3. Know epidemiology and definition of UGI bleeding
Identify etiologies of UGIB
Understand the approach to Upper GI bleeding
Determine the prognosis based on risk stratification
Determine different management options in patients
presenting with UGIB
9/30/2023 3
4. Gastrointestinal bleeding presents as either overt or occult bleeding.
Overt GIB:- manifested by hematemesis, melena &hematochezia.
Occult GIB:- in the absence of overt bleeding when patients
present with:-
symptoms of blood loss or anemia
routine diagnostic evaluation reveals IDA or a positive FOBT.
9/30/2023 4
5. GIB is also categorized by the site of bleeding as:-
Upper GI bleeding – bleeding proximal to the ligament of
Treitz (esophagus, stomach, duodenum)
Lower GI bleeding – bleeding below the ligament of Treitz
Obscure GI bleeding – recurrent acute or chronic bleeding
for which no known source is identified
9/30/2023 5
6. Severe GI bleeding:- documented GI bleeding (hematemesis,
melena, hematochezia, or positive NG lavage) accompanied by
shock or orthostatic hypotension
decrease in the hematocrit value by at least 6% (or a decrease
in the hemoglobin level of at least 2 g/dL)
transfusion of at least 2 units of packed red blood cells
(RBCs).
9/30/2023 6
7. Acute Upper GI bleeding is a common emergency condition.
Approximately 50% of admissions for GI bleeding are for UGIB ,
40% are for LGIB, and 10% are for obscure bleeding
The annual incidence of hospital admissions for UGIB in the US
and Europe is 0.1% per year.
The mortality rate of severe UGIB is 5-10% despite advances in
medical therapy, ICU care, endoscopy, and surgery.
9/30/2023 7
8. Endoscopic therapy has been shown to reduce the rate of
rebleeding, the need for blood transfusions, and surgery.
Bleeding is self-limited in 80% of patients with Upper GI
hemorrhage, even without specific therapy.
Of the remaining 20% who continue to bleed or rebleed, the
mortality rate is 30% to 40%, they benefit from acute
medical, endoscopic, angiographic or surgical therapy.
9/30/2023 8
10. Upper GI bleeding refers to bleeding from oesophagus, stomach,
duodenum (i.e. Proximal to ligmanet of treitz).
Presentation
Hematemesis:- vomiting of fresh blood or coffee ground vomit
Melena:- black tarry, foul-smelling stool, may persist for 5-7 days
Hematochezia:- fresh blood, clot, or currant jelly stool, most often
with lower GI bleed, and can be massive UGIB.
9/30/2023 10
15. A defect in the gastric or duodenal mucosa (>5 mm ), extends
through the muscularis mucosa into the deeper layers of the wall.
PUD is the most common cause of UGIB, ~50% of cases.
Prevalence of H.pylori infection is >80% (developing) 20-50%
(developed)
Lifetime risk of PUD from Hp infection is 3% in US, 25% in Japan
9/30/2023 15
16. Peptic ulcers may present with dyspeptic or other gastrointestinal
symptoms, or may be initially asymptomatic and then present with
complications such as hemorrhage or perforation.
Greater than 50% of patients with ulcer-related hemorrhage bleed
without any preceding warning signs or symptoms.
Peptic ulcers are most commonly caused by a decrease in mucosal
defense mechanisms attributable to aspirin or other NSAIDs,
H. pylori infection, or both.
9/30/2023 16
18. Prevention of recurrent bleeding focuses on the 3 main factors
Helicobacter pylori, NSAIDs and acid.
Eradication of H. pylori decreases rates of rebleeding to <5%.
Majority of patients with bleeding PUD will stop bleeding
spontaneously & one third of patients will rebleed within the
next 1–2 years if no preventive strategies are employed
9/30/2023 18
20. 9/30/2023 20
Endoscopic, clinical, and laboratory features may be useful for
risk stratification of patients who present with acute UGIB
Stratified for risk of mortality , rebleeding and to triage patients
for best care and urgent endoscopy
Pre-endoscopy scoring systems for non-variceal bleeding
Blatchford Score ▪ Clinical Rockall Score
AIMS65 score ▪ Artificial neural network score
23. Simple risk score that predicts in-hospital mortality, LOS, cost
in patients with acute UGIB
Score >2 are
considered high risk
23
Variables Score
lbumin <3.0 g/dl 1
NR > 1.5 1
ental status altered 1
ystolic BP <90 1
+ years old 1
9/30/2023
24. Overall, the predictive value of the GBS was superior as
compared to pre-endoscopy Rockall score and AIMS65.
Prior to endoscopy we will discharge patients with a GBS of 0-1
Most patients who have received endoscopic treatment for high-
risk stigmata should be hospitalized for 72 hours to monitor for
rebleeding
In validation goup, scores of 6 or more were associated with a
greater than 50% risk of needing an intervention.
9/30/2023 24
25. IA : Active or Spurting hemorrhage
IB : Oozing hemorrhage
IIA: Non-bleeding visible vessel
IIB: Adherent clot
IIC: A flat pigmented spot
III: A clear ulcer base
9/30/2023 25
Forrest's Classification
It describes the ulcer, predicts rebleeding risk and provides
clue for subsequent management.
28. Passed through the working channel of an endoscope & applied to an
ulcer to determine if blood flow is present beneath the ulcer base.
