Upper Gastrointestinal Bleeding

Upper Gastrointestinal Bleeding 27 may 2009

Sathaporn Kunnathum M.D.

Overview • • • •

Cause of Gastrointestinal bleeding Clinical Presentation Evaluation Treatment

Introduction • Causes depend on site – UGI = proximal to ligament of Treitz – LGI = distal to ligament of Treitz

Causes of Significant GI Bleeding Upper Peptic ulcer dz Gastric erosions Varices Mallory-Weiss Esophagitis Duodenitis

Percentage Lower 45 23 10 7 6 6

Percentage

Diverticulosis

18-43

Angiodysplasia

20-40

Unknown

11-32

Cancer/polyps

9-33

Rectal disease

8-9

IBD

1-7

Clinical Presentation • Most common = hematemesis, melena, hematochezia or black stools – Hematemesis associated with bleeding proximal to lig of treitz – Melena usually proximal to jejunum with greater than 4 hrs transit time • requires blood 50-100 mL

Clinical Presentation – Hematochezia usually due to colonic source BUT UGIB > 1000 mL and less than 4 hours transit may be red or maroon

• UGIB: 71% have melena, 56% hematemesis, 21% maroon stool

Evaluation • First priority is ABCs • Intubation occasionally necessary for overwhelming UGIB • Aggressive fluid resuscitate if hemodynamic unstable = Mandatory to have 2 Large Bore I.V. or central access • While stabilizing, get initial history, place on monitor and start O2

Evaluation • History: – Duration, quantity, color of blood, associated symptoms ,precipitating factor, history of GIB, alcohol, drugs use, underlying disease

• Physical Exam

Evaluation

Vital signs – PR, BP, RR – Hypothermia with significant volume depletion Others

– General appearance: pale?jaundice? conscious? – Skin: turgor, capillary refill, petechiae/purpura – Lungs/Heart – Abdominal exam – PR

Evaluation • Laboratory – Hct – CBC,plt – PT/PTT for correctable coagulopathy – Cross match – Blood chemistry for azotemia/ARF/Acidosis – LFT – ABG if indicated

Treatment • • • • • • • •

NPO Always start with ABCs O2 2 Large bore IVs Monitor NG tube Foley cath ET tube ?

Treatment • NG lavage – Essential to differentiate UGI vs. LGI – 10-15% of pts with hematochezia have UGIB

Treatment • NG lavage, cont. – 79% sensitive for ACTIVE UGIB – Useful to assess for ongoing hemorrhage – Not therapeutic – Not harmful in varices or MW tear

Treatment • NG lavage, additional notes – Must confirm placement of tube prior to lavage – Sterile lavage fluid not necessary – Lavage until clear

Treatment • Fluid resuscitation – Crystalloid initially – PRC,Fresh whole blood, FFP, plt conc

• Critical to monitor

Treatment • Coagulation Defects - consider FFP, Vit K • Thrombocytopenic (<50,000 and bleeding) transfuse platelets • For severe bleeds - consult GI early as well as general surgery

Treatment • Additional options – Empiric acid-suppressive therapy : PPI and H2 receptor antagonist – Octreotide - Besson in NEJM 1995 showed decreased rebleeding in varices after Octreotide - no change in mortality, however (50 mcg bolus, then 25-50/hr)

Treatment • Sengstaken-Blakemore Tube – Generally not used except in dire circumstance – High rate of complications and death (14%, 3%) including aspiration, esophageal and gastric rupture, mucosal and nasal necrosis – Attempt only after failure of Octreotide as a bridge to endoscopy in pts exsanguinating from known varices – Need to be intubated prior to placement

Treatment • Endoscopy – Most accurate tool for evaluating source of bleeding – Not usually necessary in first 12 hrs • no increase in diagnostic accuracy if done earlier

– May be necessary if bleeding is ongoing, unresponsive to resuscitation or recurrent to dictate therapy

• Intervention angiography

Treatment • Surgery – 15-34% of patients with GIB require surgery – Mortality for emergency surgery is 23%

• Thank you for your attention