Upper Gastrointestinal Bleeding: Assessment and Management

1. Upper Gastrointestinal Bleeding:Assessment and Management ThomasGenuit, MD, MBA, FACS Sinai Hospital of Baltimore

3. Upper GI Bleed: Symptoms Differential diagnoses for UGIB: Gastric ulcer Duodenal ulcer Esophageal varices Gastric varices Mallory-Weiss tear Esophagitis Neoplasm Hemorrhagic gastritis Dieulafoy lesion Angiodysplasia Hemobilia Pancreatic pseudocyst Pancreatic pseudoaneurysm Aortoenteric fistula Proximal to lig of Treitz also means no bleeding from biliary tree, liver, and pancreas Non bilious aspirate does NOT rule out bleeding distal to the pylorusProximal to lig of Treitz also means no bleeding from biliary tree, liver, and pancreas Non bilious aspirate does NOT rule out bleeding distal to the pylorus

4. Upper GI Bleed: Symptoms Acute Sx: Hematemesis - 40-50% Hematochezia - 15-20% Melena - 70-80% Syncope - 14.4%, Presyncope - 43.2% Sx 30 days prior: Dyspepsia - 18% Epigastric pain - 41% Heartburn - 21% Diffuse abd. pain - 10% Dysphagia - 5% Weight loss - 12% Jaundice - 5.2% Proximal to lig of Treitz also means no bleeding from biliary tree, liver, and pancreas Non bilious aspirate does NOT rule out bleeding distal to the pylorusProximal to lig of Treitz also means no bleeding from biliary tree, liver, and pancreas Non bilious aspirate does NOT rule out bleeding distal to the pylorus

5. Assessment / Tests: NGT Clears particulate matter, clots facilitates EGD Assessment volume of bleeding Increases/decreases risk of aspiration Blood/Coffee-grounds: clear indication for EGD Clear aspirate � no gastric sourceBilious aspirate � no source proximal to lig. of Treiz OR bleeding has stopped Proximal to lig of Treitz also means no bleeding from biliary tree, liver, and pancreas Non bilious aspirate does NOT rule out bleeding distal to the pylorusProximal to lig of Treitz also means no bleeding from biliary tree, liver, and pancreas Non bilious aspirate does NOT rule out bleeding distal to the pylorus

6. Endoscopy For hematemesis: < 1st hour Consider intubation Other bleeding: Urgent � elective Diagnostic and therapeutic to 2nd portion of duodenum Consider Erythromycin 2 randomized controlled studies (146 pts): single dose (3 mg/kg IV over 20-30 min; give 30-90 min prior to EGD) improves visibility, decreases EGD time, decreases need for second look Consider airway protection Diagnostic and therapeutic tx of choice for active bleeding and prevention of rebleeding Endoscopic maneuvers include injection, thermal coagulation, and mechanical occlusion of bleeding sites (by means of clip application or variceal banding) ECN is motilin agonistDiagnostic and therapeutic tx of choice for active bleeding and prevention of rebleeding Endoscopic maneuvers include injection, thermal coagulation, and mechanical occlusion of bleeding sites (by means of clip application or variceal banding) ECN is motilin agonist

7. Capsule Endoscopy For bleeding beyond lig. Treitz Diagnostic only, time requirement up to 24 hours Decreased yield w. large vol. bleed and/or intermittend bleed Angiodysplasia and SB tumors most common Diagnostic and therapeutic tx of choice for active bleeding and prevention of rebleeding Endoscopic maneuvers include injection, thermal coagulation, and mechanical occlusion of bleeding sites (by means of clip application or variceal banding) ECN is motilin agonistDiagnostic and therapeutic tx of choice for active bleeding and prevention of rebleeding Endoscopic maneuvers include injection, thermal coagulation, and mechanical occlusion of bleeding sites (by means of clip application or variceal banding) ECN is motilin agonist

