Stopping acute upper-GI bleeds Risk stratification and quick intervention can save lives.

By Carolyn D. Meehan, PhD, RN, and Catherine G. McKenna, MSN, RN

AN ACUTE upper-GI bleed (UGIB) the ED nurse, notes pallor, weakness, Initially, the bleeding source may is a significant cause of hospital ad - and poor skin turgor. She immedi - be unclear, and examining the stool missions. (See UGIB fast facts .) Re - ately places Mr. Sullivan on a car - alone isn’t a reliable indicator. Pa - cent advances in care include risk diac monitor, inserts two 18G I.V. tients exhibiting hematemesis along stratification when the patient ar - lines, starts oxygen via nasal cannu - with hematochezia may be bleed - rives in the emergency department la, and sends blood work for com - ing from the upper-GI tract, esoph - (ED) to help predict the need for plete blood count (CBC), serum agus, stomach, or proximal duode - specific interventions, such as trans - chemistry, type and crossmatch, pro - num. However, when the patient fusions, therapeutic endoscopy, or thrombin time, and serum lactate doesn’t have hematemesis, the dis - surgery. The Glasgow-Blatchford level. The provider orders no oral in - tinction between UGIB versus low - Score (GBS), a stratification tool take for Mr. Sullivan in preparation er-GI bleeding must be determined commonly used in EDs, is based for potential procedures. quickly by completing a thorough on well-documented risk factors history, collecting laboratory data, known to influence hospitalization Finding the source and using a risk stratification tool. and rebleeding. (See GBS—A risk A UGIB occurs above the ligament stratification tool .) of Treitz, located between the jeju - Management in the ED In this article, we present a case num and duodenum. Possible causes Many of the patients who arrive in study that uses risk stratification for include gastric and duodenal ulcers, the ED with significant UGIB are early intervention of acute UGIB in esophagitis, gastritis, varices, and elderly; patients older than 75 are the ED. malignancies; drug-induced causes at an increased risk of dying from a include overuse of nonster oidal UGIB because of multiple comor - Mr. Sullivan arrives in the ED antiinflammatory drugs (NSAIDs). bidities and polypharmacy. Thor - Mark Sullivan, a 75-year-old retired Aligning the potential cause of the oughly review the patient’s medical teacher, is brought to the ED by his bleed ing with the symptoms helps pro - history and current prescription family. He reports abdominal pain viders determine the source, improv - and over-the-counter medications— and says he passed a dark maroon ing care and over all mortality. especially anticoagulants, aspirin, stool this morning and then fainted. antiplatelet agents, and NSAIDs. Mr. Sullivan has a history of atrial The patient’s cardiopulmonary fibrillation, heart failure, and degen - UGIB fast facts health, cerebrovascular conditions, erative joint disease. His current and history of GI bleeding will help prescription medications include • Acute upper-GI bleeds (UGIBs) you prioritize care. Keep in mind hydrochlorothiazide 25 mg daily, are associated with over 400,000 that more than half of patients with li sin opril 5 mg daily, aspirin 81 mg U.S. hospital admissions each a history of GI bleeding are bleed - daily, and apixaban 5 mg twice dai - year. ing from the same lesion, and the ly. Mr. Sullivan denies smoking, alco - • The admission rate for UGIB is es - presence of a single comorbidity hol abuse, or previous episodes of timated to be six times higher doubles the mortality rate, which than that for lower-GI bleeds. fainting or gastric bleeding, and he can range from 6% to 10%. reports taking ibuprofen 400 mg • UGIB incidence is higher in men Providers may make decisions than women and increases with every day for knee pain. His current about fluid resuscitation based on advancing age. vital signs are temperature 98.8˚ F findings from the physical exam. • Advances in pharmacologic ther - (37˚ C), heart rate (HR) 103 beats per You can assess the extent of in - apies, such as proton pump in - minute (bpm) and irregular, respira - hibitors and antibiotics to treat travascular volume loss by carefully tory rate 18 breaths per min ute and Helicobacter pylori bacteria, have checking vital signs, mucous mem - regular, pulse oximetry 91%, and helped reduce the overall inci - branes, and urine output. You can blood pressure 110/60 mmHg when dence of UGIB, except for pa - presume that patients with an HR supine, 98/60 mmHg when sitting. tients more than 70 years old. greater than 100 bpm and posi - During the physical exam, Erin, tive orthostatic changes in systolic

