Upper Gastrointestinal Bleeding

27 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 Bleeding

Upper
Peptic ulcer dz
Gastric
erosions
Varices
Mallory-Weiss
Esophagitis
Duodenitis

Percentage Lower
45
23
10
7
6
6

Percentage

Diverticulosis

18-43

Angiodysplasia

20-40

Unknown

11-32

Cancer/polyps

9-33

Rectal disease

8-9

IBD

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

 Physical Exam

Evaluation

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