DEP has been utilized to risk stratify patients with SRH into:
High risk: active arterial bleeding [FIA], NBVV [FIIA] &
adherent clot [FIIB]
Intermediate risk: oozing bleeding [FIB], & flat spots [FIIC]
Low risk: clean ulcer base [FIII])
9/30/2023 28
30. UGIB hospitalizations due to varices ranges from 2–40%, and is
the 2nd most common cause of severe UGI bleeding.
The mortality rate with each bleeding is ~30%
Rate of new varices development in cirrhotic patients is 5% per year and
rate of growth from small to large varices is 10% per year
Variceal hemorrhage occurs in 25 – 40% of patients with cirrhosis
9/30/2023 30
31. GEV present in 50% cirrhotic patients:
30-40% compensated, 85% decompensated
In Compensated cirrhosis, varices develop at a rate of 7-8% per year.
Two years risk of bleeding in in patients with varices
<5 mm in diameter is 7%, >5 mm in diameter is 30%.
Up to 25% of patients with newly diagnosed varices will experience
variceal bleeding within 2 years.
The best clinical predictor of bleeding appears to be variceal size.
9/30/2023 31
32. Screening endoscopy is recommended as cirrhosis is
diagnosed:
Compensated + no varices Q2-3yr
compensated + small varices Q1-2yr
At time of decompensation
LS <20 kPa and Platelet count >150,000/mm3 a very low
probability (<5%) of having high-risk varices.
33. Factors predict the risk of bleeding;
the size and location of the varix
Severity of cirrhosis (Child's class)
Patients with tense ascites.
the height of wedged-hepatic vein pressure
certain endoscopic stigmata, including red wale signs, hematocystic
spots, diffuse erythema, cherry-red spots, or white-nipple spots.
9/30/2023 33
34. Of patients who have stopped bleeding, approximately one third will
rebleed within the next 6 weeks. (40% within 5 days)
Predictors of rebleeding include;
active bleeding at emergency endoscopy
bleeding from gastric varices
hypoalbuminemia
renal insufficiency
HVPG greater than 20 mm Hg.
9/30/2023 34
35. The highest risk of death:
Patients who rebleed early
MELD score over 18
Require more than 4 units of packed RBC transfusions
Renal failure
Alcoholic liver cirrhosis
Higher serum bilirubin level
Lower serum albumin level
Hepatic encephalopathy
9/30/2023 35
36. The best known criteria are those compiled by the Japanese Research
Society for Portal Hypertension.
The descriptors include;
red color signs,
color of the varix,
form (size) of the varix
location of the varix
9/30/2023 36
38. Isolated gastric varices (IGV)
◦ IGV 1 (7%)
Isolated in the fundus
◦ IGV 2 (2%)
Found in the antrum,
corpus and around
Gastro-esophageal varices (GOV)
◦ GOV 1 (70%)
continuous with esophageal
varices and extend along the
lesser curve
◦ GOV 2 (21%)
extend from the esophagus
below the GE junction toward
the fundus
38
9/30/2023
39. Account for 2–10% of UGIB hospitalizations.
It is characterized by longitudinal mucosal lacerations (intramural
dissection) in the distal esophagus and proximal stomach.
Mucosal lacerations develops secondary to a sudden increase in
intraabdominal pressure.
Bleeding occurs when the tear involves the underlying esophageal
venous or arterial plexus.
9/30/2023 39
40. Bleeding from gastric side of the gastroesophageal junction, stops
spontaneously in 80–90% of patients and recurs in only 0–10%.
The classic history is vomiting, retching, or coughing preceding
hematemesis, especially in an alcoholic patient.
Precipitating factors include vomiting, straining or lifting,
coughing, seizures, blunt abdominal injury, nasogastric tube
placement, and gastroscopy.
9/30/2023 40
41. Is a large (1- 3 mm) submucosal artery that protrudes through
the mucosa in the absence of a primary ulcer.
It is located in the proximal stomach (fundus) along the lesser
curvature, near the esophagogastric junction (typically within
5cm), although they have been found in all areas of the GI tract,
including the esophagus, duodenum, and colon.
9/30/2023 41
42. Patients who bleed from Dieulafoy's lesions are typically
men with cardiovascular disease, hypertension, chronic
kidney disease, diabetes, or alcohol abuse.
The use of NSAIDS is also common among patients with
Dieulafoy's lesions; one theory is that NSAIDS incite bleeding
by causing mucosal atrophy and ischemic injury.
Bleeding episodes are often self-limited, although bleeding
can be recurrent and profuse.
9/30/2023 42
43. Linear erosions or ulcerations in the proximal stomach at the end of a
large hiatal hernia
Caused by mechanical trauma and local ischemia as the hernia moves
against the diaphragm and only secondarily by acid and pepsin
present as chronic GI bleeding and IDA(can be source of acute UGIB)
a common cause of obscure GI bleeding
Long-term medical management is usually with iron supplements
and an oral PPI
Surgical repair of the hiatal hernia(recurrent bleeding)
43
9/30/2023
44. Endoscopically visualized subepithelial hemorrhages and erosions.
These are mucosal lesions and do not cause major bleeding due to the
absence of arteries and veins in the mucosa.
Erosions develop in various clinical settings, the most important of
which are NSAID use, alcohol intake, and stress.
Stress-related gastric mucosal injury occurs only in extremely sick pts.
9/30/2023 44
45. Malignancy accounts for 1% of severe UGI bleeds.
The tumors are usually large, ulcerated masses in the esophagus,
stomach, or duodenum.
