0071643192.pdf

■ Mallory-Weiss tears present with bright red hematemesis after an episode

of forceful retching or vomiting.

■ Gastric ulcers typically present with pain immediately after eating. Duo-

denal ulcers typically present with night time pain or pain 2–3 hours after

eating.

EXAM

■ Skin for signs of shock, as well as for signs of liver dysfunction such as

jaundice or hemangiomas

■ Abdominal exam to assess for organomegaly or ascites, as well as abdominal

tenderness

■ Heme occult

DIAGNOSIS

■ History, rectal exam, nasogastric lavage

■ Inquire about medications, alcohol consumption, risk factors for viral

hepatitis, and previous history of GI bleeds.

■ NGT to evaluate ongoing bleeding

■ Hematocrit, platelets, coagulation profile, type, and crossmatch

■ Note that the initial HCT may not reflect blood loss due to hemoconcen-

tration.

■ Serial HCT to follow trend

■ Early endoscopy for both diagnostic and therapeutic purposes

TREATMENT

See Figure 11.3.

■ Treatment begins with securing an airway if necessary. Most common

cause of early death in upper GI bleeding is aspiration.

■ Insert a nasogastric tube to see if the patient is actively bleeding or if bleed-

ing has stopped.

■ Lavage with water until aspirate clears.

■ Volume replacement should be initiated with crystalloid.

■ Failure to achieve adequate resuscitation after 2 L of crystalloid is gener-

ally an indication for blood replacement.

■ Patients who are on Warfarin or have liver dysfunction may require coagu-

lation replacement with FFP and Vitamin K.

■ Proton pump inhibitors: Omeprazole IV bolus at 80 mg and a drip at

8 mg/hr for presumed ulcer or variceal hemorrhage

■ IV octreotide (25–50 μg bolus followed by drip at 25–50 μg/hour) and IV

antibiotics (third-generation cephalosporin/fluoroquinolone) if cirrhosis is

suspected

■ Early endoscopyfor direct interventions for hemostasis (focal cautery, epi-

nephrine injection, banding, and sclerotherapy)

■ Balloon tamponade (Sengstaken-Blakemore and Minnesota tubes) may be

used to stop hemorrhage; strongly advise prior airway protection

■ Transjugular intrahepatic portosystemic shunt (TIPS) may be required for

refractory variceal bleeding.

■ Treat concomitant H. pyloriinfection if suspected peptic ulcer disease (see

Table 11.1).

ABDOMINAL AND GASTROINTESTINAL

EMERGENCIES

Predictors of high mortality

include initial HCT < 30,

advanced age, hypotension or

presence of shock, and a

physical exam consistent with

advanced liver disease.