Acute UGI Bleeding

Stephen Matarazzo MD
Hillmont G.I. p.c.
Acute UGI Bleeding
Common cause of hospitalization
Appropriate resuscitation effects outcome
Endoscopic intervention is highly successful
Management decisions based on Endoscopic
findings
Acute UGI Bleeding
Presentation
Hematemesis
Vomiting BRB or coffee ground material
Melena
Black tarry stool
Hematochezia
Bright red or maroon rectal discharge
11% are UGI Bleeding
NG Lavage
Positive result
Blood or coffee ground material
Negative Result
Bile with no blood
Bleeding stopped
Bleeding beyond closed pylorus
Acute UGI Bleeding
Approach to the patient
Assess hemodynamic stability
Resuscitation
Diagnostic studies
Treatment
Acute UGI Bleeding
Hemodynamic Instability
Shock
Orthostatic hypotension
Profuse active bleeding
Decrease in HCT 10%
Anticipated transfusion > 2 units RBCs
Acute UGI Bleeding
Resuscitation
Large bore I.V.
NSS
Blood Transfusions
Correct coagulopathy INR > 1.5
FFP
Vitamin K
Correct thrombocytopenia < 50,000
NG Lavage to remove blood & clots
Protect airway if necessary with elective intubation
PPI
Octreotide
GI and Surgical Consults
Acute UGI Bleeding
Diagnostic Studies
Endoscopy
Tagged red cell bleeding scan
Angiography
Acute UGI Bleeding
Differential Diagnosis
PUD
H. Pylori
NSAIDS
Z.E.
Stress
Idiopathic
ESO / gastric varices
Portal gastropathy
Mallory Weiss tear
Esophagitis
Peptic
Pill
Infectious
Gastric Malignancy
Adeno Ca
Lymphoma
AVM
Dieulafoy
Acute UGI Bleeding
Endoscopy
Gold standard for Dx
Most sensitive study
Therapeutic potential is major asset
Decrease re-bleeding
Fewer blood transfusions
Decreases LOS
Reduces mortality
Reduces surgical procedure
Pre-Endoscopy Emycin
Acute UGI Bleeding
Risks of Endoscopy
Aspiration
Hypoventilation
Perforation
Co-Morbid Events
AMI
COPD
Acute UGI Bleeding
Risk of Stratification of PUD
Major Stigmata
Bleeding visible vessel re-bleeds 80-90%
Non-bleeding visible vessel re-bleeds 45-50%
Adherent clot re-bleeds 25-30%
Minor Stigmata
Oozing without visible vessel re-bleeds 10-15%
Flat spot re-bleeds 7-10%
Clean ulcer base re-bleeds 3-5%
Acute UGI Bleeding
Risk Stratification of PUD
Clean ulcer base
Ok to discharge after Endoscopy
Re-admission rate 1%
Exceptions
Severe Anemia
Serious co-morbid diseases
Anticoagulation therapy
Coagulopathy
46% of patients discharge in ER or 12-24hrs.
Acute UGI Bleeding
Endoscopic treatment of PUD
Epinephrine injection initial Rx only
Heater probe
Bipolar electro-coagulation
Endo clips 15-20% of ulcers cannot be clipped
Use double channel scope
Re-bleeding occurs 15-20% of non-variceal
lesions
Re-bleeding usually occurs in 24-48 hrs.
Re-scope successful 50%
Acute UGI Bleeding
PPI Treatment
Decreases re-bleeding in PUD
Decreases blood transfusions and LOS
High risk ulcers; use PPI infusion
80 mg IV bolus
8 mg 1 hr. infusion
Switch to PPI BID orally in 72 hrs.
Positive H. pylori; treat as outpatient
Variceal Bleeding
Predictionof patients at risk
Prophylaxis against first bleed

Treatment of active bleeding

Prevention of re-bleeding
Variceal Bleeding
30-40% mortality
Directly related to portal hypertension

70% risk of re-bleeding in 1 year

Occurs in 25-40% of patients with cirrhosis

most common etiology
Portal pressure flow X resistance

Normal portal pressure 5mm Hg

Variceal Bleeding
Treatment of Active Bleeding
Current Options
Octreotide
Endoscopy
Surgery
TIPS
Variceal Bleeding
Octreotide
Splanchnic vasoconstriction by inhibiting glucagon
Decrease portal flow
Rapid onset of action
Magic number; 12mm Hg portal pressure
Absent side-effects
Initial hemostasis > 75%
50ug bolus followed by 50ug/hr x5 days
Endoscopy
Endoscopic Variceal Ligation EVL
Endoscopic Variceal Sclerosis EVS
Current Recommendations
Octreotide plus EVL
Antibiotics improve survival in cirrhotics with hemorrhage
Prevention of Variceal
Re-bleeding
70% re-bleeding rate after index bleed
Risk of re-bleeding greatest immediately after cessation of index
bleeding
70% of untreated patients die in 1 year
EVL treatment of choice
EVS less successful with higher morbidity and mortality
Requires at least 4-6 bandings
Medical treatment
Propanolol
Decreases portal pressure
Titrate dose to decrease heart rate by 25%
Reduces risk of re-bleeding by 40%
Reduces mortality by 20%
Propanolol plus oral nitrates
Increase side effects
Not routinely used unless you fail beta blocker Rx
Transjugular Intrahepatic Porto
Systemic Shunts
Functions similar to surgical shunts
No surgery, done transjugular

Re-bleed rate 20% in first year

Major drawback is hepatic encephrlopathy

Shunt stenosis common

Very expensive

Best used as salvage procedure