What is the management for a patient with melena, epigastric pain, severe anemia, and acute kidney injury?

Management of Nonvariceal Upper Gastrointestinal Bleeding with Severe Anemia and Acute Kidney Injury

The patient with melena, epigastric pain, severe anemia (Hgb drop from 11 to 5.5), and acute kidney injury (BUN rise from 34 to 89) requires immediate aggressive resuscitation, blood transfusion, and urgent endoscopy within 24 hours to identify and treat the bleeding source.

Initial Resuscitation and Stabilization

Airway and Breathing

• Ensure patent airway and adequate oxygenation
• Apply supplemental oxygen to maintain SpO2 >92%
• Monitor respiratory status closely

Circulation and Volume Resuscitation

1. Establish two large-bore IV access (18G or larger)

2. Blood transfusion:

   • Initiate PRBC transfusion immediately to target hemoglobin of 7-9 g/dL 1
   • Consider more aggressive transfusion targets (Hgb >9 g/dL) for patients with significant comorbidities or ongoing bleeding
   • Type and cross for at least 4 units of PRBCs

3. Fluid resuscitation:

   • Use crystalloids (balanced solutions preferred over normal saline) 1, 2
   • Target urine output >0.5 mL/kg/hour
   • Avoid hydroxyethyl starches which can worsen AKI 2

4. Hemodynamic monitoring:

   • Continuous vital sign monitoring
   • Consider central venous pressure monitoring in hemodynamically unstable patients 1
   • Target MAP >65 mmHg

Risk Assessment

• Calculate Glasgow Blatchford Score to assess risk of rebleeding or mortality 1
• Calculate Rockall Score after endoscopy 1
• Risk factors for poor outcomes:
  • Age >60 years
  • Hemodynamic instability (tachycardia >100, SBP <100 mmHg)
  • Severe anemia (Hgb 5.5)
  • Acute kidney injury
  • BUN >89 (suggests significant blood loss)

Medication Management

1. Proton Pump Inhibitor (PPI) therapy:

   • Start IV PPI bolus (80mg) followed by continuous infusion (8mg/hr) prior to endoscopy 1
   • Continue for 72 hours after endoscopic therapy if high-risk stigmata identified

2. Medication adjustments for AKI:

   • Discontinue all nephrotoxic medications (NSAIDs, ACEIs/ARBs) 2
   • Adjust medication doses based on estimated GFR 2
   • Avoid gadolinium-based contrast agents

3. Correct coagulopathy:

   • If patient is on anticoagulants, consider reversal agents based on specific agent
   • Administer vitamin K if INR elevated
   • Consider platelet transfusion if count <50,000/μL and active bleeding

Diagnostic Evaluation

1. Laboratory studies:

   • Complete blood count with differential
   • Comprehensive metabolic panel
   • Coagulation studies (PT/INR, PTT)
   • Type and cross-match
   • Serial hemoglobin/hematocrit monitoring (every 4-6 hours until stable)
   • Urinalysis

2. Endoscopy:

   • Urgent upper endoscopy within 24 hours of presentation 1
   • Perform in a fully equipped endoscopy unit with trained staff 1
   • Consider emergency endoscopy (<12 hours) if:
     • Hemodynamic instability despite resuscitation
     • Ongoing bleeding with hemoglobin drop
     • Transfusion of multiple units without stabilization

3. If initial EGD negative:

   • Consider colonoscopy after bowel preparation
   • Consider video capsule endoscopy or deep enteroscopy if small bowel bleeding suspected

Endoscopic Management

1. For active bleeding or high-risk stigmata:

   • Combination therapy with injection (epinephrine) plus thermal or mechanical methods 1
   • Consider hemoclips, thermal coagulation, or band ligation based on lesion type
   • For Forrest Ia (active spurting) or Ib (oozing) lesions, dual endoscopic therapy is mandatory

2. For non-bleeding visible vessel or adherent clot:

   • Consider endoscopic therapy to prevent rebleeding
   • May consider clot removal with targeted therapy to underlying vessel

3. For clean-based ulcers:

   • Endoscopic therapy not required
   • Continue oral PPI therapy

Management of Acute Kidney Injury

1. Fluid management:

   • Goal-directed fluid therapy to optimize hemodynamics 2
   • Monitor urine output hourly
   • Daily monitoring of serum creatinine, BUN, and electrolytes 2

2. Nephrology consultation:

   • Indicated for all patients with Stage 3 AKI 2
   • Consider earlier consultation for patients with:
     • Oliguria/anuria despite fluid resuscitation
     • Severe electrolyte abnormalities
     • Metabolic acidosis
     • Need for renal replacement therapy

3. Indications for renal replacement therapy:

   • Severe metabolic acidosis
   • Refractory hyperkalemia
   • Volume overload unresponsive to diuretics
   • Uremic symptoms 2

Ongoing Management and Monitoring

1. ICU admission criteria:

   • Hemodynamic instability
   • Ongoing bleeding
   • Multiple comorbidities
   • Need for ventilatory support
   • Severe AKI requiring RRT

2. Monitoring:

   • Continuous cardiac monitoring
   • Frequent vital signs (q1-4h based on stability)
   • Serial hemoglobin/hematocrit (q6h until stable)
   • Strict intake and output
   • Daily BUN, creatinine, and electrolytes

3. Prevention of rebleeding:

   • Continue PPI therapy
   • Avoid NSAIDs
   • Test for H. pylori and treat if positive
   • Consider prophylactic endoscopic therapy for high-risk lesions

Disposition and Follow-up

1. Hospital discharge criteria:

   • Hemodynamic stability
   • No evidence of ongoing bleeding
   • Stable hemoglobin
   • Improving renal function
   • Tolerating oral intake

2. Follow-up:

   • Outpatient follow-up within 1-2 weeks
   • Repeat endoscopy in 8-12 weeks for gastric ulcers to confirm healing
   • Nephrology follow-up within 3 months for patients with AKI 2
   • Earlier nephrology follow-up (2-4 weeks) for patients with Stage 3 AKI or pre-existing CKD 2

Common Pitfalls to Avoid

1. Delayed endoscopy in high-risk patients with ongoing bleeding
2. Inadequate fluid resuscitation leading to worsening of AKI
3. Overaggressive fluid resuscitation leading to volume overload and pulmonary edema
4. Failure to discontinue nephrotoxic medications during AKI
5. Overlooking alternative sources of bleeding if initial EGD is negative
6. Inadequate monitoring after initial stabilization
7. Premature discharge before ensuring hemodynamic stability and renal recovery