Thoracic Ultrasound on Upper Gastrointestinal Bleeding (ECOBLEDSTUDY)
Condition: Upper Gastrointestinal Bleeding
MeSH terms: Gastrointestinal Hemorrhage; Hemorrhage
Study type: Observational

Summary: 
      Upper Gastrointestinal bleeding (UGIB) is a medical emergency and the most common cause of
      hospitalization associated with digestive disease. Proper initial resuscitation is the first
      step in the management of UGIB patients. Today, modern pulmonary ultrasound is used in
      different clinical settings, such as intensive care, emergency medicine and/or traumatology.
      In the last years, the use of this has been standardized both in internal medicine and in
      pulmonary medicine. The primary objective is to describe the findings of pulmonary ultrasound
      and its relationship with severity in patients with UGIB. The investigators will include all
      patients with UGIB. A pulmonary and vena cava ultrasound will be performed on admission to
      the emergency room, 10 minutes prior to endoscopy and 24 hours after having performed the
      endoscopy.

      The use of thoracic point-of-care ultrasound (TPOCUS) has been standardized in both internal
      and pulmonary medicine. There is a concern about the role of TPOCUS useful as a severity
      prognostic tool in patients with UGIB.

      The team proposes that TPOCUS is a severity prognostic tool in UGIB patients.

      Main Outcome: To describe the findings of TPOCUS in patients with variceal and non-variceal
      UGIB.

      Secondary Objectives:

        1. Correlate the presence of B-type lines on TPOCUS with mean arterial pressure in UGIB
           patients.

        2. Correlate the inferior vena cava diameter with the Model for End-stage Liver Disease
           scale in UGIB patients.

        3. Correlate the inferior vena cava diameter with the 48 hours post-admission mortality of
           UGIB patients.

      Authors design a prospective, longitudinal, descriptive study to identify the findings of
      TPOCUS in patients with variceal and non-variceal UGIB. Patients will be included in the
      study since May 15th through October 30th 2019, admitted to the University Hospital, "Dr.
      José E. González", Universidad Autónoma de Nuevo León.
    

Detailed description: 
      Inclusion criteria:

        1. Patients with a diagnosis of UGIB documented by endoscopy.

        2. Any gender.

        3. Over 18 years old.

      Exclusion criteria:

        1. Patients with UGIB previously treated in other hospitals.

        2. Patients under 18 years of age.

        3. Patients with suspected UGIB who did not undergo endoscopy.

        4. Pregnant.

        5. Patients with chronic obstructive pulmonary disease.

        6. Patients with interstitial lung disease.

        7. Patients with pleural effusion at the time of admission to the emergency room.

        8. Refusal to participate in the protocol.

      Method The investigators will study all patients who come to the emergency room of the
      hospital due to suspicion of UGIB (melena, hematemesis, vomiting in coffee grounds and
      hematochezia with hemodynamic instability). These patients will undergo a pulmonary and vena
      cava ultrasound.

      Patients with suspected UGIB who are candidates for upper endoscopy during their hospital
      stay will undergo a second pulmonary and vena cava ultrasound ten minutes prior to upper
      endoscopy.

      The investigators will include in the research study patients with UGIB documented by upper
      endoscopy. The investigators will perform a third pulmonary and vena cava ultrasound 24 hours
      after the endoscopic procedure.

      The investigators will exclude patients with suspected UGIB but who are not candidates for
      endoscopy.

      The technique used is a bilateral intercostal thoracic point-of-care ultrasound (TPOCUS) with
      the patient in supine decubitus with the head at 30 degrees. Each hemithorax will be divided
      into 4 areas: anterior and lateral, superior and inferior. The anterior area will be
      delineated between the clavicle and the diaphragm and between the parasternal line to the
      anterior axillary line. The lateral area will be delineated between the axilla and the
      diaphragm and between the anterior to the posterior axillary line. The superior area will be
      delineated from the 1st to the 3rd intercostal space and the lower area from the 4th to the
      6th intercostal space. A total of 8 areas of the chest will be visualized during normal
      breathing.

      The TPOCUS findings to report are:

      B-type lines: Those lines are hydro-aerial artifacts presenting as comet tail images, begin
      in the pleural line, are hyper-echoic, well defined, disseminated towards the end of the
      screen, delete A-type lines, and move with the pleural slip when this it is present. The
      lines separated from each other around 7 mm correspond to interstitial edema, while those
      that distance 3 mm indicate the presence of alveolar edema. The presence of more than 3
      B-type lines indicates the presence of an alveolar-interstitial syndrome.

      The inferior cava vein evaluation will be performed by measuring the diameter and percentage
      of collapse of this vein. It will be performed in the subxiphoid window with the
      identification of the four cardiac chambers, then a 90º turn of the transducer will made in
      the cephalad direction, which will show the right atrium, the union of the inferior vena cava
      and the liver above it. The diameter measurement will be beyond the point of confluence of
      the hepatic veins, usually found approximately 2 cm from the union of the inferior vena cava
      and the right atrium. Based on the diameter and collapse percentage measurement of the
      inferior vena cava on spontaneous breathing, a volume status will be defined as lack of
      volume if the diameter is <2 cm and the collapse percentage is >50%; however, a diameter >2
      cm and a collapse percentage <50% will be classified as hypervolemic state.
    

Observational model: Case-Only
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Patients with variceal and non-variceal UGIB, who arrive to the emergency department of the
        University Hospital, "Dr. José E. González" Universidad Autónoma de Nuevo León.
      
Keywords: Upper Gastrointestinal Bleeding