Case

A 74-year-old man presents with vomiting of blood for two days. He has a history of daily alcohol and tobacco use. Vital signs are: blood pressure, 88/50; heart rate, 120; respiratory rate, 36. He is actively vomiting coffee ground emesis. His abdomen is soft with voluntary guarding. What is the best management of this condition?

Upper gastrointestinal bleeding (UGIB) is a significant problem in the U.S., with 350,000 hospitalizations annually and a mortality rate of five to 10 percent.^1,2 The three most common causes are peptic ulcer disease (often secondary to nonsteroidal anti-inflammatory drug use or Helicobacter pylori infection), esophagogastric varices (often due to cirrhosis with portal hypertension), and erosive esophagitis (often secondary to severe GERD or alcohol use).¹ UGIB will typically manifest as melena, hematemesis, or hematochezia.¹

Rapid assessment of vital signs and degree of bleeding should determine whether a patient is stable or unstable. There are several scoring systems available, such as the Glasgow-Blatchford system, but none of these are superior to physician assessment. Tachycardia, hypotension, tachypnea, mental status, and degree of bleeding are important indicators of stability.

Initial stabilization should be done for all patients. Patients should be assessed for evidence of hypovolemia or active exsanguination. Whatever the underlying cause, the patient should have two large-bore intravenous (IV) lines placed and be put on pulse oximetry and cardiac monitoring. Fluid resuscitation should be initiated. Initial laboratory studies should include CBC, complete metabolic profile, blood type and screening, and coagulation studies. Hemoglobin takes several hours to reflect blood loss and should not be used as the sole indicator of bleeding severity. Repeat measurements of hemoglobin may be helpful in assessing stability.

Unstable Patients

The unstable patient with UGIB should be stabilized initially with airway, breathing, and circulatory support. Active UGIB may lead to altered mental status or airway compromise via aspiration. Intubation may be challenging because of both rapid desaturation and extensive hemorrhage. Pre-oxygenation with nasal cannula or face mask should be provided. Nasal cannula oxygen delivery should be maintained during intubation. Suction should be available. Maintain the head of the bed at 45 degrees and ensure that a bag-valve mask is available if initial attempts at intubation fail. Lower doses of sedatives may be used to minimize hypotension. Video laryngoscopy may be attempted, although visualization may be obscured by active bleeding and direct laryngoscopy may be appropriate. Suction-assisted laryngoscopy and airway decontamination, or SALAD, can also be used—in this technique, a rigid suction catheter can simultaneously act as a tongue lifter or depressor while providing continuous suction.