The Approach to Upper GI Bleeding

1. The Approach to Upper GI Bleeding Group D – Analyst Grp Vigilia, Patrice Villaflor, Irene Villafuerte, Marc Villar, Cherry Villasis, Ramon Vistal, Kristine Yap, Margaux

2. Presentation Objectives • Review of the anatomy and physiology of the digestive tract. • Presentations of GI bleeding, its classifications, and its sources. • Approach to a patient with Upper GI bleeding. • Enumerate the different tools used in the evaluation and diagnosis of patients presenting with GI bleeding.

3. The Anatomy GI Tract • extends from the mouth to the anus, and comprises several organs with distinct functions • separating the organs are specialized independently controlled thickened sphincters that assist in the gut compartmentalization • gut wall: is organized into well-defined layers that contribute to the functional activities in each region Harrison’s Principle of Internal Medicine, 17th ed.

4. Important Point: • The anatomic cut-off for upper GI is the Ligament of Treitz • It is located in the fourth portion of the duodenum (the last 2 inches). • It connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon. Snell’s Clinical Anatomy, 7th ed.

5. Functions of the GI Tract • Two main functions: • Assimilation of nutrients • Elimination of wastes Harrison’s Principle of Internal Medicine, 17th ed.

6. GI Bleeding Presentation • Hematemesis - vomitus of red blood or coffee-grounds material • Melena – black, tarry, foul-smelling stool • Hematochezia – passage of bright red or maroon blood from the rectum • Occult GI Bleeding – identified through fecal occult blood test or the presence of iron deficiency • Systemic signs of Blood Loss or Anemia – lightheadedness, syncope, angina, dyspnea Harrison’s Principle of Internal Medicine, 17th ed.

7. GI Bleeding Classification • Acute vs Chronic • UGI Bleeding vs LGI Bleeding

8. Acute vs Chronic • Acute - typically presents with overt blood loss that can be readily recognized by the patient or treating physician • Chronic - long-term GI bleeding may go unnoticed or may cause fatigue, anemia, black stools, or a positive test for microscopic blood Washington manual of medical therapeutics, 32nd edition emedicinehealth.com

9. UGI Bleeding vs LGI Bleeding UGI Source of bleeding is ABOVE the ligament of Treitz • Usually presented as: • HEMATEMESIS • MELENA, indicates that blood has been present in the GI tract for at least 14 hrs • May also present as HEMATOCHEZIA if an upper lesion bleeds briskly that blood does not remain in the bowel long enough for melena to develop. • May be occult LGI • Source of bleeding is BELOW the LIGAMENT of TREITZ • Usually presented as • HEMATOCHEZIA – passage of bright red or maroon blood from the rectum. • May be occult Harrison’s Principle of Internal Medicine, 17th ed.

10. Harrison’s Principle of Internal Medicine, 17th ed.

11. Approach to the patient • Measurement of the heart rate and blood pressure is the best way to assess the patient. • Clinically significant bleeding leads to postural changes in HR or BP, tachycardia and recumbent hypotension.

12. Approach to the patient • Hemoglobin Determination • Does not fall immediately with acute GIB: this is due to the proportionate reduction in plasma and red cell volumes. • As extravascular fluid enters the vascular space to restore volume, the hemoglobin falls.

13. UPPER GI BLEEDING • History and PE in not usually diagnostic. • Upper endoscopy is the test of choice and should be performed urgently in patients with hemodynamic instability. Harrison’s Principle of Internal Medicine, 17th ed.

14. Endoscopy • procedure is the best method for examining upper GI mucosa • minimally invasive diagnostic medical procedure • used to assess interior surfaces of organs by inserting a tube into the body • instrument may have a rigid or flexible tube & not only provide an image for visual inspection and photography, but also enable taking biopsies & retrieval of foreign objects • sedatives may be given so as to relieve discomfort Harrison’s Principle of Internal Medicine, 17th ed.

