Upper GI bleed vs bleeding espohageal varices

scattycarrot, BSN, RN · Oct 3, 2007

Resuscitation of the patient with severe EV and managing the bleeding are priority here. Emergency management of the bleed would be insertion of a Sengstaken/Minnesota (at least thats what we call it in the UK, it may have a different name here), which looks like a large bore NG tube with deflated ballons along its length. One balloon is a gastric balloon and the other sits in the esopahgus and these are inflated to tamponade the bleed. It totally possible to pass these while the patient is impersonationg Old Faithful. However, its VERY messy and the person passing the tube needs to wear their protective gear. Especially, as EV's are often in highrisk patients. While this is all going on, hopefully someone has arranged a surgical admission for endoscope/banding/or whatever fancyshamcy techniques the hospital has and the patient has plenty of widebore access in which blood is being pored in...usually as fast as it is coming out. Remember that in the alcoholic liver disease patients, their clotting is often deranged and the patient may need Vit K,clotting factors or FFP as well. These patients also go off quite quickly and they may need their airway securing by way of intubation, so a full resus team should be present.

core0 · Oct 3, 2007

I am studying bleeding esohageal varices secondary to liver disease, and it makes me wonder how a nurse might be able to distinguish between an esophageal varices bleed and a "regular" upper GI bleed? Is it related to the amount of blood involved?
Thanks.

You really can't tell the difference. Some people will tell you they can tell the difference between bright red arterial bleeding and venous bleeding of a varix but I can't.

Varices only occur in the setting of portal hypertension. Usually the patient will have other signs such as ascites which would lead one to suspect liver disease.

In these days where everyone is on Coumadin even small ulcers can produce impressive amounts of blood. Even in end stage liver disease ulcers are frequent and coagulopathy that is associated with this can lead to large volume bleeding.

Generally hematemesis is bleeding from either the esophagus or the stomach. Generally if the stool is black it comes from an area above the transverse colon. If it is red or bright red it is from the transverse or descending colon. The rub here is that high volume bleeds with a fast transit time can be red (even bright red). Normal transit time is 2 hours or so for liquids but blood is very irritating for the intestine and transit time can be as fast as 20 minutes.

As far as treatment, usually resuscitation and urgent endoscopy is the mainstay of US treatment. Usually medications such as IV proton pump inhibitor and Octreotide are used. The Sengstaken-Blakemore tube (usually called a Blakemore here) can be used but I saw it used only once in five years in a busy GI practice (it took a while to find it). If there is a gastric bleed that cannot be stopped by an EGD you can try a GDA ligation. Most variceal bleeds can be stopped with banding. Beta Blockers if the BP will allow this also help.

Mostly its resuscitate and transfer to the ICU. It really doesn't matter what the etiology is the treatment is the same. You have to keep up with the volume and get ready to scope. In the age of IV Protonix about the only things that will get a GI physician out of bed at night is an upper GI bleed or a foreign body.

David Carpenter, PA-C

vashtee, RN · Oct 3, 2007

You guys are great! Thanks for all the advice. :yeah:

scattycarrot, BSN, RN · Oct 3, 2007

As far as treatment, usually resuscitation and urgent endoscopy is the mainstay of US treatment. Usually medications such as IV proton pump inhibitor and Octreotide are used. The Sengstaken-Blakemore tube (usually called a Blakemore here) can be used but I saw it used only once in five years in a busy GI practice (it took a while to find it). If there is a gastric bleed that cannot be stopped by an EGD you can try a GDA ligation. Most variceal bleeds can be stopped with banding. Beta Blockers if the BP will allow this also help.

Further to this, the use of a Sengstaken tube is not a treatment but rather a way to try and manage the bleeding varices until you can get the patient to endoscopy. It can successfully control bleeding in about 90% of patients but roughly 55% do rebleed with it in situ so its obvioulsy just a tool to buy the patient time. Which is vital if you work in a department with no immediate access to endoscope. Interestingly, the last time the Sengstaken tube was used in my old place of work was on a woman in labour who had severe preeclampsia and acute fatty liver disease of pregnancy. She developed a severe acute GI bleed and they passed a Sengstaken to buy some time. It worked and she made it (eventually, after a few weeks in ITU). So, while this woman did not have a varices (at least,I don't think she did), sometimes you use what tools you have on hand!