6Nasogastric TubeHelps in diagnosisFacilitates endoscopy
7General Management Triage General Support Fluid Resuscitation: Airway, Clinical Status, V/S, ECG, UO, NG OutputOxygenNPO2 large-bore peripheral IV canulasCentral Venous Line? / Pulm Artery Catheter?Elective Intubation?Fluid Resuscitation:Hemodynamic Instability/Active Bleeding Rapid bolus infusions of isotonic crystaloids.
8Blood Transfusions Transfuse for: Hemodynamic instability despite crystalloid resuscitationHemoglobin <10 g/dL (100 g/L) in high-risk patients (eg, elderly, coronary artery disease)Hematocrit <7 g/dL (70 g/L) in low-risk patientsGive fresh frozen plasma for coagulopathy (INR > 1.5)Give platelets for thrombocytopenia (platelets <50,000) or platelet dysfunction (eg, chronic aspirin therapy)1 FFP for every 4 units of PCs.
9Acid Suppression IV PPI Reduces rate of rebleeding Omeprazole (80mg bolus, 8mg/hr infusion)PantoprazoleEsomeprazole72 hrs… -> PO Pantoprazole 40mg/d, Omeprazole 20mg/d.Reduces rate of rebleedingReduces hospital stayReduces need for blood transfusionReduces endoscopic signs of active bleeding (6.4 vs 14.7%) and the need for endoscopic hemostatic therapy (19.1 vs 28.4%)(Chan WH, Khin LW, Chung YF, et al. Randomized controlled trial of standard versus high-dose intravenous omeprazole after endoscopic therapy in high-risk patients with acute peptic ulcer bleeding. Br J Surg 2011; 98:640.)
10Somatostatin and its Analogs Variceal BleedingOctreotide (IV bolus mcg, continuous infusion 25-50mcg/hr)May also reduce risk of bleeding due to nonvariceal causes. (Ann Intern Med 1997; 127:1062)
11EsophagoGastroDuodenoscopy Diagnostic modality of choice for acute UGI bleeding.Early endoscopy (within 24 hours) is recommended for most patients with UGIBResults in reductions in blood transfusion requirements, a decrease in the need for surgery, and a shorter length of hospital stay
12EsophagoGastroDuodenoscopy In general, 20% to 35% of patients undergoing EGD will require a therapeutic endoscopic intervention, and 5% to 10% will eventually require surgery1% to 2% of patients with upper GI hemorrhage, the source cannot be identified because of excessive blood impairing visualization of the mucosal surface
16AngiographyConsensus statement from the American College of Radiology:Endoscopy is the best initial diagnostic and therapeutic procedure.Surgery and transcatheter arteriography/intervention (TAI) are equally effective following failed therapeutic endoscopy, but TAI should be considered particularly in patients at high risk for surgery.TAI is less likely to be successful in patients with impaired coagulation.TAI is the best technique for treatment of bleeding into the biliary tree or pancreatic duct
17Indications for Surgery for Peptic Ulcer Hemorrhage Failure of endoscopic therapy.Hemodynamic instability despite vigorous resuscitation (> 6 unit transfusion).Recurrent hemorrhage after initial stabilization (with up to 2 attempts at obtaining endoscopic hemostasis).Shock associated with recurrent hemorrhage.Continued slow bleeding with a transfusion requirement > 3 units per day.