Endoscopic hemostasis can temporarily control acute bleeding in
most patients and allow time to determine the appropriate long-
term management.
Angiography with embolization should be considered for patients
with severe UGI bleeding who do not respond to endoscopic
therapy.
45
9/30/2023
46. GAVE
Located at Gastric Antrum
Watermelon stomach
Patients usually present with slow
UGIB and iron deficiency anemia.
Mucosal vascular ectasia, fibrin
thrombi, fibrohyalinosis & spindle
cell proliferation (Biopsy)
Endoscopic hemostasis with
thermal heat modalities have been
reported successful.
PHG
Located mostly @ gastric fundus &
upper body of stomach
DX: diffuse oozing from lesions
Subclinical bleeding, IDA
Mild(snake skin mosaic pattern)
Severe( Mild+ flat or bulging red
marks /black brown spots)
Beta blockers are recommended
Iron supplements
46
47. Initial assessment
The initial evaluation of a patient with acute UGIB includes;
the airway, breathing, circulation
History, physical examination, and laboratory tests.
Identify potential sources and severity of the bleed
Determine if there are conditions present that may affect subsequent
management.
9/30/2023 47
48. If the patient is hemodynamically stable & no evidence of active
bleeding (out /and in patient management)
Manage at ICU If the patient:
◦ Is hemodynamically unstable
◦ Is continuously bleeding
◦ Hct drops by 6%
◦ Significant comorbidities: Ischemic liver, CAD
◦ Advanced elderly
48
9/30/2023
49. Localizing symptoms: Hematemesis, Melena, Hematochezia
History of prior GIB: 60% bleed at the same site
Odynophagia, Dysphagia: esophageal ulcer
Dizziness, SOB, syncope: severity of bleeding
Recent Abdominal surgery: ulcer at site of anastomosis
History of bleeding problems: coagulopathy
49
9/30/2023
53. Nasogastric lavage
The use of nasogastric tube (NGT) placement in patients with
suspected acute upper GI bleeding is not recommended, as studies
have failed to demonstrate a benefit with regard to clinical outcomes
(mortality, length of hospital stay, surgery, or transfusion requirement)
Patients only undergo NGT lavage if particulate matter, fresh blood,
or clots need to be removed from the stomach to facilitate endoscopy.
9/30/2023 53
54. Upper GI endoscopy-
Diagnostic, Therapeutic, Prognostic for acute upper GI bleeding.
Early endoscopy (within 24 hrs) is recommended for acute UGIB
Prokinetics(erythromycin, metoclopramide) 30 to 90 minutes before
EGD to aid gastric motility and emptying
When severe hemorrhage requires rapid interventions, endoscopy
may be performed with simultaneous blood product administration.
9/30/2023 54
55. Goals of Therapy
Hemodynamic resuscitation
Cessation of bleeding source
Prevention of future recurrence
9/30/2023 55
59. PUD
Low risk
Flat pigmented spot or clean base (Forrest grade IIC or III)
Do not perform endoscopic hemostasis.
Consider early hospital discharge after endoscopy if the
patient has low clinical risk and safe home environment.
Treat with an oral proton-pump inhibitor
9/30/2023 59
60. 60
High Risk Stigmata
Perform endoscopic hemostasis using
contact thermal therapy alone
mechanical therapy using clips
epinephrine injection, followed by contact thermal therapy
Endoscopic removal of adherent clot if underlying active
bleeding or nonbleeding visible vessel is present
9/30/2023
62. Primary prophylaxis is indicated in any patient with
◦ Large varices, small varices (red wale marks, Child class C)
Most trials addressed the use of NSBB for primary
prophylaxis demonstrated a decrease in the risk of
bleeding(25% vs 15%)
In patients with cirrhosis who have large varices, it is
recommended that 10 prophylaxis either NSBB or EVL
62
9/30/2023
66. Only be used in uncontrolled bleeding as a temporary ‘bridge’
until definitive treatment can be instituted for max 24hrs
Varices are easily compressed b/c (superficial and thin-walled)
Achieves hemostasis in the majority of cases (70-90%).
Recurrent bleeding after decompression of the balloon 30-50%
Self-expanding covered esophageal metal stents , efficacious ,
safer option than balloon tamponade
66
9/30/2023
67. Rebleeding risk (60% in the first year),
with a mortality of up to 33%
Combined therapy with EVL and NSBB
(long-acting propranolol or nadolol)
TIPS:- bleeding recures despite
combined pharmacological and
endoscopic therapy
67
9/30/2023
68. Angiography
Diagnostic , setting of non-localized lesions
Therapeutic through the arterial instillation of vasoactive drugs,
arterial embolization, or a combination of the two.
