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 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

5. 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

6. Nasogastric Tube
Helps in diagnosis
Facilitates endoscopy

7. 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.

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 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.)

10. Somatostatin and its Analogs
Variceal Bleeding
Octreotide (IV bolus 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

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

15. Refractory Bleeding
Repeat Endoscopy
Angiography
Surgery

16. 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

17. 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.

18. 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

20. Non variceal Bleeding

21. 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

22. 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

23. 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

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

25. 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

26. 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

27. 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

28. 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

29. 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

30. 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

32. 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

33. 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)

34. 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

35. 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…)

36. 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

37. 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

38. 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

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

40. Bleeding related to Portal Hypertension

41. 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

42. 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%!!!!

44. Management

45. 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

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