8. RBC scan / Angiography 0.5 � 1 ml/min bleeding requirement,set up req. 1-2 hours, test time 1-2 hours RBC scan may not accurately locate bleed,screening test Therapeutic (embolization) potential Tube passed into proximal small bowel and barium, methylcellulose, and air is injected. Superior to SBFT Tagged cell � bldg must be 0.1 to 0.5 ml/min Angio - > 1 ml/min Tube passed into proximal small bowel and barium, methylcellulose, and air is injected. Superior to SBFT Tagged cell � bldg must be 0.1 to 0.5 ml/min Angio - > 1 ml/min

9. Peptic Ulcer Disease History: Pain / dyspepsia BRB (hematemesis) or Coffe-grounds NSAIDS, ETOH, Type A personalitypersonal Hx (antacids �) First Line Therapy: Hemodynamic Support, correction of coagulation / PLT. abnormalities (FFP, Cryo, PLT, F Via) PPI: IV gtt vs. BID IV Endoscopy Most ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. More recent literature suggest that adherent clots should be removed and tx�d endoscopically which reduces risk of rebleed to <10% but should be done only by HIGHLY EXPERIENCED ENDOSCOPIST Most ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. More recent literature suggest that adherent clots should be removed and tx�d endoscopically which reduces risk of rebleed to <10% but should be done only by HIGHLY EXPERIENCED ENDOSCOPIST

10. Peptic Ulcer Disease Endoscopic therapy: Injection of vasoactive* / sclerosing agents* Bipolar electro-* / thermal probe coagulation* Band ligation / constant probe pressure tamponade Argon plasma / laser photocoagulation* Hemostatic materials, including biologic glue Predictors of re-bleeding: Active bleeding during EGD- 90% recurrence Visible vessel- 50% recurrence Adherent clot- 25-30% recurrence Most ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. More recent literature suggest that adherent clots should be removed and tx�d endoscopically which reduces risk of rebleed to <10% but should be done only by HIGHLY EXPERIENCED ENDOSCOPIST Most ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. More recent literature suggest that adherent clots should be removed and tx�d endoscopically which reduces risk of rebleed to <10% but should be done only by HIGHLY EXPERIENCED ENDOSCOPIST

11. Peptic Ulcer Disease Most ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. More recent literature suggest that adherent clots should be removed and tx�d endoscopically which reduces risk of rebleed to <10% but should be done only by HIGHLY EXPERIENCED ENDOSCOPIST Most ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. More recent literature suggest that adherent clots should be removed and tx�d endoscopically which reduces risk of rebleed to <10% but should be done only by HIGHLY EXPERIENCED ENDOSCOPIST

12. Peptic Ulcer Disease If bleeding controlled: pantoprazole, 80 mg bolus then 8 mg/hr infusion x 24 hrs. then 40 mg IV qd-BIDthen transition to oral PPIs for 6-8 wks � or lifelong Helicobacter pylori treatment, if presenttriple or quadruple drug regimen x 2-3 wksrecurrent colonization 70-90% within few month to yr. Eliminate/reduce NSAIDs, add misoprostol (PGE2) Repeat endoscopy < 6-8 wks Most ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. (e.g., a 14-day course of metronidazole, 500 mg p.o., t.i.d.; omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500 mg p.o., b.i.d.) Diet has little effect on rebleeding ratesMost ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. (e.g., a 14-day course of metronidazole, 500 mg p.o., t.i.d.; omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500 mg p.o., b.i.d.) Diet has little effect on rebleeding rates

13. Peptic Ulcer Disease Indications for Surgery: Severe life-threatening hemorrhage not responsive to resuscitative efforts Failure of medical therapy and endoscopic hemostasis with persistent / recurrent bleeding A coexisting reason for surgery such as perforation, obstruction, or malignancy Prolonged bleeding with loss of 50% or more of the patient's blood volume A second hospitalization for peptic ulcer hemorrhage Most ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. (e.g., a 14-day course of metronidazole, 500 mg p.o., t.i.d.; omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500 mg p.o., b.i.d.) Diet has little effect on rebleeding ratesMost ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. (e.g., a 14-day course of metronidazole, 500 mg p.o., t.i.d.; omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500 mg p.o., b.i.d.) Diet has little effect on rebleeding rates

