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 Non variceal bleeding Percentage 80% Portal hypertensive bleeding Percentage 20% Peptic ulcer disease 30-50% Gastroesophageal Varices >90% Mallory Weiss tears 15-20% Hypertensive Portal Gastropathy <5% Gastritis & duodenitis 10-15% Isolated Gastric Varices Esophagitis 5-10% Arteriovenous malformations 5% Tumors 2% Other

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

Nasogastric Tube Helps in diagnosis Facilitates endoscopy

General Management Triage General Support Fluid Resuscitation: 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.

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.

Acid Suppression IV PPI Reduces rate of rebleeding 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.)

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)

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

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

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

Refractory Bleeding Repeat Endoscopy Angiography Surgery

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

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.

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

Non variceal Bleeding

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

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

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

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

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 unrelaxed cardia, resulting in mucosal laceration of the proximal cardia as a result of the increase in intragastric pressure

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

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

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

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

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

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

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)

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

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…)

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

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

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Angio embolization

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

Bleeding related to Portal Hypertension

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

Gastroesophageal Varices 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%!!!!

Management

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

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