Esophageal varices

• Hematemesis
  • Coffee-ground emesis
• Vomiting + retching followed by hematemesis is more likely Mallory-Weiss (esophageal)
• Dark, tarry stools
• Syncope or pre-syncope
• Dyspepsia, epigastric pain or heartburn

• Tachycardia, hypotension
• Liver disease
  • Spider angiomata, palmar erythema, jaundice, gynecomastia
• Coagulopathy
  • Petechiae/purpura
• Melena

• Peptic ulcer disease (most common cause)
• Gastritis/esophagitis
• Gastric/esophageal varices
• Mallory-Weiss tear
• Malignancy
• Aortoenteric fisulta
• Boerhaave
• Dieulafoy's lesion
• Angiodysplasia
• Hemobilia
• Hemorrhagic gastritis, EtOH
• Celiac
• Dengue
• Other intrabdominal bleeds
  • Hemorrhagic pancreatitis
  • Splenic rupture
  • Subcapsular cavernous hemangiomas
  • Peliosis hepatis

• Hemoptysis
• Vaginal/Urethra bleeding
• ENT bleeding
• Dietary (Iron, bismuth, beets)
• Swallowed maternal blood (in neonate)

• 2 large bore IVs
• Type and cross
• CBC & serial hemoglobin
• Chemistry
  • BUN/creatinine >30 suggests UGI if no history of renal failure (increased absorption/digestion of hb)
• Coags
• LFTs
• Fibrinogen
• Guiac
  • More useful for diagnosing chronic occult bleeding (it could be positive for up to 2 weeks after an acute bleed)
  • False-positive: vitamin C, red meat, methylene blue, bromide preparations, turnips, horseradish
• ECG (if >40 yo or if suspicious for silent MI, especially from demand ischemia)
• CXR (if suspect perforation)

• Pros[1]
  • Positive aspirate proves strong evidence for an upper GI source of bleeding
  • Can assess presence of ongoing active bleeding
  • Can prepare patient for endoscopy
• Cons[1]
  • Uncomfortable
  • Negative aspirate does not conclusively exclude upper GI source
  • Provides useful information in only minority of patients without hematemesis
  • Erythromycin 200mg IV can provide equal endoscopy conditions as lavage[2]

• Place 2 large bore IVs and monitor airway status
• Crystalloid IVF can be used for initial resuscitation but should be limited due to the dilutional anemia and dilatational coagulopathy that can result (i.e. IV fluid use in non-compressible hemorrhage)

• Pantoprazole or esomeprazole 80mg x 1; then 8mg/hr
  • Intermittent dosing of pantoprazole, esomeprazole, or omeprazole 40 mg IV BID not inferior to continuous infusion dosing[3]
  • Reduces the rate of re-bleeding and need for surgery if there is an ulcer, but does not reduce morbidity or mortality[4][5]
  • There is a mortality benefit in Asian patients[6]

For short-term prophylaxis against SBP and bacteremia[7]

• Ceftriaxone 1gm daily x 7 days (first line)[8]
• OR ciprofloxacin IV or PO 500mg BID x7 days
• Indicated for:
  • Patients with cirrhosis or history of ETOH abuse (regardless of whether bleeding is variceal or not)
  • Prior to endoscopy or as soon as possible after endoscopy

• Consider octreotide (50 mcg IV bolus, then 50 mcg/hr continuous, maintained at 2-5 days in patients with concern for variceal bleeding)[9]
• Consider vasopressin
  • 0.4 unit bolus, then infuse at 0.4 - 1 unit/min[10]
  • Give with IV nitroglycerin at 10 - 50 mcg/min to bolster portal hypotension and reduce vasopressin systemic effects[11]
  • Associated with many vasoconstrictive complications to include peripheral necrosis, dysrhythmias, myocardial ischemia [12]
  • Terlipressin (analog of vasopressin, available outside U.S.)
    • Alternative to vasopressin with mortality benefit
    • Given as 2mg IV q4 hrs, then decrease to 1mg IV q4 hrs until bleeding stops[13]
• tranexamic acid (TXA) may help, NNT = 30, no one harmed[14]; HALT-IT trial RCT underway[15]

Indications:

• Hemoglobin <7 g/dl
  • In hemodynamically stable patients, the goal transfusion threshold should be 7 g/dl; NICE guidelines recommend avoidance of over-transfusion[16]
• Continued active bleeding
• Failure to improve perfusion and vital signs after infusion of 2L NS
• Known varicele bleeding[17]

Consider initiating massive transfusion protocol

• Prothrombin complex concentrates[18]
• Cryoprecipitate to raise fibrinogen (goal >120mg/dL)
• Platelets (goal >50-100k/μL
• FFP can be used to correct anticoagulated patients, but is not indicated in cirrhotics with variceal bleeding[19]

For life-threatening hemorrhage if endoscopy is not available

• Adverse reactions are frequent:
  • Mucosal ulceration
  • Esophageal/gastric rupture
  • Tracheal compression (consider intubation prior to balloon insertion)

Should be performed at the discretion of the gastroenterologist; within 12 hrs for variceal bleeding[20]

• Early endoscopy does not necessarily improve clinical outcomes[21]
• Consider erythromycin 3mg/kg IV over 20-30min, 30-90min prior to endoscopy
  • Achieves endoscopy conditions equal to lavage[22]

Protection of airway from massive aspiration, especially prior to endoscopy; does not protect against pneumonia or cardiopulmonary events[23]

NO CHRISTMAS[24]

Have bed-side push-dose pressors on hand

• NGT (salem sump to remove stomach contents)
  • Varices not contraindication to NGT
  • Consider metoclopramide 10mg IV
• Good pre-Oxygenation critical
• Chest and HOB elevation to 45 degrees - consider intubating from 45 degrees to prevent gastric contents coming up
• RSI - consider halving sedation dosages for lost blood volume
  • Etomidate or ketamine for sedation
  • Succinylcholine and vecuronium increases LES tone
• Intubation with strong chance for first pass
• Slow and gentle BVM breaths at 10 breaths/min if first pass fails
• Trendelenberg if vomiting, keeping emesis out of lungs (have many suctions available before this happens)
• Meconium aspirator may be hooked up to ETT for large bore suction
• Antibiotics not needed in early phase of aspiration
  • Chemical pneumonitis in first 24 hours, not bacterial pneumonia
  • Early antibiotics may predispose patient to resistant bacterial superinfection
• SIRS-like response often occurs from aspiration, but otherwise not sepsis if there is no other concerning source or suspicion
  • May require pressors and fluids
  • Consider withholding early antibiotics, but doing the rest of the sepsis treatments