CURRENT Essentials of Critical Care.pdf

176 Current Essentials of Critical CareUpper Gastrointestinal Bleeding■ Essentials of Diagnosis• Hematemesis, coffee ground emesis, melena with source abovethe ligament of Treitz; occasionally hematochezia• Symptoms depend on amount and acuity of blood loss: asymptomatic,lightheadedness, syncope, dyspnea, angina; early satietyseen in gastric cancer• Physical findings variable: none; orthostatic hypotension; stigmataof liver disease; mucosal pigmentation (Peutz-Jeghers syndrome);multiple telangiectasias (Osler-Weber-Rendu)• Acute bleeding initially with normal blood cell count; chronicleads to iron deficient microcytic anemia• Nasogastric lavage demonstrates coffee ground material, blood• Esophagogastroduodenoscopy (EGD) to determine bleedingsource; nuclear medicine scan or angiography helpful if EGDnondiagnostic• Mortality risks: advanced age; signs of systemic shock; significantcomorbidities; diagnosis of malignancy; endoscopic findingsof large varices, active bleeding, or visible vessel■ Differential Diagnosis• Gastric erosions/gastritis • Peptic ulcer disease• Varices • Esophagitis• Mallory-Weiss tear • Malignancy■ Treatment• Support and protect airway• Stabilize hemodynamics: adequate intravenous access; infuseisotonic crystalloid; transfuse blood products as necessary• Serial assessment of vital signs, hemoglobin, platelets, coagulationpanel• EGD can identify lesions and treat with sclerotherapy, band ligation,application of hemostatic agents• Intravenous or oral proton pump inhibitors• Consider early use of octreotide or terlipressin in suspected casesof variceal bleeding• Surgery reserved when above measures fail■ PearlEarly endoscopy is indicated in patients over 60 years of age, historyof chronic liver disease, bright red blood per rectum associated withhypotension, and bleeding requiring more than 4 units of blood in a6-hour period.ReferenceConrad SA: Acute upper gastrointestinal bleeding in critically ill patients:causes and treatment modalities. Crit Care Med 2002;30:S365. [PMID:12072663]