This therapy is low risk and may lead to greater than 65 %
success
It treats severe bleeding (Rate bleeding (>0.5 ml/min)
9/30/2023 68
69. Ongoing bleeding despite endoscopic & percutaneous interventions
Bleeding related to a prior surgical procedure,
Development of an acute abdomen (Perforation)
Massive hemorrhage with failed resuscitation
Need more than 6 Unit of blood in the 1st 24hr
Slow continuous bleeding >24hrs
9/30/2023 69
Occult= symptoms of blood loss or anemia such as lightheadedness, syncope, angina, or dyspnea; or when
Obscure GI bleeding is bleeding from a site that is not apparent after routine endoscopic evaluation with EGD, colonoscopy, and possibly push enteroscopy
Hematemesis includes vomiting of bright red blood, which suggests recent or ongoing bleeding, and dark material (coffee-ground emesis), which suggests bleeding that stopped some time ago. Melena is defined as black tarry stool and results from degradation of blood to hematin or other hemochromes by intestinal bacteria
More common in males
Approximately 50% of admissions for GI bleeding are for UGI bleeding (from the esophagus, stomach, and duodenum), 40% are for LGI bleeding (from the colon and anorectum), and 10% are for obscure bleeding (from the small intestine) The case fatality of patients hospitalized with GIB is ∼2% in the United States. Patients generally die from decompensation of other underlying illnesses rather than exsanguination .
in part because of an increase in the proportion of older patients with GI bleeding who die of severe comorbid conditions rather than exsanguination, and an increase in the number of patients with cirrhosis and variceal bleeding. Patients today rarely die from exsanguination, but rather die due to decompensation of other underlying illnesses.
[mortality 10.4% TASH]
Melena:- black tarry, foul-smelling stool, may persist for 5-7 days and occult blood can be positive for 21 days.
Hematochezia:- fresh blood, clot, or currant jelly stool, most often with lower GI bleed, and can be massive UGIB if the bleeding is enough to cause hemodynamic instability
Occult GI bleeding: blood in the stool in the absence of overt bleeding. Positive guaiac test (FOB test) Symptoms of blood loss or anemia
It is Diagnostic of UGIB
Bright red blood suggests moderate to severe bleeding that may be ongoing
coffee-ground emesis suggests slower bleed
melena
Degradation of hemoglobin to hematin by acid + Bowel bacteria and digestive enzymes.
Indicates that blood has been present in the GI tract for at least 14 hours.
Occur when 50-100ml bleeding.
usually due to an upper GI bleed (in 90%) (ddx – LGIB with slow transit, iron medications
Hematochezia: passage of bright red (left colon) or maroon blood (right colon) from the rectum.
most often with lower GI bleed,
but can be seen with massive upper GI bleeding, in 10% (brisk bleeding)
Occult GI bleeding: blood in the stool in the absence of overt bleeding.
Positive guaiac test (FOB test)
Symptoms of blood loss or anemia (e.g., lightheadedness or shortness of breath) The presence of frankly bloody emesis suggests moderate to severe bleeding that may be ongoing, whereas coffee-ground emesis suggests more limited bleeding.
The majority of melena (black, tarry stool) are UGI source (90%), though it may also originate from the small bowel or right colon
Hematochezia (red or maroon blood in the stool) is usually due to lower GI bleeding. However, it can occur with massive upper GI bleeding, which is typically associated with orthostatic hypotension.
Additional risk factors (odds ratio) include chronic obstructive lung disease (2.34), chronic renal insufficiency (2.29), current
tobacco use (1.99), former tobacco use (1.55), older age (1.67), three or more doctor visits in a year (1.49), coronary heart disease (1.46), former alcohol use (1.29), African-American race (1.20), obesity (1.18), and diabetes(1.13).
Some data have suggested that the incidence of bleeding peptic ulcer decreased between 1993 and 2002, whereas the proportion of ulcers caused by NSAIDs increased. The prevalence of Hp infection is more than 80% of the population in many developing countries and 20% to 50% in industrialized countries.88 Hp gastritis most commonly involves the antrum and predisposes patients to duodenal ulcers, whereas gastric body-predominant gastritis is associated with gastric ulcers. The lifetime risk of peptic ulcer disease from Hp infection ranges from 3% in the US to 25% in Japan
Prostaglandins play a critical role in maintaining gastroduodenal mucosal integrity and repair. Greater than 50% of patients with ulcer-related hemorrhage bleed without any preceding warning signs or symptoms.
10–50% of patients with bleeding ulcers rebleed within the next year if no preventive strategies are employed..
Factors associated with rebleeding identified in a meta-analysis
Hemodynamic instability (systolic blood pressure less than 100 mmHg, heart rate greater than 100 beats per minute)
Hemoglobin less than 10 g/L
Active bleeding at the time of endoscopy
Large ulcer size (greater than 1 to 3 cm in various studies)
Ulcer location (posterior duodenal bulb or high lesser gastric curvature)
GBS is a screening tool to assess the likelihood that a person with upper gib will need to have medical interventions.
In validation goup, scores of 6 or more were ass with a greater than 50% risk of needing an intervention.
Rockall risk scoring system attempts to identify patients at risk of adverse outcome ff acute UGIB
The Rockall risk stratification schemes can also be used to identify patients at low risk for poor outcomes (i.e., Rockall Scores of 0 to 2) who should be considered for early discharge from the hospital.
AIMS65 score less than 2 is associated with a lower risk of mortality, length of stay, and cost of hospitalization than a score of 2 or more.
Length of stay
Overall, the predictive value of the GBS was superior (sensitivity and specificity of 0.98 and 0.16, respectively, as compared to
0.93 and 0.24, respectively, for the pre-endoscopy Rockall score, and 0.79 and 0.61, respectively, for the AIMS65).
Prior to endoscopy, we will discharge patients with a GBS of 0-1 provided they have no significant comorbidities, have stable vital signs, have a normal hemoglobin level, do not live far from medical care, and have a mechanism for prompt outpatient endoscopy (ie, within three days).