14. Peptic Ulcer Disease If bleeding not controlled: Angiography / embolization Emergent operation Duodenal ulcer: most common posterior bleed;longitudinal anterior duodenotomy, quadrant over-sewprotection of bile duct !!! Most ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. (e.g., a 14-day course of metronidazole, 500 mg p.o., t.i.d.; omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500 mg p.o., b.i.d.) Diet has little effect on rebleeding ratesMost ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. (e.g., a 14-day course of metronidazole, 500 mg p.o., t.i.d.; omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500 mg p.o., b.i.d.) Diet has little effect on rebleeding rates

15. Peptic Ulcer Disease If bleeding not controlled: Emergent operation Gastric ulcer: wedge excision gastric ulcer � always send for frozen to r/o cancergastric devascularization anti-ulcer operation ??? � TV&A, SV&P (PV), HSV For both: post-OP PPI, H.P. therapy, follow-up endoscopy Most ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. (e.g., a 14-day course of metronidazole, 500 mg p.o., t.i.d.; omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500 mg p.o., b.i.d.) Diet has little effect on rebleeding ratesMost ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. (e.g., a 14-day course of metronidazole, 500 mg p.o., t.i.d.; omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500 mg p.o., b.i.d.) Diet has little effect on rebleeding rates

16. Peptic Ulcer Disease Most ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. (e.g., a 14-day course of metronidazole, 500 mg p.o., t.i.d.; omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500 mg p.o., b.i.d.) Diet has little effect on rebleeding ratesMost ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. (e.g., a 14-day course of metronidazole, 500 mg p.o., t.i.d.; omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500 mg p.o., b.i.d.) Diet has little effect on rebleeding rates

17. Peptic Ulcer Disease Most ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. (e.g., a 14-day course of metronidazole, 500 mg p.o., t.i.d.; omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500 mg p.o., b.i.d.) Diet has little effect on rebleeding ratesMost ulcers from PUD stop bleeding spontaneously and will NOT rebleed during hospitalization. HOWEVER, subgroup of those pts with stigmata of ulcer hemorrhage are at higher risk for rebleeding. (e.g., a 14-day course of metronidazole, 500 mg p.o., t.i.d.; omeprazole, 20 mg p.o., b.i.d.; and clarithromycin, 500 mg p.o., b.i.d.) Diet has little effect on rebleeding rates

18. Acute Hemorrhagic Gastritis Usually in severely ill pts: Mild 10-20%; req transfusion 1-2% Predisposing: shock (pressors), multi-trauma, ARDS, SIRS/Sepsis, renal & hepatic failure 7-10 day delay Prophlaxis / medical managementessential:Antacids < Carafate < H2 blockers < PPIs effective; H. pylori therapy is adjunct

19. Acute Hemorrhagic Gastritis Surgical management: Rarely necessary; goal: control bleeding, reduce recurrence & mortality. (pts. are at extremely high risk) Simple oversewing of actively bleeding erosion: sometimes effective W. life-threatening hemorrhage : gastric resection with or without vagotomy with reconstruction may.Type of gastric resection depends on the location of the gastric erosions:antrectomy and subtotal, near total, or total gastrectomy. Operative mortality - 30-100%

20. Mallory-Weiss Tears Large, rapidly occurring, transient transmural pressure gradient across gastroesophageal junction � typical Hx found only in 30-50% 5-15% of UGIB, male:female 3:1, ETOH in 45-70%, NSAIDS in 30-40%, hiatal hernia predisposes 35-70% no specific physical signs � abd. Pain uncommon Bleeding stops spont. in 80-90%, most heal < 48-72 hours; can easily be missed if endoscopy is delayed transfusions req. in 40-70%; hemodynamic instability and shock <10%; mortality -> 8.6% earlier series now < 3% Therapy: supportive, surgery needed -> 10% for perforation, uncontrolled bleeding; mortality w. (emergent) surgery 15-25%

