UGIB

Causes of UGIB

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

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

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

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

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