UPPER GI BLEEDUPPER GI BLEED

DEMARCATION OF UPPER DEMARCATION OF UPPER AND LOWER GUTAND LOWER GUT

The World Organization of The World Organization of Gastroenerologists defines acute upper GI Gastroenerologists defines acute upper GI bleeding as:bleeding as:

The anatomic cut-off for upper GI The anatomic cut-off for upper GI bleeding is the bleeding is the ligament of ligament of TreitzTreitz, , which connects the fourth portion of which connects the fourth portion of the the duodenumduodenum to the to the splenicsplenic flexure flexure of the of the coloncolon. .

ETIOLOGYETIOLOGY EpidemiologyEpidemiology Accounts for 350,000 hospitalizations Accounts for 350,000 hospitalizations

in U.S. yearly in U.S. yearly Risk factorsRisk factors AspirinAspirin or or NSAIDNSAID use (most common use (most common

cause) cause) Helicobacter PyloriHelicobacter Pylori infection infection Elderly (especially over age 70 years) Elderly (especially over age 70 years)

Adults with acute massive Adults with acute massive GI BleedGI Bleedinging

Duodenal UlcerDuodenal Ulcer (30-37%) (30-37%) Gastric UlcerGastric Ulcer (19-24%) (19-24%) Esophageal VaricesEsophageal Varices (6-10%) (6-10%) GastritisGastritis or or DuodenitisDuodenitis (5-10%) (5-10%) Esophagitis or esophageal ulcer (5-Esophagitis or esophageal ulcer (5-

10%) 10%) Mallory-Weiss tear (3-7%) Mallory-Weiss tear (3-7%) Gastrointestinal malignancy (1-4%) Gastrointestinal malignancy (1-4%)

Dieulafoy's Lesion (1%) Dieulafoy's Lesion (1%) Artery at gastric fundus may bleed heavily Artery at gastric fundus may bleed heavily Difficult to identify on endoscopy Difficult to identify on endoscopy

Gastric antral vascular ectasia (0.5 to 2%) Gastric antral vascular ectasia (0.5 to 2%) Longitudinal erythematous stripes on gastric Longitudinal erythematous stripes on gastric

mucosa mucosa Known as Watermelon stomach Known as Watermelon stomach

Arteriovenous malformation Arteriovenous malformation Angiodysplasia of stomach or duodenum, Angiodysplasia of stomach or duodenum,

Adults with chronic Adults with chronic intermittent intermittent GI BleedGI Bleedinging

GastritisGastritis (18 to 35%) (18 to 35%) Esophagitis (18 to 35%) Esophagitis (18 to 35%) Gastric UlcerGastric Ulcer (18 to 21%) (18 to 21%) Duodenal UlcerDuodenal Ulcer (3 to 15%) (3 to 15%) Angiodysplasia (5 to 23%) Angiodysplasia (5 to 23%) Gastric CancerGastric Cancer

Adults - most commonly Adults - most commonly missed upper GI sourcesmissed upper GI sources

Large Large HiatalHiatal Hernia Hernia ErosionErosions s Arteriovenous malformation Arteriovenous malformation Peptic Ulcer DiseasePeptic Ulcer Disease

POSTERIOPR WALL POSTERIOPR WALL DUODENAL ULCERDUODENAL ULCER

GASTRIC ULCER IN GASTRIC ULCER IN ANTRUMANTRUM

VARICEAL BLEEDVARICEAL BLEED

HISTORYHISTORY Has the patient been vomiting or retching Has the patient been vomiting or retching

before the episode of haematemesis? -> before the episode of haematemesis? -> Mallory-Weiss tear Mallory-Weiss tear

Enquire about the colour of the vomitus Enquire about the colour of the vomitus Was there a previous incident of peptic ulcer or Was there a previous incident of peptic ulcer or

haematemesis/melaena? haematemesis/melaena? Heartburn -> Reflux oesophagitis Heartburn -> Reflux oesophagitis Drug history (including aspirin and over the Drug history (including aspirin and over the

counter medicines -> peptic ulcer) counter medicines -> peptic ulcer) Alcohol -> Liver failure -> oesophageal varices Alcohol -> Liver failure -> oesophageal varices

-> upper GI bleed-> upper GI bleed

ASSESSMENTASSESSMENT

One should first determine the One should first determine the amount amount of blood lossof blood loss, and the site of bleeding. , and the site of bleeding.

