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:
- Differential diagnosis of UGIB
- Colour code scheme for IV access
- Critical elements of past medical history
- Pertinent investigations in the bleeding patient
- 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
- Note: PICCs are suboptimal for urgent resuscitation (long, narrow catheter confers maximal resistance)
- Insert “large bore” but what does this mean?
Big-Picture Questions of Relevance on History:
- Guided by differential diagnosis (see above)
- Make bleeding harder to control: coagulopathy, thrombocytopenia, liver dysfunction
- Make someone susceptible to complications of anemia (heart disease, lung disease)
- Increased risk of complications from transfusion/resuscitation (kidney disease, CHF)
- 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.