15. Endoscopy • Used to determine the cause of bleeding, pain, nausea and vomiting, weight loss, altered bowel function and fever • Upper endoscopy • evaluates the esophagus, stomach and duodenum • initial test performed in patients with suspected ulcer disease, esophagitis, neoplasm, malabsorption and Barrett's metaplasia because it directly visualizes abnormality Harrison’s Principle of Internal Medicine, 17th ed.

16. Endoscopy • Risks of procedure: • risk of bleeding • gastrointestinal perforation Harrison’s Principle of Internal Medicine, 17th ed.

17. Acute Upper GI Bleeding Ulcer Esophageal Varices Mallory-Weiss Tear Ligation (preferred) or sclerotherapy + IV octreotide Active bleeding No active bleeding Active bleeding or visible vessel Adherent Clot Flat, pigmented spot Clean base IV PPI therapy + endoscopic therapy IV PPI therapy +/- endoscopic therapy No IV PPI or endoscopic therapy No IV PPI or endoscopic therapy ICU for 1-2 days; ward for 2-3 days Endoscopic therapy No endoscopic therapy Ward for 1-2 days ICU for 1 day; ward for 2 days Ward for 3 days Ward for 3 days Discharge Discharge Algorithm for patients with acute upper gastrointestinal bleeding Harrison’s Principle of Internal Medicine, 17th ed.

18. Other tests that may be performed: • Laboratory Tests (CBC, Serum Electrolyte, Fecal Occult Blood, BUN/Crea Ratio) • Radiography (Barium Swallow, CT Scan) Harrison’s Principle of Internal Medicine, 17th ed.

19. Summary • Assess the patient by doing History and PE • Heart Rate and Blood Pressure • Do an Endoscopic Exam • Perform other laboratory and radiographic exams if necessary

20. Salient Features 55 y/o female History of vague epigastric discomfort hematochezia [2 episodes of melena (2 cupfuls/episode)] hematemesis [1 episode of coffee ground vomiting] cold clammy sweats and dizziness intake of Diclofenac Na intermittently regular medications: clopidogrel (anticoagulant) (+) DM overweight [BMI = 26.5]

21. 10 kg weight loss for the past 6 months • orthostatic hypotension (BP 120/80 when supine, 100/60 at sitting) • PR 105/min RR 22/min • Pale palpebral conjuctiva and anicteric sclera • no cervical lymphadenopathy • lung and heart sounds are normal • apex beat at 6th LICS • Abdomen with hyperactive bowel sounds, soft non tender, without palpable mass or organomegaly • DRE maroon colored stools

22. Clinical Impression: • Acute Upper GI bleeding secondary to PUD (to rule out Gastric CA)

23. Peptic Ulcer Causes of Upper GI Bleeding Esophageal Varices Mallory Weiss Tears Hemorrhagic or Erosive gastropathy Gastric CA Differential Diagnosis

24. Peptic Ulcer Disease Siy, Jeniffer, So, Roizza, Solang, Jenifer, Soriano, Whitney, Soto, Ian, Suelto, Jeremy, Suero, Diane

25. INCIDENCE and EPIDEMIOLOGY

26. Incidence and Epidemiology • Acid peptic disorders - 4 million individuals (new cases and recurrences) affected per year • Lifetime prevalence of PUD in the United States • ~12% in men and10%in women • an estimated 15,000 deaths per year - as a consequence of complicated PUD • estimated burden on direct and indirect health care costs of ~$10 billion per yearin the United States Harrisons principles of internal madicine 17th ed p1838

27. Incidence and Epidemiology Duodenal Ulcers • occur in 6–15%of the Western population • incidence of DUs declined steadily from 1960 to 1980 and has remained stable since then. • death rates, need for surgery, and physician visits have decreased by >50% over the past 30 years • Eradication of H. pylori has greatly reduced recurrence rates. Harrisons principles of internal madicine 17th ed p1838