The measurement of The measurement of vital signsvital signs provides provides the only accurate assessment of blood the only accurate assessment of blood loss (orthostatics, heart rate, complaints loss (orthostatics, heart rate, complaints of weakness or dizziness, syncope). of weakness or dizziness, syncope).

An An NG tubeNG tube should be placed as part of should be placed as part of the assessment. The gastric lavage may the assessment. The gastric lavage may aid the endscopist to obtain a clear view aid the endscopist to obtain a clear view of the bleeding site.  of the bleeding site. 

PHYSICAL EXAMINATIONPHYSICAL EXAMINATION

Vital signs, in order to determine the Vital signs, in order to determine the severity of bleeding and the timing of severity of bleeding and the timing of intervention intervention

Abdominal and rectal examination, in Abdominal and rectal examination, in order to determine possible causes of order to determine possible causes of hemorrhage hemorrhage

Assessment for portal hypertension and Assessment for portal hypertension and stigmata of chronic liver disease in order stigmata of chronic liver disease in order to determine if the bleeding is from a to determine if the bleeding is from a variceal source. variceal source.

DIAGNOSISDIAGNOSIS

Sometimes, the Sometimes, the source can be naso-source can be naso-or oropharyngealor oropharyngeal.. A careful exam of A careful exam of the nares and oral pharynx should be the nares and oral pharynx should be done. done.

The presence of The presence of "coffee ground "coffee ground emesisemesis represents blood altered by represents blood altered by gastric contents and usually means gastric contents and usually means that there has been that there has been slow bleeding slow bleeding from the region between the from the region between the esophagus and the duodenum. esophagus and the duodenum.

A A positive NG tube aspiratepositive NG tube aspirate for for blood usually signifies that the site of blood usually signifies that the site of bleeding is proximal to the ligament of bleeding is proximal to the ligament of Treitz. Treitz.

Other characteristics of upper GI Other characteristics of upper GI bleeding are bleeding are elevated BUNelevated BUN and and hyperactive bowel soundshyperactive bowel sounds. .

The source of bleeding can be The source of bleeding can be identified in 90% of cases if endoscopy identified in 90% of cases if endoscopy is done within the first 24 hours. is done within the first 24 hours.

Upper GI Bleeding ScoreUpper GI Bleeding Score

CriteriaCriteria

Blood Urea NitrogenBlood Urea Nitrogen (BUN) (BUN) BUN 18.2 to 22.4 mg/dl: Score 2 BUN 18.2 to 22.4 mg/dl: Score 2 BUN 22.4 to 28 mg/dl: Score 3 BUN 22.4 to 28 mg/dl: Score 3 BUN 28 to 70 mg/dl: Score 4 BUN 28 to 70 mg/dl: Score 4 BUN >70 mg/dl: Score 6 BUN >70 mg/dl: Score 6

HemoglobinHemoglobin Men Men

HemoglobinHemoglobin 12 to 13 g/dl: Score 1 12 to 13 g/dl: Score 1 HemoglobinHemoglobin 10 to 12 g/dl: Score 3 10 to 12 g/dl: Score 3 HemoglobinHemoglobin <10 g/dl: Score 6 <10 g/dl: Score 6

Women Women HemoglobinHemoglobin 10 to 12 g/dl: Score 1 10 to 12 g/dl: Score 1 HemoglobinHemoglobin <10 g/dl: Score 6 <10 g/dl: Score 6

Systolic Systolic Blood PressureBlood Pressure (SBP) (SBP) SBP 100 to 109 mmHg: Score 1 SBP 100 to 109 mmHg: Score 1 SBP 90 to 99 mmHg: Score 2 SBP 90 to 99 mmHg: Score 2 SBP <90 mmHg: Score 3 SBP <90 mmHg: Score 3

Miscellaneous Markers Miscellaneous Markers Pulse >100 per minute: 1 Pulse >100 per minute: 1 Presentation with Presentation with MelenaMelena: 1 : 1 Presentation with Presentation with SyncopeSyncope: 2 : 2 Hepatic disease: 2 Hepatic disease: 2 Cardiac function: 2 Cardiac function: 2

InterpretationInterpretation

Assesses probability for intervention Assesses probability for intervention Endoscopy Endoscopy Surgery Surgery

