Gastroenterology Book

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Upper Gastrointestinal Bleeding

Aka: Upper Gastrointestinal Bleeding, Upper GI Bleed
  1. See Also
    1. Gastrointestinal Bleeding Management
    2. Esophageal Varices
  2. Epidemiology
    1. Accounts for 400,000 hospitalizations in U.S. yearly
  3. Risk factors
    1. Helicobacter Pylori infection (present in 64% of cases)
      1. Upper Gastrointestinal Bleeding Odds Ratio: 1.7
      2. Adheres to gastric epithelium, predisposing underlying mucosa to injury by toxins
    2. Aspirin or NSAID use (most common cause)
      1. See NSAID Gastrointestinal Adverse Effects for Relative Risk of specific NSAIDs
      2. Upper Gastrointestinal Bleeding Odds Ratio: 4.8
      3. Upper Gastrointestinal Bleeding Odds Ratio: 6.1 if Helicobacter Pylori positive in addition to NSAID use
    3. Elderly (especially over age 70 years)
    4. Male gender (twice as common as women)
    5. Acid suppression therapy does not reduce bleeding risk
  4. Causes: Adults
    1. Adults with acute massive GI Bleeding
      1. Peptic Ulcer Disease (62%)
        1. Gastric Ulcer (up to 55%)
        2. Duodenal Ulcer (30-38%)
      2. Esophageal Varices (6-10%)
      3. Gastritis or Duodenitis (5-10%)
      4. Esophagitis or esophageal ulcer (5-10%)
      5. Mallory-Weiss tear (3-7%)
      6. Gastrointestinal malignancy (1-4%)
      7. Arteriovenous malformation (10%)
      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. Conditions associated with angiodysplasia of Stomach or duodenum
        1. Chronic Renal Failure
        2. Aortic Stenosis
        3. Cirrhosis
        4. Von Willebrand's Disease
    2. 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
    3. Most commonly missed upper GI sources
      1. Large Hiatal Hernia erosions
      2. Arteriovenous malformation
      3. Peptic Ulcer Disease
  5. Causes: Children
    1. Esophagitis
    2. Gastritis
    3. Peptic Ulcer Disease
    4. Esophageal Varices
    5. Mallory-Weiss Tear
  6. History
    1. History: Gastrointestinal
      1. Peptic Ulcer Disease
      2. Prior Gastrointestinal Bleeding
      3. Prior abdominal surgery
      4. Chronic Liver Disease
        1. Cirrhosis
        2. Chronic Hepatitis
        3. Esophageal Varices
    2. History: Comorbidity
      1. Coronary Artery Disease
      2. Diabetes Mellitus
      3. Chronic Kidney Disease
      4. Chronic Obstructive Pulmonary Disease
    3. Habits
      1. Tobacco abuse
      2. Alcohol Abuse
    4. Medications
      1. See Drug Induced Platelet Dysfunction
      2. Clopidogrel (Plavix)
      3. Warfarin (Coumadin)
      4. NSAIDs
      5. Aspirin
      6. Corticosteroids
      7. Selective Serotonin Reuptake Inhibitors (SSRI)
        1. Inhibit platelet aggregation
  7. Symptoms
    1. Abdominal Pain
    2. Hematemesis
    3. Coffee-ground Emesis
    4. Black tarry stools or Melena
    5. Bright red blood per Rectum or Hematochezia (if bleeding is brisk)
  8. Signs
    1. Vital Signs
      1. Do not be reassured by normal Vital Signs
        1. In contrast, abnormal Vital Signs mandate emergent management
      2. Tachycardia
        1. Initially normal
      3. Hypotension or Orthostasis
        1. Late finding, requires 20% loss of Blood Volume
    2. Respiratory Exam
      1. Exclude Epistaxis source
      2. Exclude Hemoptysis source
    3. Abdominal exam
      1. Hyperactive Bowel Sounds
      2. Hematemesis
        1. Large volume, coffee ground or brownish Emesis
        2. Contrast with Hemoptysis (cough with smaller volume, bright red, frothy Sputum)
    4. Nasogastric aspirate bloody
      1. False Negative Rate is at least 15% and likely higher (negative aspirate does not exclude GI Bleed)
      2. Fresh blood suggests persistant bleeding and suggests a high risk lesion
      3. Lavage offers higher sensitivity but increases risk of aspiration and is controversial
