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Upper GI Bleeding

Upper GI Bleeding. Dr M. Ghanem. Definition. Refers to GI bleeding from a source proximal to the Ligament of Treitz. Presentation. Hematemesis Coffee-ground vomiting Melena Hematochezia. Causes. Initial Evaluation. ABC’s History: Bleeding Manifestations PMHx Medications? P/E:

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Upper GI Bleeding

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  1. Upper GI Bleeding Dr M. Ghanem

  2. Definition • Refers to GI bleeding from a source proximal to the Ligament of Treitz

  3. Presentation • Hematemesis • Coffee-ground vomiting • Melena • Hematochezia

  4. Causes

  5. Initial Evaluation • ABC’s • History: • Bleeding Manifestations • PMHx • Medications? • P/E: • Hemodynamic Stability? • Abdomen • PR • Labs: • Routine • Blood Type + Cross match • BUN:Cr > 20:1

  6. Nasogastric Tube • Helps in diagnosis • Facilitates endoscopy

  7. General Management • Triage • General Support • Airway, Clinical Status, V/S, ECG, UO, NG Output • Oxygen • NPO • 2 large-bore peripheral IV canulas • Central Venous Line? / Pulm Artery Catheter? • Elective Intubation? • Fluid Resuscitation: • Hemodynamic Instability/Active Bleeding  Rapid bolus infusions of isotonic crystaloids.

  8. Blood Transfusions • Transfuse for: • Hemodynamic instability despite crystalloid resuscitation • Hemoglobin <10 g/dL (100 g/L) in high-risk patients (eg, elderly, coronary artery disease) • Hematocrit <7 g/dL (70 g/L) in low-risk patients • Give fresh frozen plasma for coagulopathy (INR > 1.5) • Give platelets for thrombocytopenia (platelets <50,000) or platelet dysfunction (eg, chronic aspirin therapy) • 1 FFP for every 4 units of PCs.

  9. Acid Suppression • IV PPI • Omeprazole (80mg bolus, 8mg/hr infusion) • Pantoprazole • Esomeprazole • 72 hrs… -> PO Pantoprazole 40mg/d, Omeprazole 20mg/d. • Reduces rate of rebleeding • Reduces hospital stay • Reduces need for blood transfusion • Reduces endoscopic signs of active bleeding (6.4 vs 14.7%) and the need for endoscopic hemostatic therapy (19.1 vs 28.4%) (Chan WH, Khin LW, Chung YF, et al. Randomized controlled trial of standard versus high-dose intravenous omeprazole after endoscopic therapy in high-risk patients with acute peptic ulcer bleeding. Br J Surg 2011; 98:640.)

  10. Somatostatin and its Analogs • Variceal Bleeding • Octreotide (IV bolus 20-50 mcg, continuous infusion 25-50mcg/hr) • May also reduce risk of bleeding due to nonvariceal causes. (Ann Intern Med 1997; 127:1062)

  11. EsophagoGastroDuodenoscopy • Diagnostic modality of choice for acute UGI bleeding. • Early endoscopy (within 24 hours) is recommended for most patients with UGIB • Results in reductions in blood transfusion requirements, a decrease in the need for surgery, and a shorter length of hospital stay

  12. EsophagoGastroDuodenoscopy • In general, 20% to 35% of patients undergoing EGD will require a therapeutic endoscopic intervention, and 5% to 10% will eventually require surgery • 1% to 2% of patients with upper GI hemorrhage, the source cannot be identified because of excessive blood impairing visualization of the mucosal surface

  13. ENDOSCOPIC THERAPY • Thermal Coagulation • Injection Therapy • Hemostatic Clips • Fibrin Sealant (or glue) • Argon Plasma Coagulation • Combination Therapy

  14. Refractory Bleeding • Repeat Endoscopy • Angiography • Surgery

  15. Angiography • Consensus statement from the American College of Radiology: • Endoscopy is the best initial diagnostic and therapeutic procedure. • Surgery and transcatheter arteriography/intervention (TAI) are equally effective following failed therapeutic endoscopy, but TAI should be considered particularly in patients at high risk for surgery. • TAI is less likely to be successful in patients with impaired coagulation. • TAI is the best technique for treatment of bleeding into the biliary tree or pancreatic duct

  16. Indications for Surgery for Peptic Ulcer Hemorrhage • Failure of endoscopic therapy. • Hemodynamic instability despite vigorous resuscitation (> 6 unit transfusion). • Recurrent hemorrhage after initial stabilization (with up to 2 attempts at obtaining endoscopic hemostasis). • Shock associated with recurrent hemorrhage. • Continued slow bleeding with a transfusion requirement > 3 units per day.

