenging• Effective Mx = good PT outcomes• Underlying comorbidities ∧ complexities• Team approach• Pharmacology & procedural approach

Upper Vs Lower

• Consider upper first– More life threatening

• Haematemisis = Upper GI source• Bright red blood not always = LOWER GI

Case Study

• 52 Male• Chronic ETOH abuse• Known varices

C/O – Vomiting blood post binge

What to Look for!

His Vitals

The Upper GI Bleeder

Multi Team Approach:• ED, ICU – resuscitate• Gastro – scope• Interventional Radiologist – therapeutic Ix• Surgeons – surgical intervention

The Source

• Duodenal ulcers- 28%• Gastric ulcers- 26%• Gastritis- 13%• Varices - 12%• Esophagitis - 8%

• “Massive GI Bleed Mortality rate 20-39%”

The DDx!

• Intranasal• Intrapulmonary

Remember!

Early Interventioncan mean

difference between

Life & Death

The 3 Goals of Resuscitation

1 Provide Intravascular Volume Resuscitation

2 Optimise Oxygen-Carrying Capacity

3 Reverse Coagulopathy

Initial Resuscitating

• Start with ABCDE• x2 Large bore IVC – Bloods• Full monitoring• Get specialties involved• Arrange blood products• Consider limitations of care!

Intravascular Volume Resuscitation

• Limit crystalloid fluid –to early phase

Prepare for transfusion:• HB <80• Coagulopathy• Persistent hypotension

Intravascular Volume Resuscitation

• PRBC’s not enough• Replace clotting factors• Consider massive transfusion protocol• “PRBC:FFP:platelet ratio 1:1:1”

• Tranexamic Acid?

Optimise Oxygenation

Signs of decreased O2 delivery:– Decreased LOC– Evidence of cardiac ischaemia– Increased lactate– Cold peripheries

Optimise Oxygenation

• Give blood so oxygen can get to the tissue

Initially:– Provide High Flow 02

Crashing:• Intubate early

Stablised:• Titrate oxygen to need• Considered humidified

Intubating Isn’t Easy!

1. Intubate early2. Empty stomach (NGT)3. Intubate with HOB at 45°4. Preoxygenation5. Limit BVM6. Use experience7. Prepare for vomit

Reverse Coagulopathy

• Tailor to etiology.

Causes:• Anticoagulation• Shock– Metabolic acidosis –tissue hypoperfusion

• Chronic disorders– ETOH abusers

Pharmacological Interventions

• Proton Pump Inhibitors• Somatostatin• Vasopressin

Proton Pump Inhibitors

• Suppress gastric acid production• Potential reduction haemorrhage during scope

The evidence though:

Somatostatin

• (Octreotide)Reduces:• Portal venous blood flow• Splachinic vasoconstriction

=decrease GI Bleeding

Use• Variceal GI bleeds• Limited evidence – low side effect profile

Vasopressin

(Telipressin)• Reduces portal hypertension• Splachnic vasoconstrictor• Can cause ischaemia

• Last ditch effort in bleeding varices

Antibiotics

• Infection on varices– Causes bleeding

• Give antibiotics (broad spectrum)

Procedural Interventions

• Endoscopy• Balloon Tamponade

Endoscopy

• Diagnostic & therapeutic tool

Interventions:• Clips• Banding• Thermocoagulation• Sclerosant injection % adrenaline

Balloon Tamponade

Balloon Tamponade

• Temporising rescue device

Indicated:– Endoscopy not available– Endoscopy not successful

• Need to secure airway prior

Questions

Take Home Points

• Early recognition• Team approach is needed• Resuscitate with blood products• Advocate for early intervention