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The Rational Clinical Examination |

Does This Patient Have a Severe Upper Gastrointestinal Bleed?

F. Douglas Srygley, MD; Charles J. Gerardo, MD; Tony Tran, MD; Deborah A. Fisher, MD, MHS
JAMA. 2012;307(10):1072-1079. doi:10.1001/jama.2012.253.
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Published online

Context Emergency physicians must determine both the location and the severity of acute gastrointestinal bleeding (GIB) to optimize the diagnostic and therapeutic approaches.

Objectives To identify the historical features, symptoms, signs, bedside maneuvers, and basic laboratory test results that distinguish acute upper GIB (UGIB) from acute lower GIB (LGIB) and to risk stratify those patients with a UGIB least likely to have severe bleeding that necessitates an urgent intervention.

Data Sources A structured search of MEDLINE (1966-September 2011) and reference lists from retrieved articles, review articles, and physical examination textbooks.

Study Selection High-quality studies were included of adult patients who were either admitted with GIB or evaluated in emergency departments with bedside evaluations and/or routine laboratory tests, and studies that did not include endoscopic findings in prediction models. The initial search yielded 2628 citations, of which 8 were retained that tested methods of identifying a UGIB and 18 that identified methods of determining the severity of UGIB.

Data Extraction One author abstracted the data (prevalence, sensitivity, specificity, and likelihood ratios [LRs]) and assessed methodological quality, with confirmation by another author. Data were combined using random effects measures.

Data Synthesis The majority of patients (N = 1776) had an acute UGIB (prevalence, 63%; 95% CI, 51%-73%). Several clinical factors increase the likelihood that a patient has a UGIB, including a patient-reported history of melena (LR range, 5.1-5.9), melenic stool on examination (LR, 25; 95% CI, 4-174), a nasogastric lavage with blood or coffee grounds (LR, 9.6; 95% CI, 4.0-23.0), and a serum urea nitrogen:creatinine ratio of more than 30 (summary LR, 7.5; 95% CI, 2.8-12.0). Conversely, the presence of blood clots in stool (LR, 0.05; 95% CI, 0.01-0.38) decreases the likelihood of a UGIB. Of the patients clinically diagnosed with acute UGIB, 36% (95% CI, 29%-44%) had severe bleeding. A nasogastric lavage with red blood (summary LR, 3.1; 95% CI, 1.2-14.0), tachycardia (LR, 4.9; 95% CI, 3.2-7.6), or a hemoglobin level of less than 8 g/dL (LR range, 4.5-6.2) increase the likelihood of a severe UGIB requiring urgent intervention. A Blatchford score of 0 (summary LR, 0.02; 95% CI, 0-0.05) decreases the likelihood that a UGIB requires urgent intervention.

Conclusions Melena, nasogastric lavage with blood or coffee grounds, or serum urea nitrogen:creatinine ratio of more than 30 increase the likelihood of a UGIB. Blood clots in the stool make a UGIB much less likely. The Blatchford clinical prediction score, which does not require nasogastric lavage, is very efficient for identifying patients who do not require urgent intervention.

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Figure 1. Anatomical Landmarks and Location of Gastrointestinal Bleeding
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Bleeding sources proximal to the duodenojejunal junction, as approximated by the ligament of Treitz, are considered upper gastrointestinal bleeds.

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Figure 2. Key Steps in Nasogastric (NG) Tube Insertion
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Prior to insertion of the NG tube, inspect the nares to confirm the absence of any obstruction. If the nares are symmetrical, insert the tube in the side with the larger passageway. Most experts suggest applying topical lidocaine in the nares for patient comfort during insertion. A, With the patient seated and head level, insert the first 10 cm of a lubricated NG tube along the floor of the nasopharynx (parallel to the ground). B, Advance the tube through the oropharynx past the epiglottis and trachea into the esophagus and stomach. C, Confirm proper location of the NG tube by aspiration for stomach contents, auscultation over the stomach after pushing air through the tube with a syringe, or by an abdominal radiograph.

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