21. Dieulafoy�s Lesions Aka exulceratio simplex Dilated aberrant submucosal artery, < 6 cm GE jct. 1-3 mm diameter, 2-5% of UGIB ETOH association, 30-50 yr old patients, m>f Endoscopic therapy (coagulation/clipping) 95% successful, re-bleeding 10-15% - most controlled endoscopically Surgical wedge resection if repeat endoscopic therapy fails � mortality 25-40% reflection of co-morbid conditions

22. Angiodysplasia: Dilated, thin-walled vmucosal ascular channels; appear macroscopically as a cluster of cherry spots, 2-4% of UGIB and 5-6% LGIB Most common: stomach & duodenum. Acquired or congenital: Hereditary hemorrhagic telangiectasia  Rendu-Osler-Weber syndrome von Willebrand disease  Chronic renal failure req. hemodialysis; Cirrhosis Aortic valvular disease (esp. aortic stenosis).

23. Angiodysplasia: Bleeding can be occult � lifethreatening Endoscopic treatment > 90% successful (contact probe coagulation, injection, band ligation) When surgery required (often multiple lesions) partial / total gastrectomy may be required

24. Cameron Lesions Linear erosions/ulcers in hiatal hernia sac at the level of the diaphragm May be present in -> 5% of pts with hiatal hernia Rare cause of acute or chronic UGIB, Fe-def. anemia Bleeding is treated endoscopically Stable pt: surgical repair of hernia since this lesion is mechanically induced

25. Neoplasms

26. Portal HTN, Esophagogastric Varices Often life threatening bleeding, 50-60% bleed, 30-40% bleed < 2 y from Dx; mortality 30-50% (better w. nl. liver fct.) Segmental or systemic portal HTN (> 10 mm Hg pressure), diversion of -> 1l/min portal flow Presinusoidal, Sinusoidal, Post Sinusoidal 60-70% 30% w/ each episode 60-70% 30% w/ each episode

27. Portal HTN, Esophagogastric Varices 60-70% 30% w/ each episode 60-70% 30% w/ each episode

28. Esophagogastric Varices Treatment strategies: Resuscitation, supportive therapy, balloon tamponade Pharmacologic therapy Endoscopic therapy Decompressive therapy (radiologic and surgical) Liver transplantation Follow up with banding or injectionFollow up with banding or injection

29. Esophagogastric Varices Balloon tamponade: Initially temporizing measure in all pts, now < 10%temporary hemostasis in 85%, neear 100% re-bleed on removal 20% complication rateEsophageal rupture, Tracheal rupture, Duodenal rupture, Respiratory tract obstruction, Aspiration, Tracheoesophageal fistula, Esophageal necrosis / ulcer Follow up with banding or injectionFollow up with banding or injection

30. Esophagogastric Varices Pharmacologic treatment : Vasopressin splanchnic vasoconstriction; 0.2-0.4 (0.7) U/min � improved hemostasis, no survival benefit; newst studies: Tellipressin (pro-drug) w. benefits in hemostasis and survival Nitroglycerine gtt 40 mcg/min; systemic hypotension and venous pooling, counteract cardiac effects of vasopressin; titrate to SBP 90-100 Beta-Blockers: Propranolol 40 mg BID; maintenance therapy before incidence and after bleeding controlled Follow up with banding or injectionFollow up with banding or injection

31. Esophagogastric Varices Pharmacologic treatment : Octreotide: 250 mcg bolus, 250 mcg/hr infusion; Decreases gastric acid, pepsin, gastric blood flow Endoscopy Cornerstone: band ligation and sclerotherapy, glue Lower mortality, re-bleed, esoph perf and stricture w. banding; can be done prophylactically Initial success rate -> 90%, re-bleed 30-50% Endoscopic surveillance q3 mo x 1 y then q6 mo x 1 y then annually Follow up with banding or injectionFollow up with banding or injection