      4. Lavage positive for coffee ground material or bright red blood confirms upper gastrointestinal source
        1. However a negative lavage does not exclude Upper Gastrointestinal Bleeding
      5. Gastric Lavage may also help clear the Stomach of blood prior to endoscopy and improve the evaluation
      6. Allows for monitoring of ongoing upper gastrointestinal GI Bleeding
  9. Labs
    1. Complete Blood Count
      1. Baseline Hemoglobin (trails bleeding by 24 hours)
    2. Blood Type and Cross-match
    3. Coagulation Factors
      1. Prothrombin Time
      2. Platelet Count
    4. Liver Function Tests
    5. Renal Functions tests
      1. Blood Urea Nitrogen (BUN)
      2. Serum Creatinine
      3. BUN to Creatinine ratio
        1. Does not reliably distinguish upper GI source
  10. Evaluation
    1. See Upper GI Bleeding Score
    2. See Rockall Risk Score
    3. See Upper Endoscopy Evaluation of GI Bleeding
  11. Management: Acid reduction
    1. Proton Pump Inhibitor (preferred)
      1. Start Intravenous Proton Pump Inhibitor in all Upper Gastrointestinal Bleeding cases
        1. Better outcomes with use, although mixed results (see below)
      2. Dosing
        1. Massive Hemorrhage
          1. Protonix 80 mg IV, then 8 mg/h
        2. Typical dosing
          1. Protonix 40 mg IV
      3. Effects
        1. Full protection (achlorhydria) is delayed for the 5-7 days required to deactivate the proton pump
          1. Consider H2 Blocker initially (see below)
        2. Not proven in-vivo to aid clotting
        3. Omeprazole may heal peptic ulcer if near-achlorhydria
        4. No proven benefit in mortality
        5. No benefit or harm seen when PPI given at Upper GI Bleeding presentation
          1. Dorward (2006) Cochrane Database Syst Rev (4): CD005415 [PubMed]
        6. Cochrane study suggested PPI benefit in specific measures when given in endoscopy suite
          1. May reduce Incidence of re-bleeding (NNT 15)
          2. May reduce Incidence of Gastrointestinal Bleeding requiring surgery (NNT 30)
          3. Peptic ulcer related bleeding appears to benefit from PPI in China and Japan (but possible associated worse outcomes in U.S.)
          4. Leontiadis (2006) Cochrane Database Syst Rev (1): CD002094 [PubMed]
      4. References
        1. Newman in Herbert (2014) EM:Rap 14(1): 4
        2. Daneshmend (1992) BMJ 304:143-47 [PubMed]
        3. Sreedharan (2010) Cochrane Database Syst Rev (2): CD005415 [PubMed]
        4. Sung (2009) Ann Intern Med 150(7): 455-64 [PubMed]
    2. H2 Blocker
      1. Use is controversial in Acute Gastrointestinal Hemorrhage
      2. Consider starting initially concurrently with Proton Pump Inhibitor to bridge the delay in full PPI activity
      3. Ranitidine
        1. Intermittent: 50 mg IV or IM every 6-8 hours
        2. Continuous: 6.25 mg/hour IV
  12. Management: Stabilization of the actively bleeding patient
    1. General measures
      1. See Acute Gastrointestinal Bleeding Management
      2. ABC Management
      3. Supportive care
        1. Oxygen
        2. Two large bore IVs (14-16 gauge)
        3. Fluid Resuscitation
        4. Consider intubation (for airway protection)
      4. Intensive Care Unit admission for significant bleeding or hemodynamically unstable
      5. Replace blood and Coagulation Factors if needed
        1. Consider pRBC, PCC, Fresh Frozen Plasma, Platelet Transfusion, Vitamin K
        2. See Gastrointestinal Bleeding Management for indications
      6. Upper endoscopy urgently to emergently
        1. Notify GI or surgery on patient presentation to ready for upper endoscopy
        2. See Upper Endoscopy Evaluation of GI Bleeding
        3. See protocols below
    2. Esophageal Varices
      1. See Bleeding Esophageal Varices
      2. Upper Endoscopy emergently for banding
      3. Vasoactive agents (e.g. Octreotide 50 mcg IV bolus)