If patients do not meet the above criteria we admit them to a monitored setting or intensive care unit (depending upon the severity of bleeding, comorbidities, and stability of vital signs). Most patients who have received endoscopic treatment for high-risk stigmata should be hospitalized for 72 hours to monitor for rebleeding, since most rebleeding occurs during this time.
In validation goup, scores of 6 or more were ass with a greater than 50% risk of needing an intervention.
The decision to discharge the patient also depends on individual-patient factors, (reliability for follow-up and confidence of the endoscopists in the diagnosis).
Other scoring systems to predict outcomes from UGI bleeding after endoscopy include the Baylor Scoring System and the Cedars-Sinai Bleeding Index.
In general, all of these scoring systems are better at determining mortality than rebleeding.79
Patients at high risk of rebleeding without treatment are those with active arterial bleeding (90%), an NBVV (50%), or
an adherent clot (33%)
The presence of a blood flow signal correlates with the risk of rebleeding before and after endoscopic therapy.
decision-analysis study found that the DEP is the preferred costminimizing strategy over conventional endoscopic therapy alone
in patients with acute peptic ulcer bleeding
In patients with small varices at initial endoscopy, progression to large varices occurs at a rate of about 10% per year and is related predominantly to the degree of liver
dysfunction.
the long-term survival rate is less than 40% after 1 year with medical management alone.
Liver Cirrhosis results in portal hypertension and development of porto-systemic anastamosis.
wedged-hepatic vein pressure- an estimate of pressure within the portal venous system HVPG= WHVP-FHVP Normal HVPG is 3-6mmHg
Location of varices (Esophageal varices at the gastroesophageal junction, Varices in the gastric fundus also bleed frequently)
Appearance of varices (Red wale marks are longitudinal red streaks on varices that resemble red corduroy wales Cherry red spots, Hematocystic spots, Diffuse erythema)
Location of varices
Esophageal varices at GEJ
Gastric varices: IGV1>GOV2>GOV1
Size of varices
Large, coil-shaped varices that occupy >1/3rd of the lumen
Appearance of varices
Red wale marks, Cherry red spots
Clinical features of the patient
CTP-C, coagulopathy, alcohol intake
history of previous bleed: 70% experience further episode of bleeding.
Variceal pressure
HVPG >16mmHg
The risk ofdeath associated with acute variceal bleeding is 5% to 8% at 1week and about 20% at 6 weeks.209 Patients who rebleed early,have a MELD score over 18, require more than 4 units ofpacked RBC transfusions,217 and in whom renal failure develops have the highest risk of death. Alcohol as the cause of cirrhosis, a higher serum bilirubin level, a lower serum albuminlevel, hepatic encephalopathy, and HCC are additional factor
factors associated with poor outcomes in patients with VH are the presence of bacterial infections and an HVPG >20 mm Hg.
If untreated, recurrent VH occurs in 60% of patients, usually within 1-2 years of index hemorrhage.
Mortality an isolated complication of cirrhosis (20% 5-year mortality) or in association with other complications (over 80% 5-year mortality).
Six-week mortality, which is for acute VH ranges between 15% and 25%.
Various criteria have been used to try to standardize the reporting of esophageal varices.
Sarin classification
(GOV1) extend 2 to 5 cm below the gastroesophageal junction
(GOV2) are in the cardia and fundus of the stomach
whereas varices that occur in the gastric body, antrum, or pylorus are called isolated gastric varices type 2 (IGV2).
-Approximately 25% of patients with portal hypertension have gastric varices, most commonly GOV1, which comprise approximately 70% of all gastric varices.
-Splenic vein thrombosis usually results in IGV1, but the most common cause of fundal gastric varices may be cirrhosis
-Bleeding is thought to be more common in patients with GOV2 and IGV1
The pathogenesis of Mallory-Weiss syndrome is not completely understood.
Endoscopic therapy is indicated for actively bleeding Mallory-Weiss tears
The etiology of Dieulafoy's lesion is unknown. Additionally, events triggering bleeding are not well understood.
Cameron lesions are erosions or ulcers occurring in the sac of a hiatal hernia
They are usually an incidental finding, but they rarely cause acute or massive UGIB. They may also cause chronic bleeding leading to iron deficiency anemia
Surgery for recurrent bleeding despite medical tx
Long-term medical management is usually with iron supplements and an oral PPI.192,193 Surgical repair of the hiatal hernia may be needed for patients with severe acute or chronic GI bleeding and failure of medical management
Half of patients who chronically ingest NSAIDs have erosions, whereas up to 20% of actively drinking alcoholic patients with symptoms of UGIB have evidence of subepithelial hemorrhages or erosions.
Stress-related gastric mucosal injury occurs only in extremely sick patients, such as those who have experienced serious trauma, major surgery, burns covering more than one-third of the body surface area, major intracranial disease, or severe medical illness (i.e., ventilator dependence, coagulopathy).
Erosions
in the esophagus, stomach, or duodenum commonly cause mild
UGIB, with erosive gastritis and duodenitis accounting for perhaps
∼10–15% and erosive esophagitis (primarily due to
gastroesophageal reflux disease) accounting for ∼1–10% of UGIB
hospitalizations
Endoscopic hemostasis with MPEC, laser, injection therapy, or hemoclips can temporarily control acute bleeding in most patients and allow time to determine the appropriate long-term management.194,195 Patients with an ulcerated subepithelial mass (usually a GIST or leiomyoma) should undergo surgical resection of the mass to prevent rebleeding and, in the case of a GIST Angiography with embolization should be considered for patients with severe UGI bleeding caused by malignancy who do not respond to endoscopic therapy. External beam radiation can provide palliative hemostasis for patients with bleeding from advanced gastric or duodenal cancer
-Mucosal changes in the stomach in patients with portal hypertension include portal hypertensive gastropathy (PHG) and gastric vascular ectasia.
