Upper GI Bleeding

1. Upper GI Bleeding Tad Kim, M.D. UF Surgery tad.kim@surgery.ufl.edu (c) 682-3793; (p) 413-3222

2. Overview • Definitions • Initial Patient Assessment • ABC & Resuscitation • Differential Diagnosis • Identify the Source & Stop the Bleeding • History & Physical • Endoscopy & Potential Complications • Other diagnostics tests • Role of Surgery • Prevention

3. Definitions • Upper GI Bleeding = proximal to ligament of Treitz • Hematemesis = vomiting blood • This is diagnostic of upper GI bleeding • Melena = passage of tarry or maroon stool • Can be upper or lower (more commonly upper) • Hematochezia = Bright red blood per rectum • Usually characteristic of colonic hemorrhage

4. Initial Patient Assessment • Get to patient’s bedside, assess ABC • Can the patient protect his airway? • Does he need to be intubated? • Is the patient hemodynamically unstable? • Is he in hemorrhagic shock? • 2 large bore IV, Bolus 2L fluids, Type & Cross blood, send CBC & Coags • Place patient on O2 & continuous monitor • Place an NGT and lavage with NS • To confirm if the bleeding source is upper GI

5. Differential Diagnosis • Peptic Ulcer Disease (PUD) >50% cases • Gastritis / Duodenitis (15-30%) • Subset due to NSAID use • Varices from portal hypertension (10-20%) • Mallory-Weiss tears at GE junction (5%) • Esophagitis (3-5%) • Malignancy (3%) • Dieulafoy’s lesion (1-3%) • Nasopharyngeal bleed – swallowed blood • Other- Aortoenteric fistula, angiodysplasia, Crohn’s, hemobilia, hemosuccus pancreaticus

6. History & Physical • History of prior ulcers, NSAID use, stress • History of Helicobacter pylori & treatment • Alcohol abuse • Retching -> Mallory Weiss tear • Alcoholic cirrhosis -> portal hypertension and varices • On Physical Exam, assess hydration • Look for stigmata of cirrhosis & portal HTN

7. Management – Acute UGI Bleed • Once again, make sure pt is resuscitated • If anemic and symptomatic, give blood • Place NGT/lavage (helps for endoscopy) • Perform Upper endoscopy (EGD) • For ulcers: if visible clot, visible vessel, or active bleeding, should cauterize/coagulate and inject sclerosing agent • For acute variceal bleeding: sclerotherapy + somatostatin or endoscopic band ligation. If fail/rebleed: TIPS vs surgical shunt. Balloon tamponade is an emergency temporizing measure • Start proton pump inhibitor (PPI) infusion

8. Potential Complications • Perforation of esophagus • Aspiration • Desaturation or respiratory distress • Adverse reaction to conscious sedation • ↑risk of complications with: • Inadequate resuscitation or hypotension • Comorbidities • Consider elective intubation prior to EGD if active bleeding, altered respiratory or mental status

9. Other Diagnostic Tests • If bleeding is unresolved with endoscopy or endoscopy is contraindicated • 1. Angiography (Diagnostic & Therapeutic) • Intra-arterial vasopressin • Embolization • 2. Tagged red blood cell (TRBC) scan • Only diagnostic & usually for occult bleeding • More sensitive than angiography • Can detect bleeding rate of 0.1-0.5 mL/min

10. Role of Surgery • If medical and endoscopic therapy fail • In the event that bleeding source is unidentified -> exploratory laparotomy • Recurrent bleeding peptic ulcers • Anti-ulcer surgery (i.e. vagotomy/antrectomy, or vagotomy/pyloroplasty, or selective vagot)

11. Prevention • After the acute situation is resolved, educate patient on preventive measures • Top 2 reasons for ulcers: Hpylori & NSAID • 1. Testing for H.pylori (i.e. antral biopsy during endoscopy) • 2. Treat H.pylori (amoxicill, clarithromycin x1wk plus PPI x4wk) • 3. Reduce intake of NSAID

12. Take Home Points • Always, always perform ABC’s first & resuscitate with two #16ga IV’s & isotonic crystalloids (blood if pt doesn’t respond) • NGT/lavage to confirm active bleeding • Focused H&P looking for common causes: ulcers, varices, “-itis”, Mallory-Weiss, AVM • Endoscopy is 1st line for acute UGIB • Don’t forget to start intravenous PPI infusion • Endoscopy has associated complications • Angio or surgery if still bleeding