REBEL Core Cast 39.0 – Upper GI Bleed

Take Home Points

Focus on resuscitating well by focusing on the basics
Recognize Massive GIB (MGIB) with a thorough exam of the patient and vital signs (Shock index >0.7 is ABNORMAL and signals impending shock)
Obtain large bore PIV access and prioritize transfusion over crystalloids for MGIB
Get consultants on board early
Give adjunctive medications that impact mortality (ie A 3^rd generation cephalosporin in patients with variceal bleeding or a history of cirrhosis)

Not one consensus definition exists
Any bleeding from the GI tract (upper or lower) that results in
- Hemodynamic instability (hypotension, dysrhythmias)
- Poor perfusion (AMS, syncope, pallor, delayed capillary refill, decreased pulses)
- Overt and rapid bleeding
- Transfusion of ≥2 units pRBC in initial resuscitation
Spend time at the bedside looking for these things
- AMS
- Skin temperature, color
  - Pallor
  - Mottling
  - Capillary refill
- Vital signs
  - Hypotension
  - Hypoxia
  - Shock Index (HR/SBP)
    - > 0.7 is ABNORMAL
    - > 1.0 may signal a need for massive transfusion
Characteristics that may predict the need for immediate intervention
- UGIB
  - Tachycardia (LR 4.9)
  - Syncope (LR 3.0)
  - Hx of malignancy or cirrhosis (LR 3.7)
  - NG lavage returning BRB (LR 3.1)
- LGIB
  - Similar for LGIB
  - Tachycardia
  - Syncope
  - HD instability
  - Active rectal bleeding
  - Non-tender abdominal exam
  - ASA use
  - Hx/o renal failure, liver failure, malignancy
A NORMAL HR is predictive for a NON-massive GIB
- Check if patient is on a BB or CCB that may mask tachycardia
Localizing the bleed
- Hematemesis
  - UGIB
- Melena
  - Usually UGIB or
  - Proximal LGIB
- Hematochezia
  - Usually LGIB or
  - Brisk UGIB (very sick patients!)

Proton pump inhibitors (PPI)
- Cochrane Review
  - No effect on mortality, rebleeding, need for surgery
  - Decrease high risk stigmata in patients with peptic ulcer disease (PUD)
- Bottom line: Doesn’t affect mortality so don’t prioritize during the initial resuscitation. May give bolus after.
Octreotide
- Somatostatin analog, vasoconstricts the splanchnic circulation
- No effect on mortality in undifferentiated GIB
- However, can decrease
  - Initial bleeding
  - Total transfusion
  - Need for surgery
- Bottom line: Doesn’t affect mortality so don’t prioritize during the initial resuscitation. May give bolus + infusion after.
TXA
- Reduces the breakdown of fibrin clots, fibrinogen, and other plasma proteins
- Recently published HALT-IT Trial provided good quality evidence
  - No difference in 5 day mortality due to bleeding
  - There WAS an increase in VTE (adverse events)
- Bottom line: Not recommended to give routinely
- If TEG/ROTEM demonstrates excessive fibrinolysis then TXA would be indicated
Antibiotics – Cephalosporins!
- Decreases mortality in patients with variceal bleeding or undifferentiated bleeding in patients with cirrhosis
  - These patients are immunocompromised at baseline and GI bleeding puts them at risk for subsequent sepsis
  - 3^rd generation cephalosporin
    - Ceftriaxone 1 gram
    - Cefotaxime 2 grams

Focus on resuscitating well by focusing on the basics
Recognize MGIB with a thorough exam of the patient and vital signs (Shock index >0.7 is ABNORMAL and signals impending shock)
Obtain large bore PIV access and prioritize transfusion over crystalloids for MGIB
Get consultants on board early
Give adjunctive medications that impact mortality (ie A 3^rd generation cephalosporin in patients with variceal bleeding or a history of cirrhosis)

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

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