Paucis Verbis: Upper GI bleeding

Did you know that it takes at least 100 cc of blood in the upper GI tract to produce melena?

 We commonly see patients with upper gastrointestinal bleeding in the Emergency Department. They range from mild (a little hematemesis with normal vital signs and no comorbidities) to frighteningly ill (hypotensive and vomiting copious amounts of blood with a history of cirrhosis).

Since my favorite publication series, EM Clinics of North America, just came out with a bundle of GI-related review articles, I thought I would summarize the GI Bleeding article.

There are some interesting factoids

• A BUN-to-Creatinine ratio of ≥ 36 suggests an upper GI bleeding. I've picked up a few subtle GI bleeds in patients with altered mental status and hypotension based on these lab values.
• We commonly give proton pump inhibitors (PPIs) and octreotide for severe upper GI bleeds with likely variceal bleeding, despite the fact that they are likely of no mortality benefit. Interestingly, the NNT website mentions that PPIs and octreotide don't reduce rebleeding rates or need for surgery either. While interesting, until our Medicine admitting teams and GI consultants are on board with this, I'm still going to be giving them. This just illustrates how hard it is to discontinue medications, which have been part of accepted practice, despite all of the literature (eg. high-dose steroids in spinal cord injuries).
• Also useful are the dosing regimens for FFP and platelets, which I pulled from the Rosen and Roberts/Hedges textbooks. I often get asked how much to give. It's always nice to review the dosing protocol.