Score predicting resolution without Score predicting resolution without intervention: <4 intervention: <4

Score predicting intervention: >5 Score predicting intervention: >5

MANAGEMENTMANAGEMENT

INITIAL:INITIAL: NasogastricNasogastric Tube Tube with aspirate with aspirate Fresh blood suggests persistant bleeding Fresh blood suggests persistant bleeding Avoid lavage due to aspiration risk Avoid lavage due to aspiration risk If severe bleeding and suspected If severe bleeding and suspected

variceal source variceal source See See Esophageal VaricesEsophageal Varices Octreotide 50 ug bolus, then 50 ug/hour Octreotide 50 ug bolus, then 50 ug/hour

Management: General Management: General MeasuresMeasures

Helicobacter PyloriHelicobacter Pylori management management Empiric acid reduction (Empiric acid reduction (

Proton Pump InhibitorProton Pump Inhibitor) ) Not proven in-vivo to aid clotting Not proven in-vivo to aid clotting No proven benefit in mortality and other No proven benefit in mortality and other

outcomes outcomes Does not lower overall Does not lower overall IncidenceIncidence of re- of re-

bleeding bleeding OmeprazoleOmeprazole may heal ulcer if near- may heal ulcer if near-

achlorhydria achlorhydria

Management: Low risk Management: Low risk patientspatients

Indications Indications Hemodynamically stable within 1 hour Hemodynamically stable within 1 hour

of of ResuscitationResuscitation Minimal Minimal Blood ProductsBlood Products required (2 required (2

PRBC or less) PRBC or less) No evidence of active bleeding No evidence of active bleeding NasogastricNasogastric Tube Tube aspirate without aspirate without

blood blood No active comorbid medical conditions No active comorbid medical conditions

Protocol Protocol Consider for rapid protocol Consider for rapid protocol

Immediate Immediate Upper Endoscopy Evaluation of GI BleedingUpper Endoscopy Evaluation of GI Bleeding

Discharge to home if low-risk endoscopy Discharge to home if low-risk endoscopy results results

Admit if rapid protocol not available Admit if rapid protocol not available Follow moderate risk patient protocol below Follow moderate risk patient protocol below

General measures as above General measures as above

Management: High risk Management: High risk patientspatients

Indications Indications Active ongoing bleeding Active ongoing bleeding Hypotension persists despite Hypotension persists despite

ResuscitationResuscitation Severe active comorbid condition Severe active comorbid condition

exascerbation exascerbation Liver disease exascerbation Liver disease exascerbation EndotrachealEndotracheal IntubationIntubation for airway for airway

protection protection

Protocol Protocol General measures as above General measures as above Admit to intensive care unit for first 24 Admit to intensive care unit for first 24

hours hours Observe in hospital for 48 to 72 hours or Observe in hospital for 48 to 72 hours or

more more Urgent upper endoscopy when stabilized Urgent upper endoscopy when stabilized See See

Upper Endoscopy Evaluation of GI BleedingUpper Endoscopy Evaluation of GI Bleeding Consider arteriography if source not evident Consider arteriography if source not evident

OutcomesOutcomes

Overall Mortality: 2-15% (often Overall Mortality: 2-15% (often related to comorbidity) related to comorbidity)

Bleeding stops and does not recur: Bleeding stops and does not recur: 70% (<2% Mortality) 70% (<2% Mortality)

Bleeding after initially stopped: Bleeding after initially stopped: 25% (10% Mortality) 25% (10% Mortality)

Continued active bleed: 5% (30% Continued active bleed: 5% (30% Mortality) Mortality)

PredictorsPredictors

Bleeding characteristic Bleeding characteristic predictors of poor outcome predictors of poor outcome

EmesisEmesis or nasogastric aspirate or nasogastric aspirate contains red blood contains red blood

Low initial Low initial HematocritHematocrit Coagulopathy (low platelets or high Coagulopathy (low platelets or high

INR) INR)

Comorbid condition predictors of poor Comorbid condition predictors of poor outcomeoutcome Active Active Coronary Artery DiseaseCoronary Artery Disease Congestive Heart FailureCongestive Heart Failure Active lung disease Active lung disease Renal Failure Renal Failure Sepsis Sepsis Metastatic cancer Metastatic cancer Advanced liver disease Advanced liver disease Advanced age Advanced age

ThanksThanks