      4. Non-selective Beta Blocker (e.g. Propranolol, Nadalol, Timolol)
      5. Prophylactic Antibiotics (e.g. Norfloxacin, Ciprofloxacin, Ceftriaxone)
      6. Consider Balloon Tamponade (e.g. Linton Tube, Sengstaken-Blakemore Tube)
        1. Indicated for stabilization until endoscopy
    3. Non-variceal persistent bleeding
      1. Angiography (with sclerotherapy) Indications for Persistent Bleeding
        1. Endoscopy not available
        2. Biliary bleeding
        3. Pancreatic bleeding
        4. Gastric Ulcer
        5. Mallory-Weiss Tear
      2. General Surgery Indications
        1. Acute Abdomen (peritonitis)
        2. Continued massive bleeding without known source
        3. Failed medical therapy, endoscopy and angiography
  13. 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
      4. Upper GI Bleeding Score <1
        1. Mustafa (2015) Eur J Gastroenterol Hepatol 27(5):512-5 +PMID:25822859 [PubMed]
    2. Protocol
      1. Home with follow-up within days
      2. General measures as above
  14. 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
  15. 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
  16. 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
        2. Consider repeat routine recheck upper endoscopy in 24 hours for high risk lesions
      5. Consider arteriography if source not evident
  17. Management: Refractory and Recurrent Bleeding
    1. Indications
      1. Persistent or recurrent bleeding despite EGD
      2. See Upper Endoscopy Evaluation of GI Bleeding
    2. Procedures
      1. Consider arteriography with embolization
        1. First-line study
        2. Equivalent efficacy to surgical intervention
      2. Surgical Intervention
        1. Gastroduodenotomy
        2. Vagotomy
        3. Peptic ulcer resection
  18. Management: Disposition
    1. See prevention measures below
    2. See Helicobacter Pylori management
    3. Repeat Upper Endoscopy
      1. Perform at 8-12 weeks after initial endoscopy
      2. Indications
        1. Gastric Ulcer (Confirm healing and exclude cancer)
        2. Severe esophagitis (exclude Barrett's Esophagus)
    4. Iron Deficiency Anemia
      1. Transfused blood will keep Hemoglobin increased only 2-3 weeks
      2. Ferrous Sulfate 325 mg daily to three times daily
        1. Continue until Serum Ferritin and Hemoglobin return to normal
  19. Prevention
    1. See Helicobacter Pylori management
    2. Avoid NSAIDs
    3. Consider longterm Proton Pump Inhibitor if Aspirin or Clopidogrel (Plavix) cannot be stopped
      1. See Clopidogrel (Plavix) for potential Proton Pump Inhibitor interactions
    4. Tobacco Cessation
    5. Avoid Alcohol
  20. Prognosis: Outcomes
    1. Mortality: 2-15% overall (often related to comorbidity)
      1. In hospital mortality: 13%
      2. Duodenal Ulcer: 3.7%
        1. Higher risk of erosions into larger vessels
      3. Gastric Ulcer: 2.1%
    2. Course
      1. Bleeding stops and does not recur: 85% (<2% Mortality)
      2. Re-bleeding after initially stopped: 15% (10% Mortality)
      3. Continued active bleed: 5% (30% Mortality)
  21. 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
  22. References
    1. Spangler, Swadron, Mason and Herbert (2016) EM:Rap C3, p. 1-11
    2. Gupta (1993) Med Clin North Am 77(5):973-92 [PubMed]
    3. Fallah (2000) Med Clin North Am 84(5):1183-208 [PubMed]
    4. Longstreth (1995) Am J Gastroenterol 90(2):206-10 [PubMed]
    5. Peter (1999) Emerg Med Clin North Am 17(1):239-61 [PubMed]
    6. Terdiman (1998) Postgrad Med 103(6):43-64 [PubMed]
    7. Wang (2010) Ann Surg 215(1):51-8 [PubMed]
    8. Wilkins (2012) Am Fam Physician 85(5): 469-76 [PubMed]
    9. Zuckerman (2000) Gastroenterology 118:201-21 [PubMed]

Upper gastrointestinal hemorrhage (C0041909)

Definition (NCI_CTCAE) A disorder characterized by bleeding from the upper gastrointestinal tract (oral cavity, pharynx, esophagus, and stomach).
