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Snapshot
  • A 65-year-old migrant who works as a construction worker presents to the emergency room after being found in the portable restroom with blood around his mouth. According to his co-workers, the patient had been taking more ibuprofen, tylenol, and aspirin due to lower back pain. The patient's blood pressure is 80/40 mmHg, pulse is 140/min, and respirations are 30/min. The patient is unconscious. Large-bore intravenous access is established, after which the patient is sedated and intubated for airway protection. The patient receives 2 units of red blood cells while the laboratory results are processing. The patient is emergently brought to the operating room for an upper endoscopy, where a bleeding stomach ulcer is found. 
Introduction
  • Overview
    • upper gastrointestinal bleeding (UGIB) is pathologic bleeding in the upper gastrointestinal tract proximal to ligament of Treitz (suspensory ligament where duodenum transitions to jejunum)
  • Epidemiology 
    • most GIBs are UGIBs (75%)
      • above the GE junction
        • epistaxis
        • esophageal varices
        • esophagitis
        • esophageal cancer
        • Mallory-Weiss tear
      • stomach
        • gastric ulcer
        • gastritis
        • gastric cancer
        • gastric antral vascular ectasia
        • Dieulafoy's lesion
      • duodenum
        • duodenal ulcer
        • aortoenteric fistula
      • coagulopathy
      • vascular malformation
    • risk factors
      • alcohol use
      • tobacco use
      • liver disease
      • repeated NSAID/aspirin use
      • chronic vomiting
      • history of peptic ulcer disease
  • Prognosis
    • most stop spontaneously (80%)
    • mortality due to peptic ulcer bleeding low (2%) unless rebleeding occurs (10%)
    • endoscopic predictors of rebleeding
      • spurt/ooze
      • visible vessel
      • fibrin clot
    • esophageal varices have high rebleeding rate (55%) and mortality (30%)
    • H2-antagonists have little impact on rebleeding rates and need for surgery
Presentation
  • Symptoms
    • order of severity (most to least)
      • hematochezia, hematemesis, coffee ground emesis, melena, occult blood in stool
      • rarely hematochezia (more common in lower GI bleeds)
      • hematemesis (bloody vomiting)
        • coffee ground appearance
        • can threaten the airway 
      • melena (dark stools)
        • secondary to metabolized RBCs passing into lower GI tract
      • some cases may not present with observable bleeding
    • malaise/weakness
    • fever
  • Physical exam
    • inspection
      • tachycardia, fever
      • poor capillary refill, pale conjunctiva
    • provocative tests
      • positive stool guaiac
      • orthostatic hypotension
Studies
  • Serum labs
    • complete blood count
      • recall that hematocrit is not an accurate measure of acute blood loss
      • may be used to monitor treatment (i.e. effectiveness of transfusions)
    • type and screen
    • coagulation studies (PT / PTT / INR)
    • chem-10
  • Invasive studies
    • endoscopy 
      • may identify specific anatomic source of bleeding, and can facilitate banding procedures
Differential
  • Lower gastrointestinal bleeding (below ligament of Treitz)
Treatment
  • Medical
    • resuscitation (circulation, airway, breathing) 
      • intubation may be indicated to protect the airway
      • intravenous fluid resuscitation for hypotension
      • blood transfusion to raise hemoglobin
        • transfusion goal of hemoglobin > 7 g/dL is associated with fewer transfusions, better survival, and fewer adverse events
    • empiric treatment of underlying condition
      • intravenous proton pump inhibitors for peptic ulcer disease
        • for clot stabilization, NOT ulcer healing acceleration
        • decreases need for endoscopic intervention if administered before endoscopy
      • suspected/confirmed variceal bleeding
        • octreotide
          • for splanchnic vasoconstriction
        • antibiotic prophylaxis (e.g. ceftriaxone, norfloxacin)
          • reduces bacterial infection, rebleeding rate, hospitalization length, and all-cause mortality
    • keep NPO
  • Surgical
    • epinephrine injection + thermal hemostasis
      • for bleeding peptic ulcers
    • endoscopic banding or sclerotherapy
      • indicated for esophgeal varices
        • both are equally effacious
    • open surgical procedure
      • rarely required, indicated only in severe bleeds
    • transjugular intrahepatic portasystemic shunt (TIPS)
      • consider in patients with recurrent variceal bleeding
        • 1st two bleeding episodes should be managed endoscopically and TIPS should be considered on 3rd episode
      • recommended for patients with Child-Pugh B or C cirrhosis
 

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Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M3.GI.13) A 65-year-old man presents to the emergency department with blood in his vomit. The patient is an immigrant and has no known past medical history. He drinks alcohol regularly, endorses IV drug use, and is currently sexually active with both men and women. His temperature is 99.4°F (37.4°C), blood pressure is 166/104 mmHg, pulse is 82/min, respirations are 22/min, and oxygen saturation is 99% on room air. Physical exam is notable for an obese man with a distended abdomen. A fluid sample is sent from the fluid collection seen in Figure A. During the patient's exam, he begins vomiting bright red blood again. He stops vomiting after receiving omeprazole and ondansetron. Laboratory studies are ordered as seen below.

Hemoglobin: 7.9 g/dL
Hematocrit: 25%
Leukocyte count: 8,200/mm^3 with normal differential
Platelet count: 192,500/mm^3

The patient is started on IV fluids. Which of the following is the most appropriate next step in management?
Review Topic

QID: 102642
FIGURES:
1

Balloon tamponade

0%

(0/6)

2

Esophagogastroduodenoscopy

33%

(2/6)

3

Nadolol

17%

(1/6)

4

Packed red blood cells

33%

(2/6)

5

Transjugular intrahepatic portosystemic shunt

17%

(1/6)

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(M2.GI.15) A 55-year-old man presents to the emergency department with hematemesis that started 1 hour ago but has subsided. His past medical history is significant for cirrhosis with known esophageal varices which have been previously banded. His temperature is 97.5°F (36.4°C), blood pressure is 114/64 mmHg, pulse is 130/min, respirations are 12/min, and oxygen saturation is 98% on room air. During the patient's physical exam, he begins vomiting again and his heart rate increases with a worsening blood pressure. He develops mental status changes and on exam he opens his eyes and flexes his arms only to sternal rub and and is muttering incoherent words. Which of the following is the most appropriate next step in management? Review Topic

QID: 102594
1

Emergency surgery

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2

Emergency variceal banding

20%

(1/5)

3

Intubation

60%

(3/5)

4

IV fluids and fresh frozen plasma

20%

(1/5)

5

Transfuse blood products

0%

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