UPPER GASTROINTESTINAL BLEEDING Bernard M. Jaffe, MD Professor of Surgery Emeritus

UPPER GI BLEEDING Bleeding from the Distal Esophagus Stomach Duodenum proximal Small Bowel (Rare)

CAUSES Gastritis (Commonest) Peptic Ulcer Mallory-Weiss Tear (Mucosal Laceration Near E-G Junction) Varices (Esophageal > Gastric) Dieulafoy’s Lesion (Tortuous Arteriole Protruding Through Gastric Mucosa )

CAUSES OF GASTRITIS H. Pylori Infection NSAID’s Atrophic Gastritis Pernicious Anemia Alkaline Enterogastric Reflux (Bile is Offending Material)

UPPER GI BLEED Vomiting Coffee Ground Material Bright Red Blood Per Rectum Melena Bright Red Blood (Very Rapid Bleeding)

WORK-UP History- Peptic Ulcer Disease, Liver Disease, NSAID Use Physical Exam- Usually Normal (Except Features of Cirrhosis) Lab Tests- Serum Gastrin level Hemoglobin/Hematocrit Type and Cross-Matching Imaging Studies Not Helpful

NON-OPERATIVE THERAPY Irrigation of Clots from Stomach (May Require Ewald Tube) Urgent EGD- Heater Probe, Cautery Clip of Visible Vessel Anti-Secretory Therapy Vasopressin Somatostatin

VISIBLE VESSEL Gastroduodenal Artery in Posterior Duodenum Bleeds Massively (Arterial) Temporize by Endoscopic Means (Clips, Cautery) Requires Operative Therapy Need to Oversew Artery Above and Below Bleeding Site

PROGNOSIS 80% Are Self-Limiting Mortality Rate 8-10% Increases with Patient Age Mortality Related to Severity Site/Cause High Transfusion Rate Shock

PROGNOSIS (2) Bleeding in Hospital Worse Than Bleeding Outside (33 vs. 17%) Recurrent Bleeding Increases Mortality from 8-30% Visible Vessel Mortality 16%

OPERATIVE THERAPY Gastritis- Oversew Bleeding Arreas Vagotomy and Pyloroplasty Ulcer- Resect the Ulcer Definitive Ulcer Procedure Mallory Weiss Tear- Oversew Bleeding Area Suture Torn Area Dieulafoy’s Lesion- Oversew Arteriole

VARICES Sengstaken-Blakemore Tube Puts Pressure on Varices Sclerotherapy TIPS Procedure (Transjugular Intrahepatic Portosystemic Shunt) If Operation Unavoidable, Perform Porta-Systemic Shunt