Upper Gastrointestinal Bleeding27 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 BleedingUpper Percentage Lower Percentage

Peptic ulcer dz

Gastricerosions

Varices

Mallory-Weiss

Esophagitis

Duodenitis

45

23

10

7

6

6

Diverticulosis

Angiodysplasia

Unknown

Cancer/polyps

Rectal disease

IBD

18-43

20-40

11-32

9-33

8-9

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

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