Gastroenterology Book

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Upper Gastrointestinal BleedingAka: Upper GI Bleed

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  1. Epidemiology
    1. Accounts for 350,000 hospitalizations in U.S. yearly
  2. Risk factors
    1. Aspirin or NSAID use (most common cause)
    2. Helicobacter Pylori infection
    3. Elderly (especially over age 70 years)
    4. Acid suppression therapy does not reduce bleeding risk
  3. Causes: Adults with acute massive GI Bleeding
    1. Duodenal Ulcer (30-37%)
    2. Gastric Ulcer (19-24%)
    3. Esophageal Varices (6-10%)
    4. Gastritis or Duodenitis (5-10%)
    5. Esophagitis or esophageal ulcer (5-10%)
    6. Mallory-Weiss tear (3-7%)
    7. Gastrointestinal malignancy (1-4%)
    8. Dieulafoy's Lesion (1%)
      1. Artery at gastric fundus may bleed heavily
      2. Difficult to identify on endoscopy
    9. Gastric antral vascular ectasia (0.5 to 2%)
      1. Longitudinal erythematous stripes on gastric mucosa
      2. Known as Watermelon stomach
    10. Arteriovenous malformation
    11. Angiodysplasia of stomach or duodenum, associated with
      1. Chronic Renal Failure
      2. Aortic Stenosis
      3. Cirrhosis
      4. Von Willebrand's Disease
  4. Causes: Adults with chronic intermittent GI Bleeding
    1. Gastritis (18 to 35%)
    2. Esophagitis (18 to 35%)
    3. Gastric Ulcer (18 to 21%)
    4. Duodenal Ulcer (3 to 15%)
    5. Angiodysplasia (5 to 23%)
    6. Gastric Cancer
  5. Causes: Adults - most commonly missed upper GI sources
    1. Large Hiatal Hernia Erosions
    2. Arteriovenous malformation
    3. Peptic Ulcer Disease
  6. Causes: Children
    1. Esophagitis
    2. Gastritis
    3. Peptic Ulcer Disease
    4. Esophageal Varices
    5. Mallory-Weiss Tear
  7. Signs
    1. Hematemesis
    2. Coffee-ground Emesis
    3. Melena
    4. Hematochezia (if bleeding is brisk)
    5. Nasogastric aspirate bloody (15% false negative)
    6. Elevated Renal Function tests (BUN, Serum Creatinine)
    7. Hyperactive Bowel Sounds
  8. Labs
    1. BUN to Creatinine ratio
      1. Does not reliably distinguish upper GI source
  9. Evaluation
    1. See Upper GI Bleeding Score
    2. See Upper Endoscopy Evaluation of GI Bleeding
  10. Management: Initial
    1. See Acute Gastrointestinal Bleeding Management
    2. Nasogastric Tube with aspirate
      1. Fresh blood suggests persistant bleeding
      2. Avoid lavage due to aspiration risk
    3. If severe bleeding and suspected variceal source
      1. See Esophageal Varices
      2. Octreotide 50 ug bolus, then 50 ug/hour
      3. Avgerinos (1995) J Hepatol 22(2):247
  11. Management: General Measures
    1. Helicobacter Pylori management
    2. Empiric acid reduction (Proton Pump Inhibitor)
      1. Not proven in-vivo to aid clotting
      2. No proven benefit in mortality and other outcomes
      3. Does not lower overall Incidence of re-bleeding
      4. Omeprazole may heal ulcer if near-achlorhydria
      5. Daneshmend (1992) BMJ 304:143
  12. Management: Very low risk patients
    1. Indications
      1. Hemodynamically stable with normal lab testing
      2. No evidence of significant bleeding in last 48 hours
      3. Nasogastric Tube aspirate without blood
    2. Protocol
      1. Home with follow-up within days
      2. General measures as above
  13. Management: Low risk patients
    1. Indications
      1. Hemodynamically stable within 1 hour of Resuscitation
      2. Minimal Blood Products required (2 PRBC or less)
      3. No evidence of active bleeding
      4. Nasogastric Tube aspirate without blood
      5. No active comorbid medical conditions
    2. Protocol
      1. Consider for rapid protocol
        1. Immediate Upper Endoscopy Evaluation of GI Bleeding
        2. Discharge to home if low-risk endoscopy results
      2. Admit if rapid protocol not available
        1. Follow moderate risk patient protocol below
      3. General measures as above
  14. Management: Moderate risk patients
    1. Indications
      1. Tachycardia persists despite Resuscitation
      2. Blood Products required >2 PRBC
      3. Active comorbid condition
    2. Protocol
      1. General measures as above
      2. Admit to regular medical bed
      3. Upper endoscopy when patient stabilized (<24 hours)
        1. See Upper Endoscopy Evaluation of GI Bleeding
        2. Disposition based on Upper Endoscopy results
          1. Low risk endoscopy: Observe for 24 hours
          2. Moderate risk endoscopy: Observe for 48-72 hours
          3. High risk endoscopy
            1. Initially observe in ICU for at least 24 hours
            2. Observe in hospital for 72 hours total or more
  15. Management: High risk patients
    1. Indications
      1. Active ongoing bleeding
      2. Hypotension persists despite Resuscitation
      3. Severe active comorbid condition exascerbation
      4. Liver disease exascerbation
      5. Endotracheal Intubation for airway protection
    2. Protocol
      1. General measures as above
      2. Admit to intensive care unit for first 24 hours
      3. Observe in hospital for 48 to 72 hours or more
      4. Urgent upper endoscopy when stabilized
        1. See Upper Endoscopy Evaluation of GI Bleeding
      5. Consider arteriography if source not evident
  16. Management: Refractory and Recurrent Bleeding
    1. Indications
      1. Persistent or recurrent bleeding despite EGD
      2. See Upper Endoscopy Evaluation of GI Bleeding
    2. Protocol
      1. Surgical Intervention (e.g. gastroduodenotomy, vagotomy, ulcer resection)
      2. Consider embolization for non-surgical patient
  17. Prognosis: Outcomes
    1. Overall Mortality: 2-15% (often related to comorbidity)
    2. Bleeding stops and does not recur: 70% (<2% Mortality)
    3. Bleeding after initially stopped: 25% (10% Mortality)
    4. Continued active bleed: 5% (30% Mortality)
  18. Prognosis: Predictors
    1. Bleeding characteristic predictors of poor outcome
      1. See Upper GI Bleeding Score
      2. Emesis or nasogastric aspirate contains red blood
      3. Low initial Hematocrit
      4. Coagulopathy (low platelets or high INR)
    2. Comorbid condition predictors of poor outcome
      1. Active Coronary Artery Disease
      2. Congestive Heart Failure
      3. Active lung disease
      4. Renal Failure
      5. Sepsis
      6. Metastatic cancer
      7. Advanced liver disease
      8. Advanced age
  19. References
    1. Gupta (1993) Med Clin North Am 77(5):973
    2. Fallah (2000) Med Clin North Am 84(5):1183
    3. Longstreth (1995) Am J Gastroenterol 90(2):206
    4. Peter (1999) Emerg Med Clin North Am 17(1):239
    5. Terdiman (1998) Postgrad Med 103(6):43
    6. Zuckerman (2000) Gastroenterology 118:201

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