We commonly see patients with upper gastrointestinal bleeding in the Emergency Department. They range from mild (a little hematemesis with normal vital signs and no comorbidities) to frighteningly ill (hypotensive and vomiting copious amounts of blood with a history of cirrhosis).
Since my favorite publication series, EM Clinics of North America, just came out with a bundle of GI-related review articles, I thought I would summarize the GI Bleeding article.
There are some interesting factoids:
- A BUN-to-Creatinine ratio of ≥ 36 suggests an upper GI bleeding. I've picked up a few subtle GI bleeds in patients with altered mental status and hypotension based on these lab values.
- We commonly give proton pump inhibitors (PPIs) and octreotide for severe upper GI bleeds with likely variceal bleeding, despite the fact that they are likely of no mortality benefit. Interestingly, the NNT website mentions that PPIs and octreotide don't reduce rebleeding rates or need for surgery either. While interesting, until our Medicine admitting teams and GI consultants are on board with this, I'm still going to be giving them. This just illustrates how hard it is to discontinue medications, which have been part of accepted practice, despite all of the literature (eg. high-dose steroids in spinal cord injuries).
- Also useful are the dosing regimens for FFP and platelets, which I pulled from the Rosen and Roberts/Hedges textbooks. I often get asked how much to give. It's always nice to review the dosing protocol.
Reference
As always Dr. Lin. I appreciate your comments, the blog and the tips. Thanks for continuing this work. Scott Fleck, PA-C
ReplyDeleteHappy to be of help, Scott! It's a win-win scenario since this blog forces me to keep up to date with the literature.
ReplyDeleteHere's a question by Tom Jerram from the chat box. I moved here as well.
ReplyDelete"Was just wondering about the absence of antibiotics in your GI bleeding card. In cirrhotic patients, my understanding was that antibiotics are pretty much the only pharmacologic intervention association with decreased mortality".
Anyone wanna comment?
NNT of 27 for mortality, and 4 for preventing bacterial infection, based on my skimming of this Cochrane review. We should add this to our site:
ReplyDeletehttp://www2.cochrane.org/reviews/en/ab002907.html
Fantastic that you mentioned Bun/Cr ratio. One wrinkle is that these folks won't have an elevated Cr from the absorbed blood. So if you have a low Cr with a BUN that is high (the > 36-40 ratio you mention) think GIB. Conversely, prerenal azotemia will elevate both BUN and Cr.
ReplyDelete@Graham: That's a great link. Thanks for telling me know about these numbers. Not sure why it wasn't in the EM Clinics review article.
ReplyDelete@Scott: This BUN/Cr ratio of >36 is one of my favorite pearls to teach. Not sure why the ratio of >20 for dehydration gets all the fanfare but GI bleed ratios don't.
Great summary Michelle!
ReplyDeleteWhat about NG sond for diagnosis, does anyone know what the literature has to say about it (forgive my laziness for not looking up my self but crowdsourcing is the modern pubmed seaching way :-) )?
Last I looked a few years ago, NG aspirations and lavages rarely added much from a diagnostic standpoint except for those who had altered mental status (couldn't tell you that they vomited lots of blood). I find them helpful to risk stratify in terms of which admission bed to arrange (ICU if lavage does not clear and continuous puts out bright red blood).
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