Upper GI Bleeding

1
Upper GI Bleeding

• Tad Kim, M.D.
• UF Surgery
• tad.kim_at_surgery.ufl.edu
• (c) 682-3793 (p) 413-3222

2
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
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
Initial Patient Assessment

• Get to patients 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
Differential Diagnosis

• Peptic Ulcer Disease (PUD) gt50 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)
• Dieulafoys lesion (1-3)
• Nasopharyngeal bleed swallowed blood
• Other- Aortoenteric fistula, angiodysplasia,
  Crohns, hemobilia, hemosuccus pancreaticus

6
History Physical

• History of prior ulcers, NSAID use, stress
• History of Helicobacter pylori treatment
• Alcohol abuse
• Retching -gt Mallory Weiss tear
• Alcoholic cirrhosis -gt portal hypertension and
  varices
• On Physical Exam, assess hydration
• Look for stigmata of cirrhosis portal HTN

7
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
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
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
Role of Surgery

• If medical and endoscopic therapy fail
• In the event that bleeding source is unidentified
  -gt exploratory laparotomy
• Recurrent bleeding peptic ulcers
• Anti-ulcer surgery (i.e. vagotomy/antrectomy, or
  vagotomy/pyloroplasty, or selective vagot)

11
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
Take Home Points

• Always, always perform ABCs first resuscitate
  with two 16ga IVs isotonic crystalloids
  (blood if pt doesnt respond)
• NGT/lavage to confirm active bleeding
• Focused HP looking for common causes ulcers,
  varices, -itis, Mallory-Weiss, AVM
• Endoscopy is 1st line for acute UGIB
• Dont forget to start intravenous PPI infusion
• Endoscopy has associated complications
• Angio or surgery if still bleeding