Advanced🫄 Gastrointestinal 50 min scenario

Acute Upper GI Bleed

A 58-year-old male with cirrhosis presents with hematemesis and melena. Manage variceal bleeding and implement aggressive resuscitation.

Patient Presentation

Age: 58 years

Sex: Male

Weight: 75 kg

Allergies: NKDA

History: Cirrhosis (alcohol-related), esophageal varices (banded 6 months ago), portal hypertension, ascites, hepatic encephalopathy

Chief Complaint: Vomiting blood and black, tarry stools

Medications: Spironolactone 100mg, Furosemide 40mg, Lactulose 30mL TID, Propranolol 20mg BID

Mr. V is brought to the ED by his wife after vomiting approximately 500 mL of bright red blood at home. He has had black, tarry stools for 2 days. He is pale, diaphoretic, and lightheaded. On arrival: BP 92/58, HR 118, RR 22, SpO2 95%, Temp 97.8°F. He is anxious and asks for water. His abdomen is distended with shifting dullness (ascites).

Assessment Findings

Vital signs: BP 92/58, HR 118, RR 22, SpO2 95%, Temp 36.6°C
General: pale, diaphoretic, anxious, ill-appearing
Skin: spider angiomata, palmar erythema, jaundice (stigmata of chronic liver disease)
Cardiac: tachycardia, weak pulses, delayed capillary refill
Abdomen: distended with ascites, positive shifting dullness, no guarding
Neuro: alert but anxious, oriented × 3, mild asterixis (flapping tremor — hepatic encephalopathy)
Rectal: black, tarry stool on digital exam (melena)
Labs: Hgb 7.2 (baseline 10.5), platelets 48 (thrombocytopenia from portal hypertension), INR 2.3 (coagulopathy from liver disease)
LFTs: AST 120, ALT 85, bilirubin 3.8, albumin 2.4
Type and crossmatch: 2 units PRBCs ordered
BUN 35, creatinine 1.8 (BUN/Cr ratio >20 — upper GI bleed)

Nursing Priorities

1
Airway protection — risk of aspiration from hematemesis
2
Two large-bore IVs (16-18g) — STAT
3
Fluid resuscitation with crystalloids — then blood products
4
Type and crossmatch — administer PRBCs
5
Correct coagulopathy — Vitamin K, FFP, platelets
6
Medication: IV octreotide (vasoconstricts splanchnic circulation)
7
Prepare for emergent endoscopy (EGD) for variceal banding
8
Monitor for hepatic encephalopathy — ammonia rises with GI bleed

Nursing Interventions

Position patient: HOB elevated 30-45°, side-lying if actively vomiting — airway protection is priority #1
Establish two large-bore IVs (16-18g) for rapid transfusion capability
Begin IV fluid resuscitation: 0.9% NS bolus 500 mL, reassess, repeat as needed
Administer PRBCs: 2 units (double-check with second RN — blood administration protocol)
Start IV octreotide infusion: 50 mcg bolus, then 50 mcg/hr continuous — reduces splanchnic blood flow and variceal pressure
Administer IV proton pump inhibitor: pantoprazole 80 mg IV bolus, then 8 mg/hr infusion
Correct coagulopathy: Vitamin K 10 mg IV (slow), FFP 2 units, platelets 1 pool (platelets <50 with active bleeding)
Insert nasogastric tube? CONTROVERSIAL — may help identify bleeding source but can precipitate more variceal bleeding. Discuss with GI.
Monitor for hepatic encephalopathy: check ammonia, continue lactulose (target 2-4 loose stools/day), assess asterixis and mental status q1-2h
Prepare for emergent EGD: NPO, informed consent, IV access, airway equipment
Monitor vital signs q15 min: watch for re-bleeding (tachycardia, hypotension after initial stabilization)
Monitor Hgb every 6-12 hours: goal >7-8 g/dL (or higher if active bleeding)
Bladder catheter for strict I&O — monitor renal function (hepatorenal syndrome risk)
Monitor for complications: aspiration, hypovolemic shock, hepatic encephalopathy, hepatorenal syndrome, spontaneous bacterial peritonitis (SBP)
If endoscopy fails to control bleeding: consider balloon tamponade (Sengstaken-Blakemore) as bridge to TIPS (transjugular intrahepatic portosystemic shunt)

Patient Education

Variceal bleeding is a life-threatening complication of cirrhosis — immediate medical attention for any vomiting blood
Medication adherence: beta-blockers (propranolol) reduce portal pressure and variceal rebleeding risk — take as prescribed
Alcohol cessation is the most important intervention — continued drinking worsens cirrhosis and variceal risk
Lactulose: take regularly to prevent hepatic encephalopathy — adjust dose to achieve 2-3 soft stools daily
Dietary: low sodium (ascites management), adequate protein (unless severe encephalopathy), avoid alcohol entirely
Recognize rebleeding signs: black/tarry stools, vomiting blood, lightheadedness, dizziness — call 911
Follow-up: gastroenterology for repeat endoscopy and variceal surveillance; hepatology for cirrhosis management
Consider TIPS procedure if recurrent variceal bleeding — reduces portal pressure

Key Takeaways 💡

⭐ AIRWAY FIRST — patients with hematemesis can aspirate blood and die from airway obstruction, not blood loss
⭐ Octreotide reduces splanchnic blood flow and variceal pressure — start immediately for suspected variceal bleed
⭐ Cirrhosis patients bleed more — thrombocytopenia (portal HTN splenomegaly), coagulopathy (decreased clotting factor synthesis), and high portal pressure all contribute
⭐ GI bleed increases ammonia — blood in the gut is protein that bacteria convert to ammonia, worsening hepatic encephalopathy
⭐ BUN/Cr ratio >20:1 suggests upper GI bleed (blood in the upper GI tract is digested, releasing protein that raises BUN)
⭐ TIPS (transjugular intrahepatic portosystemic shunt) is the definitive treatment for recurrent variceal bleeding — but increases hepatic encephalopathy risk

Patient Snapshot

Age/Sex: 58y Male