UPPER GI BLEEDING
PROFESSOR OF MEDICINE
1. Dropping hemoglobin without evidence of gross bleeding:
See patient. Workup can be postponed.
2. Coffee ground emesis or per n.g tube, 1 melanotic stool. See
patient, if stable, can postpone workup until a.m. May want
to type and screen if hematocrit is marginal. Ask nurse to
call immediately if he falls into Scenario 3.
3. Patient admitted for GI bleeding. Was stable all day but in
past hour: The n.g. tube is draining a constant stream of
bright red blood, passed 2 large maroon colored motions,
and had one episode of hematemesis. See patient ASAP. If
hemodynamically unstable ,resuscitate , transfer to IMCU
or ICU.Discuss personally the status with GI consultant.
4. Patient admitted with frank signs of cirrhosis. Just vomited
recognizable blood, passed a large maroon motion per
rectum. Hemodynamically unstable. See patient and call GI
consultant immediately. Resuscitate, order more blood that
you think you need transfer to ICU.
5. Patient had an episode of GI bleeding had successful
endoscopic hemostasis and is on oral or IV PPI. During the
past hour the patient complains of not feeling good. He or
She is sweaty, BP>:90/50, pulse >100.No gross evidence of
bleeding. See patient immediately do CAREFUL rectal
exam. If no evidence of bleeding, obtain EKG and cardiac
1. Large bore needle. One or two portals of entry.
2. Give Saline, Lactated Ringer’s or Plasma expander, wide
open for the first few hours or until vital signs are stable.
Watch for signs of overload.
3. Type and xmatch for X 2 the amount of blood that you
think the most recent hematocrit suggests if the bleeding
started in the last 24hours.
4. NG tube and Foley catheter help determine the severity of
bleeding and your success at resuscitation.
5. If you have a high index of suspicion of Variceal bleeding,
start Octreotide 50mgms bolus and 50mgms q 4-hours.
6. Start all UGI bleeders after endoscopy on oral or IV PPI.
MANAGEMENT OF PATIENTS ON WARFARIN WITH
Give 1 or two units of fresh frozen plasma
Do not give vitamin K
Can be endoscoped at any time.
After hemostasis, If patient is high risk needing
anticoagulation start on heparin.
CLINICAL FACTORS IN REBLEEDING:
1. >65 YEARS.
2. Persistent NG tube drainage of recognizable blood.
3. Patient on Warfarin, NSAIDs or both
4. Patients who start bleeding after hospitalization.
ENDOSCOPIC FACTORS IN REBLEEDING:
i. Clean Ulcer base.
ii. Cherry red spot
i. Fresh clot with underneath bleeding
ii. Visible blood vessel in the ulcer crater
iii. Actively bleeding artery.
Indications for prophylaxis[PPI ,oral and IV to keep ph
above 6, 24 hours a day]:
48 hrs. on Ventilator.
Brain trauma or Surgery.
Multiple organ failures
INDICATIONS FOR TIPS:
Failure of endoscopic therapy
Recurrent variceal bleeding
Gastric varices or Gastropathy.
MYOCARDIAL INFARCTION DURING GI BLEEDING:
50% have no chest pain.
Hemodynamic instability and CHF can occur in both.
Consider if above occurs in the absence of continuous
In elderly patients with history of CAD, consider serial
EKGs and cardiac enzymes.
Mortality rate if both coexist up to 30%