Definition (NCI) Bleeding originating from the upper gastrointestinal tract (oral cavity, pharynx, esophagus, and stomach).
Concepts Pathologic Function (T046)
SnomedCT 197474003, 37372002
English Upper GI-gastrointes haemorrh, Upper gastrointest haemorrhage, Upper gastrointest hemorrhage, Upper gastrointestinal hemorrhage, upper gastrointestinal bleeding (diagnosis), upper gastrointestinal bleeding, upper GI bleeding, UGI bleed, Upper GI blood loss, Upper Gastrointestinal Hemorrhage, bleed ugi, bleeds ugi, ugi bleed, upper gastrointestinal bleed, upper gi bleeding, bleeds gi upper, bleeding gi upper, gi haemorrhage upper, upper gi hemorrhage, upper gi bleed, upper gi haemorrhage, bleed gastrointestinal upper, bleeding gastrointestinal upper, bleeding ugi, bleed gi upper, Upper gastrointestinal haemorrhage (disorder), Upper GI bleeding, Upper gastrointestinal bleeding, Upper GI - gastrointestinal haemorrhage, Upper GI - gastrointestinal hemorrhage, Upper gastrointestinal haemorrhage, Upper GI haemorrhage, Upper GI hemorrhage, Upper gastrointestinal hemorrhage (disorder)
Italian Emorragia del tratto gastrointestinale superiore, Sanguinamento del tratto gastrointestinale superiore
Dutch bovenste maagdarmkanaalbloedverlies, bloeding van bovenste deel van maag-darmkanaal, bovenste maagdarmkanaalbloeding
French Saignement GI supérieur, Perte sanguine des voies GI supérieures, Hémorragie gastrointestinale haute, Saignement gastro-intestinal haut, Hémorragie gastro-intestinale haute
German Blutverlust im oberen gastrointestinalen Bereich, UGI-Blutung, Bluten im oberen Gastrointestinaltrakt, Blutung im oberen gastrointestinalen Bereich
Portuguese Hemorragia gastrintestinal alta, Perda de sangue GI alta, Sangramento gastrointestinal superior, Hemorragia gastrointestinal superior
Spanish Pérdida de sangre GI superior, Sangrado GIA, Hemorragia gastrointestinal superior, Sangrado del tracto GI superior, HDA, hemorragia GI superior, hemorragia digestiva alta (trastorno), hemorragia digestiva alta, hemorragia gastrointestinal alta, hemorragia gastrointestinal superior, sangrado GI superior, sangrado gastrointestinal superior, Hemorragia gastrointestinal alta
Japanese 上部消化管出血, ジョウブショウカカンシュッケツ
Czech Krvácení do horní části zažívacího traktu, Krvácení v horní části zažívacího traktu, Krvácení z horní části zažívacího traktu
Hungarian Gyomor-bélrendszer felső traktusának vérzése, Felső gastrointestinalis vérvesztés, Felső gastrointestinalis vérzés, Felső gasztrointesztinalis vérzés
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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