-A background mosaic pattern and proximal distribution favor PHG
-Mucosal biopsies are recommended when the endoscopic diagnosis is uncertain
PHG accounts for approximately one fourth of all cases of bleeding (acute and chronic) in patients with portal hypertension, but for less than 10% of all acute bleeding episodes…. Beta blockers are recommended for preventing chronic blood loss in patients who have bled from severe PHG…. transfusion-dependent despite beta blockade and iron supplementation, a TIPS may be inserted
The information gathered as part of the initial evaluation is used to guide decisions regarding triage, resuscitation, empiric medical therapy, and diagnostic testing.
Postural hypotension (15% of blood ) ,supine Hypotension (40%) ,shock
Triage -
All patients with hemodynamic instability (shock, orthostatic hypotension) or active bleeding should be admitted to an ICU for resuscitation and close observation
Other patients can be admitted to a regular medical ward,
Outpatient management may be appropriate for some low-risk patients.
+Localizing symptoms
-Hematemesis – suggests bleeding proximal to the ligament of Treitz. Bright red blood suggests ongoing moderate to severe bleeding, coffee-ground emesis suggests slower bleed
-Melena – usually due to an upper GI bleed
-Hematochezia – most often with lower GI bleed, but can be seen with massive upper GI bleedingCirrhotic patients have a 30 % chance of having a variceal bleed 60 % of these patients in particular will rebleed within the fi rst year of the index bleed, carrying a 20 % mortality rate per subsequent event [ 25 ]
Patients should be asked about prior episodes of upper GI bleeding, since up to 60 percent of patients with a history of an upper GI bleed are bleeding from the same lesion.
Finally, as with the past medical history, the physical examination should include a search for evidence of significant comorbid illnesses.
Stigmata of liver diease--Spider telangiectasias, Gynecomastia, Testicular atrophy, Jaundice,
Mild to moderate hypovolemia (less than 15 percent of blood volume lost): Resting tachycardia.
●Blood volume loss of at least 15 percent (a decrease in the systolic blood pressure of more than 20 mmHg and/or an increase in heart rate of 20 beats per minute when moving from recumbency to standing).
●Blood volume loss of at least 40 percent: Supine hypotension.
Examination of the stool color may provide a clue to the location of the bleeding, but it is not a reliable indicator. In a series of 80 patients with severe hematochezia (red or maroon blood in the stool), 74 percent had a colonic lesion, 11 percent had an upper GI lesion, 9 percent had a presumed small bowel source, and no site was identified in 6 percent [9]. Nasogastric lavage may be carried out if there is doubt as to whether a bleed originates from the upper GI tract. (See 'Nasogastric lavage' below.)
The presence of abdominal pain, especially if severe and associated with rebound tenderness or involuntary guarding, raises concern for perforation. If any signs of an acute abdomen are present, further evaluation to exclude a perforation is required prior to endoscopy.
Finally, as with the past medical history, the physical examination should include a search for evidence of significant comorbid illnesses. (See 'Past medical history' above.)
Rectal examination
Objective description of stool/blood
Assess for mass, hemorrhoids
Hemoglobin < 8 g/dL indicates severe bleeding Monitor Hgb Q2-8hr depending on severity
Microcytic hypochromic anemia suggests chronic bleeding
Patients with acute upper GI bleeding typically have an elevated blood urea nitrogen (BUN)-to-creatinine or urea-to-creatinine ratio (>20:1 or >100:1, respectively). Because blood is absorbed as it passes through the small bowel and patients may have decreased renal perfusion. The higher the ratio, the more likely the bleeding is from an upper GI source
Upper GI barium studies are contraindicated in the setting of acute upper GI bleeding because they will interfere with subsequent endoscopy, angiography, or The initial hemoglobin level in patients with acute upper GI bleeding will often be at the patient's baseline because the patient is losing whole blood. With time (typically after 24 hours or more) the hemoglobin level will decline as the blood is diluted by the influx of extravascular fluid into the vascular space and by fluid administered during resuscitation. It should be kept in mind that excessive volume administration can lead to a falsely low hemoglobin value. The initial hemoglobin level is monitored every two to eight hours, depending upon the severity of the bleed.
Patients with acute bleeding should have normocytic red blood cells. Microcytic red blood cells or iron deficiency anemia suggest chronic bleeding. Because blood is absorbed as it passes through the small bowel and patients may have decreased renal perfusion, patients with acute upper GI bleeding typically have an elevated blood urea nitrogen (BUN)-to-creatinine or urea-to-creatinine ratio. Values >36:1 or >100:1, respectively, suggest upper GI bleeding as the c
NGT aspiration This procedure may confirm recent bleeding (coffee ground appearance), possible active bleeding (red blood in the aspirate that doesnot clear), or a lack of blood in the stomach (active bleeding less likely but does not exclude an upper GI lesion) --Radionuclide imaging has been reported to detect bleeding at a rate of 0.04 mL/min. localize the general area of bleeding and thereby
guide subsequent endoscopy, angiography, or surgery.