  17. Second-Look Endoscopy • Not routine • If visualization during the initial endoscopy was limited by blood or debris. • If there is concern on the part of the endoscopist that the prior endoscopic therapy was sub-optimal . • If there is recurrent bleeding to exclude previously missed lesions and/or to retreat the bleeding ulcer

  18. Non variceal Bleeding

  19. PUD • The most frequent cause • About 10-15% of ptns with PUD bleed • Bleeding develops as a result of acid-peptic erosion into a submucosal vessel, or penetration into a larger vessel

  20. PUD • Duodenal ulcers are more common than gastric ulcers • Gastric ulcers bleed more commonly • The most significant hemorrhage occurs when duodenal or gastric ulcers penetrate into branches of the gastroduodenal artery or left gastric artery, respectively

  21. PUD • Unlike perforated ulcer, which are strongly associated with H Pylori, the association between bleeding and H pylori and bleeding is less strong • In patients who are taking ulcerogenic medications, such as NSAIDs or SSRIs, and who present with a bleeding GI lesion, these medications are stopped, and the patient is started on a nonulcerogenic alternative

  22. PUD • Ulcers greater than 2 cm, posterior duodenal ulcers, and gastric ulcers have a significantly higher risk for rebleeding

  23. Mallory Weiss Tear • Mucosal and submucosal tears that occur near the GEJ • After a period of intense retching and vomiting (alcoholics after binge drinking) • The mechanism is forceful contraction of the abdominal wall against an unrelaxedcardia, resulting in mucosal laceration of the proximal cardia as a result of the increase in intragastric pressure

  24. Mallory Weiss Tear • Diagnosis based on Hx and EGD • In endoscopy a retroflexion maneuver must be performed • Most tears occur along the lesser curvature • Supportive therapy is often all that is necessary because 90% of bleeding episodes are self-limited, and the mucosa often heals within 72 hours

  25. Stress Gastritis • Multiple superficial erosions of the entire stomach, most commonly in the body • Result from the combination of acid and pepsin injury in the context of ischemia from hypoperfusion states, although NSAIDs produce a very similar appearance • Factors increasing the risk for hemorrhage from stress gastritis included ventilator dependence for greater than 48 hours and coagulopathy

  26. Stress Gastritis • Rarely develop significant bleeding • Tx is with (H2)-receptor antagonists, PPIs, or sucralfate • When this fails, consider administration of octreotide or vasopressin selectively through the left gastric artery, endoscopic therapy, or even angiographic embolization

  27. Esophagitis • Esophageal inflammation secondary to repeated exposure of the esophageal mucosa to the acidic gastric secretions in GERD • If ulceration occursbleeding (usually chronic blood loss) • In immunosuppressed ptns consider infectious esophagitis • Due to medications, radiation, Crohns

  28. Diuelafoy’s Lesion • Vascular malformations found primarily along the lesser curve of the stomach • Typically within 6 cms of the GEJ, but can occur anywhere • Represent rupture of unusually large vessels (1-3 mm) that are found in the gastric submucosa after erosion of the overlying mucosa • Bleeding can be massive

  29. Diuelafoy’s Lesion • Tx is with endoscopy: application of thermal or sclerosant therapy is effective in 80% to 100% of cases • If this fails: angio coil emboization • If this fails consider surgery

  30. Gastric antral Vascular Ectasia • A collection of dilated venules appearing as linear red streaks converging on the antrum in longitudinal fashion, giving it the appearance of a watermelon • Usually present with chronic blood loss • Endoscopic therapy is indicated for persistent, transfusion-dependent bleeding and has been reportedly successful in up to 90% of patients (argon plasma coagulation)

  31. Malignancy • Usually present with chronic blood loss (iron deficiency anemia, +ve occult blood in stool) • Significant bleeding may occur, esp with ulcerated lesions (esp GIST) • Although endoscopy is usually successful in controlling the bleeding, rebleeding rate is high

  32. Malignancy • When a malignancy is diagnosed, surgical resection is indicated • Surgery maybe be urgent or elective, curative or palliative, depending on the clinical setup (chronic blood loss vs severe acute bleeding, ptn stability, etc…)

  33. Aortoenteric Fistula • <1% of aortic graft cases • Occur after abdominal aortic aneurysm repair or due to aortitis • Usually occur 3 years after surgery, but may occur anytime (even days after) • Should always be considered in a ptn with UGIH after abdominal aneurysm repair

  34. Aortoenteric Fistula • Hemorrhage is usually massive and can be fatal • Sentinel bleeding: a self limited bleeding that heralds the coming massive hemorrhage • Urgent endoscopy!!! bleeding from the 3rd or 4th part of the duodenum • CTair around the graft (suggestive of an infection), possible pseudoaneurysm, and rarely the presence of intravenous contrast in the duodenal lumen • Tx is surgery

  35. Hemobilia • Associated with trauma, instrumentation of the biliary tract, tumors • GI bleeding with jaundice & RUQ pain & tenderness • EGD blood from the ampulla of vater • TxAngioembolization

  36. Iatrogenic • Hemobilia after instrumentation of the biliary tract • After sphinceterotomy in ERCP • PEG • Post operative

  37. Bleeding related to Portal Hypertension

  38. Bleeding related to Portal Hypertension • Most commonly the result of bleeding from varices • Dilation of the submucosal veins due to PH providing a collateral pathway for decompression of the portal system • Distale esophagus>Stomach>Rectum

  39. GastroesophagealVarices • Develop in 30% of ptns with cirrhosis & PH • Bleeding occurs in 30% of ptns with varices • Compared to non variceal bleeding, its associated with higher risk of rebleeding, transfusions, hospital stay, mortality!!! • Massive bleeding • 6 week mortality after the 1st bleeding is 20%!!!!

  40. Management

  41. Sengstaken Blakemore tube • Gastric tube with esophageal and gastric balloons • The gastric balloon is inflated, and tension is applied to the gastroesophageal junction • If this does not control the hemorrhage, the esophageal balloon is inflated as well, compressing the venous plexus between them

  42. Sengstaken Blakemore tube • A high rate of complications related to both aspiration and inappropriate placement with esophageal perforation

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