28. Incidence and Epidemiology Gastric Ulcers • occur later in life than duodenal lesions (peak incidence reported in the sixth decade) • More than half occur in males • less commonthan Duodenal Ulcers • Autopsy studies suggest a similar incidence of DUs and GUs. Harrisons principles of internal madicine 17th ed p1838

29. Incidence and Epidemiology Helicobacter pylori • Prevalence : developing parts of the world (80% of the population by age of 20) industrialized countries (20 – 50 %) United States (~30%) • About 10% of Americans <30 are colonized with the bacteria Harrisons principles of internal madicine 17th ed p1838

30. Incidence and Epidemiology Helicobacter pylori • The rate of infection in the United States has fallen by >50% when compared to 30 years ago. Harrisons principles of internal madicine 17th ed p1838

31. Incidence and Epidemiology Helicobacter pylori • Risk Factors : • (1) birth or residence in a developing country • (2) domestic crowding • (3) unsanitary living conditions • (4) unclean food or water • (5) exposure to gastric contents of an infected individual. Harrisons principles of internal madicine 17th ed p1838

32. Clinical Presentation of Upper GI Bleeding due to PUD History PE

33. History • Abdominal or Epigastric pain • Described as burning, gnawing, aching sensation or hunger pain • Important to know the temporal pattern

34. History

35. Physical Examination

36. Physical Examination

37. DIAGNOSIS

38. Radiographic Procedure (Barium Study) • Commonly used as a first test for documenting an ulcer • Sensitivity: 80% (single contrast barium meals); 90% (double contrast) • Sensitivity is decreased in small ulcers (<0.5cm), presence of previous scarring, postoperative patients

39. Benign duodenal ulcer appears as a well demarcated crater, seen at the bulb

40. Benign gastric ulcer • Ulcer crater-collection of barium on dependent surface which usually projects beyond anticipated wall of stomach in profile (penetration) • Hampton’s line-1 mm thin straight line at neck of ulcer in profile view which represents the thin rim of undermined gastric mucosa • Ulcer collar-smooth, thick, lucent band at neck of ulcer in profile view representing thicker rim of edematous gastric wall • Ulcer mound-smooth, sharply delineated tissue mass surrounding a benign ulcer • Ring shadow-thin rim of contrast which represents an ulcer on the non-dependent surface of an air-contrast study • Thickened folds radiating directly to the base of the ulcer en face

41. Endoscopy • Provides the most sensitive and the most specific approach for examining the upper GI • Permits direct visualization of the mucosa • Facilitates photographic documentation of mucosal defect and tissue biopsy to rule out malignancy or H. pylori • Helpful in identifying lesions too small to detect by radiographic examination, for evaluation of atypical radiographic abnormalities, determine if ulcer is source of loss of blood

42. A B

43. TREATMENT

44. GOALS in treating PUD • Provide relief of symptoms (pain or dyspepsia) • Promote ulcer healing • Prevent ulcer recurrence and complications

45. Drugs used in the Treatment of PUD Harrison’s Principle of Internal Medicine 17th edition

46. Drugs used in the Treatment of PUD Harrison’s Principle of Internal Medicine 17th edition

47. Drugs used in the Treatment of PUD • Acid neutralizing/inhibitory drugs (Antacids) • MOA: neutralize secreted acids • Often used by patients for symptomatic relief of dyspepsia

48. Drugs used in the Treatment of PUD • H2 receptor antagonists • MOA: Competitive inhibitors of the action of histamine at H2 receptors • Healing in 80-90% of cases after 4-8 weeks of therapy • Cimetidine has an anti-androgenic effect due to cytochrome p450 enzyme inhibition  reversible gynecomastia and impotence Harrison’s Principle of Internal Medicine 17th edition

49. Drugs used in the Treatment of PUD • Proton Pump (H+,K+ ATPase) inhibitors • MOA: Covalently bind and irreversibly inhibit H+K+ ATPase • Given before meal, activation in acidic environment

50. Drugs used in the Treatment of PUD • Cytoprotective agents Harrison’s Principle of Internal Medicine 17th edition