=In patients with a prior abdominal aortic aneurysm repair and graft, CT with intravenous contrast can identify inflammation between the graft and duodenum and suggest graft fistulization into the duodenum. mass
Angiography – angiography can localize site of bleeding .
Radionuclide scan – radio labeled red cells may show the possible location of bleeding.
Endoscopy has a high sensitivity and specificity for locating and identifying bleeding lesions in the upper GI tract.
Therapeutic endoscopy can achieve acute hemostasis and prevent recurrent bleeding in most patients.
Intravenous erythromycin (250 mg IV bolus or 3 mg/kg over 30 min) 30–90 min prior to endoscopy administered to aid gastric motility and emptying (improve endoscopy visualization by clearing the stomach of blood, clot and food residue (comparable to NG lavage)
INR of 1.5 or less prior to endoscopy through the administration of plasma or factor concentrates. Platelet transfusion for <50,000 per ml(active bleeding) and 20,000 for stable In the setting of anticoagulation with high dose aspirin or clopidogrel, platelets should be administered prior to procedure
When severe hemorrhage requires rapid interventions, endoscopy may be performed with simultaneous blood product administration.
Risks of upper endoscopy include pulmonary aspiration, adverse reactions to medications used to achieve conscious sedation, GI perforation, and increasing bleeding while attempting therapeutic intervention
Complications (including fatal ventricular tachycardia, near respiratory arrest, and mild hypotension) occurred more often in patients who had a recent MI (8 versus 2 percent)
-ESGE does not recommend urgent (≤ 12 hours) upper GI endoscopy since as compared to early endoscopy, patient outcomes are not improved.
Prevention of the morbidity and mortality associated with UGIB should involve assessment and therapy aimed at three approaches: . Although each aim is independent, there is inherent overlap and each should proceed in a concurrent manner to achieve the best outcomes
Two large bore IVs can actually infuse more fluid faster than a central line.
Adequate resuscitation is essential prior to endoscopy or other intervention.
ETT indicated @ decreased consciousness, massive bleeding
avoid overtransfusion in patients with suspected variceal bleeding, as it can precipitate worsening of the bleeding. Transfusing patients with suspected variceal bleeding to a hemoglobin >10 g/dL should be avoided
Hemodynamic Resuscitationprompt hemodynamic resuscitation affords decreased mortality, as well as morbidity in the form of reduced incidence of myocardial infarction [ 26 ]. These authors thus recommend prompt resuscitation of adequate hemodynamic parameters and correction of hematocrit and coagulopathy. initial evaluation begins with a prompt assessment of hemodynamic instability and aggressive resuscitation afforded within a critical care setting. Delays in resuscitation lead to delays in therapeutic interventions, and thus increased morbidity [Recommendations include placement of two equal than or larger than 16 gauge intravenous lines and consideration of providing central venous access, especially if the use of a vasoactive drug is anticipated. Administration of a 1 L bolus of crystalloid fl uid should then ensue, unless contraindicated by a medical comorbidity. If hemodynamics has not improved, this bolus should be repeated. If hemodynamic compromise still exists, then blood product transfusion is recommended
During resuscitation efforts, all patients should remain nil per os . This will not only aid endoscopic measures but also help protect the patient’s airway. If there is any concern for the protection of the patient’s airway, either because of potential aspiration or due to mental status, then the patient should be promptly intubated endotracheally
Once the patient has been stabilized by resuscitation efforts, therapeutic measures to control bleeding can be activated
The choice of intervention should be made with the consultation of While 80 % of UGIB cease spontaneously, 20 % will recur, and thus the standard of care and first-line therapy is usually upper endoscopy within the first 24 h of an episode [ 36 ]. This not only allows visualization of anatomy, source localization, and establishment of predictors of recurrent bleeding (stigmata) but also allows the potential for a therapeutic intervention. The efficacy and safety of achieving endoscopic hemostasis has been reported and carries a high range of both specificity and sensitivity [ 37 – 39 ]. However, the sensitivity is dependent upon both the operator and the endoscopic fielda multidisciplinary team and consideration of immediately available resources.
Balloon tamponade may be performed as a temporizing measure for patients with uncontrollable hemorrhage likely due to varices using any of several devices (eg, Sengstaken-Blakemore tube, Minnesota tube
tracheal intubation is necessary if such a device is to be placed; ensure proper device placement prior to inflation to avoid esophageal rupture
-PPI-superior ability to maintain gastric PH at 6 and stabilize blood clot, lower rebleeding
H2Rn minor benefit in GU bleeding but not in DU
Therapeutic measures to control bleeding
Endoscopic: the standard of care and first-line therapy within the first 24 h of an episode
Epinephrine injection as definitive hemostasis therapy is not recommended IA,IB,IIA & IIB(high risk Sitgmata)
-Endoscopic hemostasis with epinephrine injection or coaptive thermal probe therapy significantly decreases the rates of ulcer rebleeding, urgent surgery, and mortality in patients with high-risk(RCTs,Meta analysis,Consensus recommendations)
-An adherent clot endoscopic treatment can decrease the rebleeding rate to less than 5%(RCTs)
Clean-Based Ulcers- rebleeding rate of less than 5%.
