1. Core Topic
UCI Internal Medicine Residency 2012

2. Learning Objectives
Review the major causes of upper GI bleeding and
important elements of the history
Know the important elements of the physical exam
and diagnostic evaluation
Understand acute management of upper GI bleeding

3. Clinical Scenario
67 yo M with history of HTN and osteoarthritis who
presents to the ED with 3 episodes of coffee –ground
emesis today.
No abdominal pain, melena or hematochezia. No history
of liver disease or coagulopathy, +occasional ETOH use.
Medications include HCTZ, Lisinopril, and Ibuprofen PRN
for joint pain
VS on arrival: T 37, HR 102, BP 108/72, similar BP
standing , Pox 99% RA
Examination: AOx3. No scleral icterus. Abdomen soft,
non-tender, no HSM. Rectal with dark brown stool, guiac
+.
Labs: Hgb 9.8, Plt 245, INR 1, LFTs nl, BUN 28/Cr 1.4.

4. Initial Evaluation
Major causes
Peptic ulcer, esophagogastric varices, arteriovenous
malformation, tumor, esophageal (Mallory-Weiss) tear
Characteristics of bleeding
Hematemesis – coffee ground vs bright red blood
Melena
Hematochezia
History
Liver disease, alcoholism, coagulopathy
NSAID, antiplatelet or anticoagulant use
Abdominal Surgeries

5. Examination
Vitals
 Tachycardia, hypotension
Abdominal examination
 Significant tenderness, organomegaly, ascites
Rectal examination
Skin examination
NG lavage - if source of bleeding unclear
Diagnostic Evaluation
Hgb/Hct, plt count, coag studies
LFTs, albumin, BUN and creatinine
Type and screen /type and cross

6. Emergent Management
Closely monitor airway, clinical status, vital signs,
cardiac rhythm
 two large bore IV lines (16 gauge or larger)
bolus infusions of isotonic crystalloid
Transfusion
pRBCs – Hgb <7, hemodynamic instability
FFP, platelets – coagulopathy, plt <50 or plt dysfunction
Triage – ICU vs Wards
Hemodynamic instability or active bleeding > ICU
Immediate GI consult

7. Medications
Acid Suppression
PPI
 Protonix 80mg IV bolus, then 8mg/hr infusion
 Esomeprazole at the same dose
Somatostatin analogues
Suspected variceal bleeding/cirrhosis
Octreotide 50mcg IV bolus, then 50mcg/hr infusion
Antibiotics
Suspected variceal bleeding/cirrhosis
Most common regimen is Ceftriaxone (1 g/day) for seven
days
 Can switch to Norfloxacin PO upon discharge

8. Clinical Scenario Conclusion
67yo M on NSAIDS with 3 episodes of coffee –ground
emesis, anemia, and tachycardia
What is the likely etiology of the bleeding?
What is the appropriate acute management?

9. Clinical Scenario Conclusion
67yo M on NSAIDS with 3 episodes of coffee –ground
emesis, anemia, and tachycardia
What is the likely etiology of the bleeding?
 Suspect peptic ulcer disease or gastritis
What is the appropriate acute management?
 Airway stable, cardiac monitoring
 Two 16 gauge IVs, immediately given 1L NS bolus and
tachycardia improved
 Type and cross sent
 Protonix 80mg IV x 1, then continuous infusion of 8mg/hr
 GI consult called
 Admitted to Medicine Wards

10. Take Home Points
Obtain a good history to identify potential sources of the
upper GI bleed and assess the severity of the bleed
Exam and diagnostic data should focus on signs that
indicate the severity of blood loss, help localize the source
of the bleeding, and suggest complications (ie perforation)
Emergent management includes ABCs, two large caliber
IVs, fluid resuscitation, possible transfusion
All patients should be treated initially with PPI. If you
suspect variceal bleed, add somatostatin analogue and
empiric antibiotics
Triage appropriately to ICU vs Wards, and contact GI
immediately