32. Esophagogastric Varices TIPS: Goal reduction of PHVP < 12 mm Hg Primary bleeding control > 90% Re-bleeding rate 16-30% at 1-year Shunt dysfunction 50-60% at 6 months W. re-dilation of the stent 1-year patency 83-85% Risk of hepatic encephalopathy 25-35% can usually be managed medically30-day mortality 14-16%,  most deaths in patients with Child C cirrhosis as a result of multisystem organ failure Follow up with banding or injectionFollow up with banding or injection

34. Esophagogastric Varices Surgical Shunts: Goal: decompression of the high-pressure portal venous system into a low-pressure systemic venous system and devascularization of the distal esophagus and proximal stomach Follow up with banding or injectionFollow up with banding or injection

36. Esophagogastric Varices Surgical Shunts: bleeding control rate >90% Different incidence of encephalopathy and risk of worsening ascites w. nonselective, selective, or partial. Encephalopathy 10-15% after selective shunt (distal splenorenal), 10-20% after a partial shunt, and in 30-40% after a total shunt. No differences in survival rates: ~5%. Follow up with banding or injectionFollow up with banding or injection

38. Hemobilia Rare Parasitic, tumors, traumatic, iatrogenic Diagnosis with endoscopy , ERCP, angiography Therapy Embolization then treatment of cause Surgery for failed embolization Selective hepatic artery ligation Hepatic resection if necessary

39. Hemosuccus Pancreaticus Rare Direct communication present from retro-/peripancreatic vessel (usually splenic artery) Tumor or pancratitis, pseudocyst erosion, trauma, iatrogenic after ERCP Presentation: Upper abdominal pain followed by hematochezia or hemeatemesis Diagnosis: CT +/- angiography Treatment: angiography/surgery Whipple, distal pancreatectomy, pseudocyst resection may be necessaryWhipple, distal pancreatectomy, pseudocyst resection may be necessary

40. Aortoenteric Fistula Rare Aortic graft erosion, usually 3rd 4th portion of duodenum, Graft infection, peptic ulcer, tumor, trauma High mortality: delayed diagnosis -> 100% operative 25-90% Presentation: History of AAA repair! Herald bleed May be followed by massive hemorrhage of hematemesis and/or hematochezia of hematemesis and/or hematochezia

41. Aortoenteric Fistula Diagnosis: CT: thickened bowel, periaortic inflammation, pseudoaneurysm, extraluminal gas or fluid collection Angio: req active bleed Ultrasound Therapy: Endoluminal stent graft Graft repair/replacement, long-term Abx, bowel diversion, � Only 11% of pts present with this triadOnly 11% of pts present with this triad

42. A 55-year-old man presents with hematemesis that began 2 hours ago. He is hypotensive and has altered mental status. No medical history is available.  How would you initiate management? ABCs, Oxygen, 2 large bore IVs, IVF, labs, T&C for blood, FFP, foley, r/o MI, transfer to ICU NGT placement

43. Patient receives 2 units of PRBCs. NGT is placed. What would you conclude from the following: Clear, non-bilious aspirate Clear, bilious aspirate Bloody aspirate

44. Blood is aspirated from NGT. How would you proceed? Intubate EGD

46. Diagnosis? Esophageal varices Management? Banding or sclerotherapy Administer concurrent somatostatin bolus/infusion After bleeding stops, start propranolol

47. Pt�s bleeding stops initially and he stabilizes. However, he intermittently requires 1-2 units of PRBC over the next 48 hrs. totaling an additional 5 unit transfusion. No further hematemesis. How would you proceed? CT/USG to rule out splenic vein thrombosis TIPS Who does TIPS in your hospital? Let�s say all the radiologists in the state are at a conference and are unavailable� Mesocaval shunt with interposition PTFE graft