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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 Percentage Lower Percentage
Peptic ulcer dz 45 Diverticulosis 18-43

Gastric Angiodysplasia 20-40


erosions 23
Unknown 11-32
Varices 10
Cancer/polyps 9-33
Mallory-Weiss 7
Rectal disease 8-9
Esophagitis 6
IBD 1-7
Duodenitis 6
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
Evaluation
• Physical Exam
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