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

2. Upper GI Bleeding 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. Upper GI Bleeding 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. Upper GI Bleeding 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. Upper GI Bleeding 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. Upper GI Bleeding 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. Upper GI Bleeding 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. Upper GI Bleeding 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. Upper GI Bleeding 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. Upper GI Bleeding 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. Upper GI Bleeding 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. Upper GI Bleeding 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 1 st line for acute UGIB –Don’t forget to start intravenous PPI infusion Endoscopy has associated complications Angio or surgery if still bleeding