• Age <50
• Melena
• BUN/CREA ration ≥ 30! (blood gets reabsorbed → ↑urea)

• DD Hematochezia from UGIB vs LGIB → aspiration
• Coffee grounds bleeding (less severe/inactive bleeding)
• negative aspirate is not helpful: 20% with neg. aspirate have UGIB!

NO, initial Hct can be misleading → Hct stays the same with loss of whole blood (until re-equilibration) 📷

≤7

Weigh risks / benefits of reversing anticoagulation (Assess degree of coagulopathy) → Vitamin K - slow acting, long-halflife → FFP - fast acting, short-halflife → RBC transfusion

Predictors of mortality in UGIB:

rockall scoring system: 📷

low risk UGIB will not likely requre endoscopic hemostasis

• Facilitate clot formation (i.e. VitK, FFP)
• PPI

• dg
• risk stratification
• hemostasis therapy

• endoscopic stigmata (high bleeding risk or active bleeding)
• recent hemorrhage

!80% resolve spontanously

low rebleeding-bleeding rates

Flat pigmented IIc

Clean base III

• inject Epinephrin
• Thermal electrocoagulation
• Hemoclips

!combined therapy superior to mono-T

• low risk: oral PPI + fed
• Endoscopic therapy: PPI infusion for 72h
• Determine HP status

restart aspirin as soon as bleeding resolved

(not dying = more important than rebleeding)

high

• Severity of liver D → child pugh score
• ↓Platelets <88k
• Splenomegaly
• Platelet count/Spleen diameter(mm) ratio <909

"variceal"

Vasoconstrictor therapy*

Antibiotics*

Resuscitation*

ICU

Endoscopy*

ALternative aka rescue therapies (TIPS)*

Betablocker*

Reduce splanchnic blood flow

→ Terlipressin

→ Somatostatin

→ Octreotide

Bacterial infection: in 66% of patients with cirrhosis and variceal bleed → Prophylactic antibiotics → decr. incidence of bacterial infection

⇒ significantly reduces early rebleeding

Ceftriaxone IV Alt: Norfloxacin po

excessive fluid → ↑↑portal pressure → ↑↑bleeding

asap after resuscitation (withing 12h)

⇒ Band ligation 📺

TIPS (Transjugular intrahepatic portosystemic shunt) 📷

esp in high risk patients → within 24-72h

esp. in gastric variceal bleeding

Sengstaken-Blakemore Tube 📷

→ compression gastric variceals

!but only temporary → high complication rate (aspiration, necrosis, perforation)

!airway protection needed!

Self expanding metal stent 📷

after acute bleeding resolved

→ ↓splanchnic vasoconstriction + ↓cardiac outbut → ↓risk for recurrent hemorrhage

10-15% of patients with presumed LGIB actually have upper GIB in the end