======UGIB======

=====Causes of UGIB=====
  * Peptic ulcers 60%
  * Esophageal varices 20%
  * Esophagitis
  * Mallory-Weiss
  * Neoplasm

=====Initial management=====
  * Assess severity
  * Therapy
    * Volume resuscitate
    * Transfuse > 7
    * PPI therapy
    * FFP if INR > 5 or on anticoagulation
    * Erythromycin if needed for motility
    * NG tube if concerned for aspiration
  * Blatchford Score
    * 0 = low risk
    * 6+ = likely need intervention
    * Parameters: urea, Hgb (adjusted for sex), SBP, tachycardia, melena, syncope, hepatic disease, cardiac failure

=====Timing=====
  * Urgent endoscopy (after hemodynamically stable)
    * Within 12 hours
    * If suspect variceal GIB
  * Non-urgent endoscopy (after hemodynamically stable)
    * Within 24 hours
  * Outpatient
    * BUN < 18.2
    * Normal Hgb
    * SBP > 109
    * HR < 100
    * No melena, syncope, liver disease, cardiac failure

=====Endoscopy Findings=====
^  Endoscopic finding ^  Active bleeding or visible vessel  ^  Adherent clot  ^  Flat pigmented spot  ^  Clean base  ^
| Intervention | Endoscopic therapy | Consider endoscopic therapy | No endoscopic therapy | No therapy |
| Medication | Intensive PPI | Intensive PPI | Once daily PPI | Once daily PPI |
| Diet | Clear liquid diet x 2 d | Clear liquid diet x 2 d | Clear liquid diet x 1 d | Regular diet |
| Length of stay | Hospitalize for 3 days | Hospitalize for 1-2 days | Hospitalize for 1-2 days | Discharge after endoscopy |

=====Risk factors for bleeding PUD=====
  * H. pylori infection
  * NSAIDs
  * Physiologic stress
  * Excess gastric acid

=====H. pylori=====
  * Diagnosis
    * Antibody testing, urea breath test, fecal antigen
    * Endoscopic
  * Treatment
    * Triple therapy x 14 days: clarithromycin + amoxicillin/metronidazole + PPI (70-80%) - high resistance to clarithromycin at LAC+USC
    * Quadruple therapy

=====Dosing=====
  * PPI: bolus 80 mg IV + continuous 8 mg/hr x 72 hours (high-risk)
  * Octreotide: 50 mg bolus + continuous 5 mg/hr x 3-5 days (variceal)
  * SBP prophylaxis x 7d:
    * Cipro 500 bleeding
    * Bactrim DS
    * ?
  * Propranolol: for esophageal varices, previous studies showed improved survival, but not robust; discontinue if refractory ascites
  * FFP:
    * AASLD: no recommendations regarding platelets
    * ASGE: platelets > 30
  * Generally, hold diuretics and propranolol for decompensation cirrhosis (initially) 
  * Aspirin:
    * Primary prevention: discontinue permanently
    * Secondary prevention: resume 1-7 days after bleeindg stop and continue PPI long term