Oozing of Blood From an Ulcer Without Other Stigmata - rebleeding rate 10-27%----Monotherapy with a thermal probe or epinephrine injection reduces the rebleeding rate to less than 5%
An adherent clot endoscopic treatment can decrease the rebleeding rate to less than 5%(RCTs)
-Initiate oral intake of clear liquids 6 hours after endoscopy in patients with hemodynamic stability. -Transition to an oral PPI after completion of intravenous therapy. IV administration of a PPI can consistently keep the gastric pH higher than 4 (and often higher than 6) over a 72-hour infusion.
Trials of IV H2RAs for the prevention of recurrent ulcer bleeding have shown no definite benefit
If IV not available , twice daily oral PPI is recommended.
---S/O can be considered in patients with severe ongoing bleeding who are not responsive to endoscopic therapy, an IV PPI, or both, and are not surgical candidates, although their effectiveness in these patients is uncertain.
IV octreotide may also be useful in patients with portal hypertension and peptic ulcer hemorrhage as an adjunct to endoscopic hemostasis and a PPI
If there is clinical evidence of ulcer rebleeding, -Repeat endoscopy may be considered on recurrent bleeding or if there is uncertainty regarding the effectiveness of hemostasis during the initial treatment
-Planned second-look endoscopy that is performed within 24 hours after initial endoscopic therapy is generally not recommended
Approximately one half of patients with a variceal bleed stop bleeding spontaneously because hypovolemia leads to splanchnic vasoconstriction, which results in a decrease in portal pressure
-Initial treatment is associated with cessation of bleeding in approximately 90% of patients
-primary prophylaxis, that is, prevention of variceal hemorrhage in patients who have never bled
All patients with large varices (diameter greater than 5 mm) should be considered for prophylactic therapy-------propranolol or nadolol
The absolute risk reduction is thus approximately 10%
-The mortality rate is reduced from 28.4% in control patients to 23.9% in patients taking a beta blocker; the absolute risk reduction is 4.5%
-In patients who do not bleed during therapy and who do not experience side effects, treatment should be continued indefinitely because withdrawal of a beta blocker can result in an increased risk of bleeding
Tech. Spray- for recurrent bl.
The hepatic venous pressure gradient (HVPG) may be measured before a nonselective β-adrenergic blocking agent is started and one month after the maximum tolerated dose of the beta blocker is reached. The goal of treatment is to reduce the HVPG to <12 mm Hg or by ≥20%. EVL, endoscopic variceal ligation; HVPG, hepatic venous pressure gradient
Red blood cells should be transfused with the goal of maintaining the hematocrit value around 25%
Antibiotics should be administered to all patients to prevent bacteremia and spontaneous bacterial peritonitis(ceftriaxone, 1 g every 24 hours for 7 days)
Pharmacologic treatment (Somatostatin, octreotide, terlipressin, and vasopressin ) eary
Endoscopic therapy is carried out as soon as the patient is hemodynamically stabilized(not morethan 12 hours after presentation)
--Sengston blackmore…….triple lumen tube , one for gastric aspirate , one gastric and one esophageal ballon inflation….gastric ballon with 200-600ml of air
--Minnesota is modified S.B in which gastric ballon is inflated with 600ml of air and has both gastric and esophageal aspiration channel
--Linton –Nachlas has only gastric ballon with 600ml of air and both gastric and esophageal aspiration channels
-BT should be used as temporizing measure(maximum 24hr) in pts with uncontrollable bleeding for whom a more definitive therapy (TIPS/Endoscopy) is planned
--Compl==Esoph. rupture
Patients recovering from a recent VH risk of rebleeding, which otherwise occurs in up to 80% of patients at two years.
-objective of therapy should prevention of an additional complication, including recurrent variceal hemorrhage & to improve survival
-BB=goal of reducing the HVPG by greater than 20% or to less than 12 mm Hg.
==If these goals are not achieved, isosorbide mononitrate may be added.(no different than NSBB alone regarding overallrebleeding or mortality, but had a higher rate of side effects )
--TIPS is indicated in patients in whom he from EV cannot ne comtrolled or in whom bleeding recurs despite combined pharmacological and endoscopic therapy
====no differences in survival and with
====a higher incidence of early encephalopathy in the TIPS group.
Angiography may be used to diagnose and treat severe bleeding (Rate bleeding(>0.5 ml/min), especially when the cause cannot be determined by upper and lower endoscopy. The sensitivity of mesenteric angiography is 30% to 50% (with higher sensitivity rates for active GI bleeding than for recurrent acute or chronic occult bleeding), and the specificity is 100%
Moreover, angiography usually does not identify the specific cause of bleeding, only its location.
Angiography= 40–80% accuracy, Allow for super –selective embolization of bleeding site. SMA is examined first(50-80% of diverticular bleeds are supplied by SMA)
Advantage =Potential for Embolization, No bowel preparation, 100% specific
Disadvanta= Variable sensitivity(30-40%) Complications (Rebleed rate 26%, Minor ischemia 18%, Major ischemia 7%, Contrast nephropathy
Exceptions may include patients with ulcers that are more than 2 cm in diameter and those who have hypotension associated with a rebleeding episode Interventional Radiology Angiography with transcatheter embolization is reserved for patients in whom endoscopic therapy has failed, especially if such patientsare high-risk surgical candidate ---Despite vigorous resuscitation with >3uBT
Rare blood group pt(O-)For persistent ulcer bleeding or rebleeding, a second attempt at endoscopic hemostasis is often effective, and is the recommended management approach