UPPER GI BLEEDING by LFnO319

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									                   UPPER GI BLEEDING
                 WALTER M.ROUFAIL,M.D.
                 PROFESSOR OF MEDICINE



SCENARIOS:
  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
     enzymes.
RESUSCITATION MEASURES:
  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
INR>2.5:
          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:
       LOW RISK:
           i. Clean Ulcer base.
          ii. Cherry red spot

          HIGH RISK:
              i. Fresh clot with underneath bleeding
             ii. Visible blood vessel in the ulcer crater
            iii. Actively bleeding artery.
STRESS ULCERS:
    Indications for prophylaxis[PPI ,oral and IV to keep ph
    above 6, 24 hours a day]:
     48 hrs. on Ventilator.
     Brain trauma or Surgery.
     Burn Unit.
     Scepticemia.
     Shock.
     Multiple organ failures



INDICATIONS FOR TIPS:
     Failure of endoscopic therapy
     Recurrent variceal bleeding
     Gastric varices or Gastropathy.
     Intractable Ascites.


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
     bleeding.
    In elderly patients with history of CAD, consider serial
     EKGs and cardiac enzymes.
    Mortality rate if both coexist up to 30%

								
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