Rosen & Barkin's 5-Minute Emergency Medicine Consult (433 page)

• 084.0 Falciparum malaria [malignant tertian]
  
• 084.1 Vivax malaria [benign tertian]
  
• 084.6 Malaria, unspecified
  

BASICS

• Partial-thickness intraluminal longitudinal mucosal tear of distal esophagus or proximal stomach
  
• Sudden increase in intra-abdominal and/or transgastric pressure causes:
  
  • Mild to moderate submucosal arterial and/or venous bleeding:
    
    • May be related to underlying pathology
      
    • “Mushrooming” of stomach into esophagus during retching has been observed endoscopically.
      
  • Responsible for ∼5% of all cases of upper GI bleeding
    

• Associated with:
  
  • Forceful coughing, laughing, or retching
    
  • Lifting
    
  • Straining
    
  • Blunt abdominal trauma
    
  • Seizures
    
  • Childbirth
    
  • Cardiopulmonary resuscitation
    
• Risk factors:
  
  • Alcoholics:
    
    • Especially after recent binge
      
  • Patients with hiatal hernia
    
  • Hyperemesis gravidarum
    
• Greater bleeding associated with:
  
  • Portal hypertension
    
  • Esophageal varices
    
  • Coagulopathy
    

DIAGNOSIS

• Multiple bouts of nonbloody vomiting and/or retching followed by hematemesis:
  
  • Most bleeding is small and resolves spontaneously.
    
  • Massive life-threatening hemorrhage can occur.
    
• Epigastric pain
  
• Back pain
  
• Dehydration:
  
  • Dizzy, light-headed; syncope
    

• Hematemesis
  
• Melena
  
• Postural hypotension
  
• Shock
  

• CBC
  
• Rectal exam for occult blood
  

• Prothrombin time (PT), partial thromboplastin time (PTT), INR
  
• Electrolytes, BUN, creatinine, glucose, LFTs
  
• Amylase/lipase if abdominal pain
  
• Type and cross-match:
  
  • At least 4 U of packed red blood cells (PRBCs) if bleeding is severe
    
• ECG if elderly or with cardiac history
  

• Upright chest radiograph for free air from esophageal or gastric perforation
  
• Upper endoscopy (esophagogastroscopy):
  
  • Procedure of choice to locate, identify, and treat source of bleeding
    

• Nasopharyngeal bleeding
  
• Hemoptysis
  
• Esophageal rupture (Boerhaave syndrome)
  
• Esophagitis
  
• Gastritis
  
• Gastroenteritis
  
• Duodenitis
  
• Ulcer disease
  
• Varices
  
• Carcinoma
  
• Vascular-enteric fistula
  
• Hemangioma
  

TREATMENT

• Airway control:
  
  • 100% oxygen or intubate if unresponsive or airway patency in jeopardy
    
• If hemodynamically unstable or massive hemorrhage:
  
  • Initiate 2 large-bore IV catheters.
    
  • 1 L bolus (peds: 20 mL/kg) lactated Ringer (LR) solution or 0.9% normal saline (NS)
    
  • Trendelenburg position
    

• ABCs:
  
  • IV access with at least 1 large-bore catheter; more if unstable
    
  • Central catheter placement if unstable for more efficient delivery of fluids and monitoring of central venous pressure
    
  • IV fluids of either 0.9% NS (or LR) at 250 mL/h if stable; wide open if hemodynamically unstable
    
  • Dopamine for persistent hypotension unresponsive to aggressive fluid resuscitation
    
• Large-bore Ewald tube placement with evidence of large amount of bleeding:
  
  • Safe
    
  • Will not aggravate Mallory–Weiss tear
    
  • Lavage blood from stomach with water while patient is on side in Trendelenburg position.
    
• Nasogastric (NG) tube placement to check for active bleeding
  
• Transfuse O-negative red blood cells immediately if hypotensive and not responsive to 2 L of crystalloid.
  
• Most bleeding stops spontaneously with conservative therapy.
  

• NPO
  
• Transfuse PRBCs if unstable or lowering hematocrit with continued hemorrhage.
  
• Place Foley catheter to monitor urine output.
  
• Monitor fluid status closely.
  
• With continuing hemorrhage, arrange for immediate endoscopy:
  
  • Control bleeding endoscopically via:
    
    • Electrocoagulation
      
    • Injection therapy (epinephrine)
      
    • Band ligation
      
    • Hemoclips
      
    • Application of blood-clotting agents
      
  • Esophageal balloon tamponade
    
  • Arterial embolization
    
• Intravenous vasopressin in massive bleeding and unavailable endoscopy
  
• In persistent/unresponsive hemorrhage, angiographic infusion of vasopressin
  
• Surgery—last but definitive treatment modality using techniques to oversew bleeding site or perform gastrectomy
  
• Failure of above may require gastric arterial embolization in patients of poor surgical risk.
  
• Antiemetics for nausea/vomiting
  
• Proton pump inhibitors or H
  ₂
  blockers for gastric acid suppression.
  
• Avoid Sengstaken-Blakemore tubes (especially in presence of hiatal hernia).
  

• Dopamine: 2–20 μ/kg/min IV piggyback (IVPB)
  
• Ondansetron 4 mg IV
  
• Pantoprazole 20–40 mg IV
  
• Vasopressin: 0.1–0.5 IU/min IVPB titrating up to 0.9 IU/min as necessary
  

FOLLOW-UP

• ICU admission for:
  
  • Continued or massive hemorrhage
    
  • Hemodynamic instability
    
  • Extreme age
    
  • Poor underlying medical condition
    
  • Complications
    
• General floor admission for
  
  • Stable patients with minimal bleed on presentation that has since cleared
    
  • Patients with risk factors for rebleeding (portal HTN, coagulopathy)
    

• History of minimal bleed that has stopped
  
• Hemodynamically stable
  
• Normal/stable hematocrit
  
• Negative or trace heme-positive stool
  
• Negative or trace gastric aspirate
  

Consult GI in ED if significant upper GI bleeding or if you suspect that requires urgent endoscopy.

GI follow-up for outpatient endoscopy if clinically stable for discharge.

• Place 2 large-bore IVs for patients with upper GI bleed.
  
• For massive GI bleed, initiate blood transfusion early.
  
• Contact GI early for emergent endoscopy with significant bleeding.
  
• Active bleeding at the time of initial endoscopy and a low initial hematocrit is associated with a complicated clinical course.
  
• Rebleeding usually occurs within 24 hr, and is most common in patients with coagulopathies.
  

• Fujisawa N, Inamori M, Sekino Y, et al. Risk factors for mortality in patients with Mallory-Weiss syndrome.
  Hepatogastroenterology
  . 2011;58:417–420.
  
• Kim JW, Kim HS, Byun JW, et al. Predictive factors of recurrent bleeding in Mallory-Weiss syndrome.
  Korean J Gastroenterol
  . 2005;46(6):447–454.
  
• Takhar SS. Upper gastrointestinal bleeding. In:Wolfson AB, Hendey GW,Ling LJ, et al., eds.
  Clinical Practice of Emergency Medicine.
  5thed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010:548–550.
  
• Wu JC, Chan FK. Esophageal bleeding disorders.
  Curr Opin Gastroenterol
  . 2004;20:386–390.
  

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