- There’s plenty of time to take history and physical from the pt
- More likely to come to the clinic w\ coffee ground than fresh blood
- Ask about medications: NSAIDS and anticoagulants
- Physical exam:
- Vital signs (tachycardic), general inspection of the pt, abdominal exam
CASE: 65 yo lady, repeated episodes of vomiting in the morning with coffee ground blood, taking NSAIDS, some tachycardia, and mild epigastric tenderness, no other relevant physical findings. Ddx?
- PUD, stomach Ca, esophageal varices
- Side note: aspirin is taken as prophylaxis against ischemic hear disease, colon ca, prostate ca
What to do next?
- Labs: CBC and coagulation profile
- Definitive dx: endoscopy (shows reflux, esophagitis, varices, duodenal or gastric ulcer, malignancy)
How to manage?
- Most of UGIB are treated medically/conservative -> PPI + eradication (after confirming H. pylori)
- If gastric ulcer -> take biopsy, why? High risk of malignancy (not if duodenal, though)
- Start w\ resuscitation (before h&p)
- If it’s severe enough -> consider urgent endoscopy as emergency to identify the source of bleeding
- During resuscitation we give blood, but has its own limitations
- Massive blood transfusion -> coagulopathy (↓), hypothermia, acidosis
- Duodenal\gastric ulcers, esophageal varices (in cirrhosis pts, it’s more common to bleed from an ulcer than varices), Mallory weiss, cancer
How to manage?
- If esophageal varices -> endoscopic banding -> if persists; esophageal transection
- If duodenal ulcer -> clips, andrenaline injection, diathermy -> if bleeds again and you can see a big pulsating blood vessel -> over saw ulcer + ligate gastroduodenal artery
- If gastric ulcer -> potentially malignant -> excision
- If cancer -> temporary clip + adrenaline
If massive massive bleeding or in trauma pts; best place to resucitate is in the OR -> do endoscopy there and try to stop the bleeding there; It might be an aorto-enteric fistula (prev aortic surgery -> graft -> infection -> erosion into GIT)
Download the PDF version: here
- Dr Boghdadly’s lecture