Variceal UGIB

In our Morning Report at WCH this week, we discussed an approach to the evaluation and management of upper gastrointestinal bleeding due to varices.

Learning Points:

  1. Differential diagnosis of UGIB
  2. Colour code scheme for IV access
  3. Critical elements of past medical history
  4. Pertinent investigations in the bleeding patient
  5. Management of variceal UGIB & coagulopathy

Differential Diagnosis of UGIB

  • Pearl: blood coming from the mouth may be from 3 sources:
    • Upper airway (i.e. retrograde epistaxis)
    • Lower airway (i.e. hemoptysis)
    • Gastrointestinal tract (UGIB)
  • Causes of true UGIB include:
    ddx-ugib
    IV access for resuscitation in the setting of UGIB

    • Insert “large bore” but what does this mean?
      • Smaller gauge/bore=wider
      • Large guage/bore=narrower
    • How to recognize the “bore” based on the catheter colour:
      IV Gauge and Colour.png
    • For massive UGIB, ideally want a 14 or 16 guage (or central line)
      • Note: PICCs are suboptimal for urgent resuscitation (long, narrow catheter confers maximal resistance)
        • large bore IV > PICC line for acute resuscitation

Big-Picture Questions of Relevance on History:

  1. Guided by differential diagnosis (see above)
  2. Make bleeding harder to control: coagulopathy, thrombocytopenia, liver dysfunction
  3. Make someone susceptible to complications of anemia (heart disease, lung disease)
  4. Increased risk of complications from transfusion/resuscitation (kidney disease, CHF)
  5. Conditions that may predispose to aspiration (dementia/hepatic encephalopathy; intubation to be considered in such settings)

Pertinent Investigations in the Bleeding Patient:

Test

Rationale For

CBC/differential

(should also be repeated serially depending on severity)

Low Hb/Plt–transfuse
INR/aPTT Coagulopathy/supratherapeutic warfarin and need for reversal
Group and Screen, Crossmatch Preparation for needing transfusion
Lytes/Cr/BUN Very elevated BUN:Cr supports UGIB
LFTs, albumin Possible liver disease/variceal bleed
Amylase/Lipase/abdo xray Pancreatitis or intraabdominal free air- risk of perforated ulcer
CK/Trop/ECG Risk of demand-related ACS in setting
CXR If hx severe n/v and Boerhave a consideration

Investigation clues indicative of variceal bleeding:

  • History and physical examination may point to the potential of known or unknown existing liver disease; investigations can further help to identify
  • Findings potentially indicative of liver disease on bloodwork include:
    • Thrombocytopenia
    • Macrocytosis
    • Blood Film: Burr Cells, Acanthocytes
    • Elevated INR/aPTT
      • Note: coagulopathy in liver disease due to reduced synthesis of clotting factors and thrombocytopenia; this can potentiate bleeding due to existing anatomic lesions such as varices
    • Hyponatremia
    • Elevated AST, ALT, ALP, Bili
    • Hypoalbuminemia

Management Principles:

  • Pearl: Approach to answering the question “how you would manage this patient?” follow through admission orders!
    • A: Admit-to ward vs ICU, depends on severity
    • D: Diagnosis-Variceal UGIB
    • D: Diet-NPO
    • A: AAT/Bed rest?
    • V: Regular vital signs monitoring; in severe bleeding/hemodynamic instability, may require continuous invasive monitoring
    • I: Investigations, as above
      • if ascites, diagnostic paracentesis to rule out SBP
    • D: Drugs and other
      • Pantoprazole IV bolus + infusion
      • Octreotide IV bolus + infusion
      • Ceftriaxone (reduces mortality in variceal UGIB in patients with ascites)
      • Treat coagulopathy/anemia
        • Hb<70 or anticipated to fall: pRBC transfusion
        • Platelets <50: pool of platelets
        • Abnormal coags in bleeding patient: Vitamin K + Fresh Frozen Plasma

Further Reading:
Garcia-Tsao, G; and Bosch, J. Management of Varices and Variceal Hemorrhage in Cirrhosis. N Engl J Med 2010;362:823-32.

 

 

 

 

 

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