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:
  
  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:
    
  • 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.