American Nurse Today Volume 13, Number 3 AmericanNurseToday.com 6 GBS—A risk stratification tool 90%, and inserting two large-caliber include gastric lavage. (See Get a The Glasgow-Blatchford Score (GBS) is I.V. catheters. Fluid resuscitation for clearer picture .) commonly used to stratify risk for pa - active GI bleeding includes lactated tients who present to the emergency Ringer’s or normal saline solution Stratifying the risk department with an upper-GI bleed. and an immediate type and cross - Assessment of an acute UGIB in - match for possible transfusion. The cludes risk stratification to identify Admission Score goal is to hemodynamically stabilize the need for intervention. The GBS risk component marker value the patient. is used in EDs to stratify risk and determine the best treatment op - Blood urea (mmol/L) Making the diagnosis tions. Patients with a GBS of zero 6.5-8.0 2 Diagnostic laboratory data include may not require any intervention 8.0-10.0 3 CBC, serum chemistries, prothrom - and could potentially be discharged 10.0-25 4 bin time, and serum lactate. Note that from the ED. Patients with scores >25 6 the initial hemoglobin in patients from one to five are at risk and with acute UGIB may be falsely ele - should be admitted to the hospital Hemoglobin (g/dL) vated. After 24 hours, hemoglobin for further evaluation and manage - for men will decline as the blood is diluted ment. High-risk patients with a 12.0-12.9 1 10.0-11.9 3 by extravascular fluid entering the score of six or more are admitted <10.0 4 vascular space and by the fluids ad - for immediate intervention to stop ministered during resuscitation. De - the bleeding. Hemoglobin (g/dL) pending on the severity of the bleed, After endoscopy, the GI team for women monitor the patient’s hemoglobin may conduct further risk assess - 10.0-11.9 1 every 2 to 8 hours, as ordered. ment using the Rockall Score. This <10.0 6 Also monitor the blood urea ni - assessment tool includes clinical cri - Systolic blood pressure trogen (BUN) and creatinine ratio teria associated with the GBS and (mmHg) to help determine the location of endoscopic findings to predict the 100-109 1 the bleed. Patients with a UGIB risk of rebleeding and death. 90-99 2 will have an elevated BUN to crea - <90 3 tinine ratio (>20:1) as a result of in - Choosing a treatment creased blood protein absorption After fluid resuscitation, the pro - Other markers into the bowel. An elevated serum vider will determine whether trans - Pulse ≥100 beats per minute 1 lactate may indicate decreased oxy - fusion is needed. Recent studies Presentation with melena 1 gen supply to the tissues and may suggest transfusing the patient, de - Presentation with syncope 2 Hepatic disease 2 be a useful predictor for increased pending on his or her clinical pres - Cardiac failure 2 mortality and a need for early in - entation, to maintain a hemoglobin tervention. Other diagnostic tools above 7 or 8 g/dL. Typically, pa - Reprinted from Blatchford O, Murray WR, Blatchford M. A risk score to predict need for treatment of upper-gas - trointestinal haemorrhage. Lancet . 2000;356(9238): 1318-21. Copyright 2000, with permission from Elsevier. Get a clearer picture Gastric lavage clears the gastric contents to aid visualization and upper-GI bleed (UGIB) treatment. A large-bore tube, such as a double-lumen gastric sump tube, is blood pressure (defined as drop - placed in the stomach to irrigate and evacuate the hemorrhage, removing bright ping 20 mmHg or more when mov - red blood, coffee ground material indicative of a UGIB, and clots from the stom - ing from lying down to sitting) have ach, helping providers see the fundus for more accurate endoscopy. a significant fluid volume deficit of The patient’s level of consciousness must be taken into consideration during at least 15%. Dry oral mucous mem - this procedure; a patient with a diminished gag reflex may require airway support branes and a decrease in urine out - with endotracheal intubation. put to less than 30 mL per hour To avoid the risks (such as aspiration, esophageal injury, laryngospasm, elec - should alert you to changes in in - trolyte disturbances, and hypoxia) and patient discomfort associated with gastric travascular fluid volume. lavage, the provider may use an alternative, such as I.V. erythromycin or proton pump inhibitors (PPIs). I.V. erythromycin (250 mg about 30 minutes before en - Initial treatment in the ED in - doscopy) induces contractions of the stomach’s antrum to accelerate emptying of cludes placing the patient on a car - gastric contents and increase visualization of the mucosa during endoscopy. PPIs diac monitor, applying oxygen ther - provide potent and prolonged gastric-acid suppression, reducing the rate of re - apy with continuous pulse oximetry bleeding and stabilizing clots. to maintain oxygen saturation above

AmericanNurseToday.com March 2018 American Nurse Today 7 tients admitted with an acute UGIB The GBS is used dark, tarry stools. Because of Mr. are treated with I.V. proton pump Sullivan’s comorbidities and antico - inhibitors (PPIs) (for example, pan - in EDs to stratify agulation therapy, the multidiscipli - toprazole 40 mg twice daily) for 72 nary team recommends that he re - hours after endoscopy. Based on and determine main on omeprazole 40 mg per day the patient’s risk factors, the gas - risk for his peptic ulcer disease. In addi - troenterologist will decide whether the best treatment tion to medication reconciliation at to continue PPI treatment after dis - the time of discharge, alternative charge. options. pain management (such as physi - Endoscopic therapy for high-risk cal therapy for strength, flexibility, bleeds includes vasoconstrictor injec - and balance; guided-imagery; bio - tions, thermal coagulation, and me - an acute UGIB. Taking into consid - feedback; and relaxation tech - chanical clipping. Early endo scopy eration Mr. Sullivan’s vital signs niques) is recommended to elimi - (within 24 hours of ad mission) de - and initial hemoglobin of 10 g/dL, nate NSAIDs. A follow-up home visit creases the need for transfusion and Erin calculates his GBS to be 12, is planned to ensure that Mr. Sulli - reduces length of hospital stay for placing him in a high-risk category van adheres to the plan of care and patients at high risk on the GBS. requiring immediate endoscopy. to provide support and assess for re - Note that 80% to 85% of patients Subsequently, his provider diag - bleeding. with an acute UGIB will achieve noses Mr. Sullivan with a bleeding hemo stasis without intervention. peptic ulcer. Visit americannursetoday.com/38813 to view Before Mr. Sullivan is discharged, a list of selected references. Erin teaches him how to recognize Mr. Sullivan’s outcome The authors work at West Chester University in West Mr. Sullivan’s BUN is 24.1 mmol/L early symptoms of rebleeding, and Chester, Pennsylvania. Carolyn D. Meehan is the pre - with a serum creatinine of 1.1 she instructs him to notify his pro - licensure program coordinator and an assistant pro - mmol/L, giving him a BUN to crea - vider if he experiences palpitations, fessor of nursing. Catherine G. McKenna is the skills tinine ratio of 21:8 and suggesting dizziness, coffee ground emesis, or lab coordinator.

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