Ep 78 - Intro to EM: Upper GI bleeding

Comprehensive Overview of Upper GI Bleeds in Emergency Medicine Upper gastrointestinal (GI) bleeding is a common and potentially life-threatening condition encountered in emergency medicine. It encompasses a broad spectrum of clinical presentations, ranging from mild cases with minimal blood loss to severe, life-threatening hemorrhages. Understanding the various causes, accurate risk stratification, and appropriate management strategies are crucial for optimizing patient outcomes. Causes and Mimics of Upper GI Bleeding Upper GI bleeding originates from the upper part of the gastrointestinal tract, including the esophagus, stomach, and the duodenum. Common causes include: Mallory-Weiss Tears: These are tears at the gastroesophageal junction caused by forceful vomiting or retching. Gastritis and Peptic Ulcer Disease: These conditions involve inflammation or ulceration in the stomach or duodenum and are frequent causes of bleeding. Esophageal Varices: Dilated veins in the esophagus, often due to liver disease and portal hypertension, can rupture and cause severe bleeding. Gastroesophageal Reflux Disease (GERD): Chronic acid reflux can lead to esophagitis and bleeding. It is also important to distinguish true upper GI bleeding from conditions that mimic it. For example, blood from a nosebleed (epistaxis) may be swallowed and later vomited, simulating GI bleeding. Additionally, differentiating between hemoptysis (coughing up blood) and hematemesis (vomiting blood) is essential for accurate diagnosis. Risk Stratification Using the Glasgow-Blatchford Score (GBS) Effective management of upper GI bleeding begins with risk stratification to determine the severity of the condition and the need for urgent intervention. The Glasgow-Blatchford Score (GBS) is a widely utilized tool that helps predict the need for medical treatment and the risk of adverse outcomes. It considers several clinical parameters, including: Blood Urea Nitrogen (BUN): Elevated levels suggest significant bleeding. Hemoglobin Levels: Low levels indicate blood loss. Systolic Blood Pressure: Hypotension is a sign of significant hemorrhage. Pulse Rate: Tachycardia can indicate a compensatory response to blood loss. Clinical Signs: The presence of melena, syncope, or liver disease increases the risk score. Patients with a GBS of zero are considered low risk and may be suitable for outpatient management with appropriate follow-up. Those with higher scores require hospitalization for further evaluation and treatment, including possible endoscopy. Initial Management and Resuscitation The immediate management of patients with upper GI bleeding involves stabilizing the patient and preventing further complications. Key steps include: Airway Management: Ensuring a clear and secure airway is critical, particularly in patients with altered consciousness or ongoing vomiting. Fluid Resuscitation: Intravenous fluids are administered to maintain hemodynamic stability. Blood Product Transfusion: In cases of significant bleeding, transfusions of packed red blood cells, fresh frozen plasma, and platelets may be necessary to manage blood loss and correct coagulopathies. Role of Endoscopy Endoscopy is a crucial diagnostic and therapeutic tool in managing upper GI bleeding. It should ideally be performed within 24 hours of presentation to determine the source of bleeding and provide treatment. Urgent endoscopy is particularly indicated for patients with hemodynamic instability or signs of significant bleeding. Special Considerations for Variceal Bleeding Variceal bleeding, often seen in patients with chronic liver disease, requires specific management strategies due to its severity and associated complications. Key considerations include: Terlipressin: A vasoconstrictor that helps reduce portal pressure and control bleeding in variceal cases. Antibiotic Prophylaxis: Administered to prevent infections, which are common in patients with liver disease and variceal bleeding. Balloon