18Second-Look Endoscopy Not routineIf visualization during the initial endoscopy was limited by blood or debris.If there is concern on the part of the endoscopist that the prior endoscopic therapy was sub-optimal .If there is recurrent bleeding to exclude previously missed lesions and/or to retreat the bleeding ulcer
21PUD The most frequent cause About 10-15% of ptns with PUD bleed Bleeding develops as a result of acid-peptic erosion into a submucosal vessel, or penetration into a larger vessel
22PUD Duodenal ulcers are more common than gastric ulcers Gastric ulcers bleed more commonlyThe most significant hemorrhage occurs when duodenal or gastric ulcers penetrate into branches of the gastroduodenal artery or left gastric artery, respectively
23PUDUnlike perforated ulcer, which are strongly associated with H Pylori, the association between bleeding and H pylori and bleeding is less strongIn patients who are taking ulcerogenic medications, such as NSAIDs or SSRIs, and who present with a bleeding GI lesion, these medications are stopped, and the patient is started on a nonulcerogenic alternative
24PUDUlcers greater than 2 cm, posterior duodenal ulcers, and gastric ulcers have a significantly higher risk for rebleeding
25Mallory Weiss TearMucosal and submucosal tears that occur near the GEJAfter a period of intense retching and vomiting (alcoholics after binge drinking)The mechanism is forceful contraction of the abdominal wall against an unrelaxed cardia, resulting in mucosal laceration of the proximal cardia as a result of the increase in intragastric pressure
26Mallory Weiss Tear Diagnosis based on Hx and EGD In endoscopy a retroflexion maneuver must be performedMost tears occur along the lesser curvatureSupportive therapy is often all that is necessary because 90% of bleeding episodes are self-limited, and the mucosa often heals within 72 hours
27Stress GastritisMultiple superficial erosions of the entire stomach, most commonly in the bodyResult from the combination of acid and pepsin injury in the context of ischemia from hypoperfusion states, although NSAIDs produce a very similar appearanceFactors increasing the risk for hemorrhage from stress gastritis included ventilator dependence for greater than 48 hours and coagulopathy
28Stress Gastritis Rarely develop significant bleeding Tx is with (H2)-receptor antagonists, PPIs, or sucralfateWhen this fails, consider administration of octreotide or vasopressin selectively through the left gastric artery, endoscopic therapy, or even angiographic embolization
29EsophagitisEsophageal inflammation secondary to repeated exposure of the esophageal mucosa to the acidic gastric secretions in GERDIf ulceration occursbleeding (usually chronic blood loss)In immunosuppressed ptns consider infectious esophagitisDue to medications, radiation, Crohns
30Diuelafoy’s LesionVascular malformations found primarily along the lesser curve of the stomachTypically within 6 cms of the GEJ, but can occur anywhereRepresent rupture of unusually large vessels (1-3 mm) that are found in the gastric submucosa after erosion of the overlying mucosaBleeding can be massive
32Diuelafoy’s LesionTx is with endoscopy: application of thermal or sclerosant therapy is effective in 80% to 100% of casesIf this fails: angio coil emboizationIf this fails consider surgery
33Gastric antral Vascular Ectasia A collection of dilated venules appearing as linear red streaks converging on the antrum in longitudinal fashion, giving it the appearance of a watermelonUsually present with chronic blood lossEndoscopic therapy is indicated for persistent, transfusion-dependent bleeding and has been reportedly successful in up to 90% of patients (argon plasma coagulation)
34MalignancyUsually present with chronic blood loss (iron deficiency anemia, +ve occult blood in stool)Significant bleeding may occur, esp with ulcerated lesions (esp GIST)Although endoscopy is usually successful in controlling the bleeding, rebleeding rate is high
35MalignancyWhen a malignancy is diagnosed, surgical resection is indicatedSurgery maybe be urgent or elective, curative or palliative, depending on the clinical setup (chronic blood loss vs severe acute bleeding, ptn stability, etc…)
36Aortoenteric Fistula <1% of aortic graft cases Occur after abdominal aortic aneurysm repair or due to aortitisUsually occur 3 years after surgery, but may occur anytime (even days after)Should always be considered in a ptn with UGIH after abdominal aneurysm repair
37Aortoenteric Fistula Hemorrhage is usually massive and can be fatal Sentinel bleeding: a self limited bleeding that heralds the coming massive hemorrhageUrgent endoscopy!!! bleeding from the 3rd or 4th part of the duodenumCTair around the graft (suggestive of an infection), possible pseudoaneurysm, and rarely the presence of intravenous contrast in the duodenal lumenTx is surgery
38HemobiliaAssociated with trauma, instrumentation of the biliary tract, tumorsGI bleeding with jaundice & RUQ pain & tendernessEGD blood from the ampulla of vaterTxAngio embolization
39Iatrogenic Hemobilia after instrumentation of the biliary tract After sphinceterotomy in ERCPPEGPost operative
41Bleeding related to Portal Hypertension Most commonly the result of bleeding from varicesDilation of the submucosal veins due to PH providing a collateral pathway for decompression of the portal systemDistale esophagus>Stomach>Rectum
42Gastroesophageal Varices Develop in 30% of ptns with cirrhosis & PHBleeding occurs in 30% of ptns with varicesCompared to non variceal bleeding, its associated with higher risk of rebleeding, transfusions, hospital stay, mortality!!!Massive bleeding6 week mortality after the 1st bleeding is 20%!!!!
45Sengstaken Blakemore tube Gastric tube with esophageal and gastric balloonsThe gastric balloon is inflated, and tension is applied to the gastroesophageal junctionIf this does not control the hemorrhage, the esophageal balloon is inflated as well, compressing the venous plexus between them
46Sengstaken Blakemore tube A high rate of complications related to both aspiration and inappropriate placement with esophageal perforation