Critical Cases - Upper GI Bleed!
- 44 yo reported history of diabetes (not on any meds), heavy daily alcohol use (12 beers per day), no known history of liver or varices disease presents reporting abdominal pain x 12 hours
- Epigastric in location. Burning in character. Nothing makes it better or worse. Severe, 10/10.
- Pt reports associated hematemesis, bright red blood for the past 12 hours. He also reports melena for the past 12 hours. Unable to quantify.
- Abdominal pain and vomiting started about 1 hour after binge drinking 10 beers last night.
Vitals T 98.8 BP 92/50 HR 148 Pox 97%
- Appears uncomfortable, pale, answers in mostly one word responses
- Lungs: clear bilaterally
- Heart: tachycardic
- Abdomen: soft, epigastric tenderness, no pulsatile masses
DDx for hematemesis
- Gastric and/or duodenal ulcers
- Severe or erosive gastritis/duodenitis
- Severe or erosive esophagitis
- Esophagogastric varices
- Mallory-Weiss syndrome
Management of unstable GI bleed
- Closely monitor airway status
- Obtain and maintain at least two large bore IV access (16 gauge)
- Treat hypotension initially with bolus infusions of isotonic crystalloid
- Transfuse 2 to 4 units PRBCs on per institutional emergent protocol
- Obtain immediate consultation with gastroenterologist and intensivist
- Give a proton pump inhibitor
- If suspected varices, give octreotide and ceftriaxone
- Consider balloon tamponade with Blakemore tube as temporizing measure
Patient management and outcome
- Patient had one witnessed episode of large volume hematemesis in ED
- Received 2 units PRBC, PPI, octreotide, ceftriaxone
- GI performed emergent EGD and variceal banding in ICU
Take home pearls
- Patients will not regurgitate textbook buzz words like "varices, alcohol use disorder, portal hypertension, melena" when relaying their history!
- Do not anchor on triage note: this patient with esophageal varices and massive hematemesis requiring time sensitive intervention was triaged as: “Abdominal pain. Started yesterday. No vomiting. Diarrhea”
Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Med Clin North Am. 2008 May;92(3):491-509, xi. doi: 10.1016/j.mcna.2008.01.005. PMID: 18387374.