Transcript Wael Youssef, MD, FACG Associate Professor of Medicine     UGIB results in over 300,000 hospital admissions annually in US with mortality of 7% to.

Wael Youssef, MD, FACG
Associate Professor of Medicine
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UGIB results in over 300,000 hospital
admissions annually in US with mortality of
7% to 10%.
UGIB refers to GI blood loss proximal to
ligament of Treitz.
UGIB can manifest as hematemesis, coffee
ground emesis, melena (black, tarry stool) with
or without hemodynamic compromise.
Hematochezia (BRBPR) may occur in patients with
extremely brisk UGIB.
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Assessment of hemodynamic stability and
Resuscitation.
Adequate resuscitation is essential prior to
endoscopy.
Two large caliber peripheral IV or central line.
Older adults with CAD should receive PRBCs
to maintain hematocrit around 30%.
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All Patients with hemodynamic instability or active
bleeding should be admitted to ICU for monitoring
and resuscitation.
Active bleeding with coagulopathy or
thrombocytopenia should be transfused with FFP and
platelets.
Octreotide should be started in the sitting of variceal
bleeding.
Elective intubation in patients with ongoing
hematemesis or altered mental status.
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Promotes gastric emptying (motilin receptors
agonist).
Two randomized controlled trials suggested
that a single dose of IV erythromycin before
endoscopy:
Improve visibility, shorten endoscopy time,
and reduce the need for a second-look
endoscopy.
Dose: 250 mg IV over 30 minutes, 30 to 90
minutes before endoscopy.
Erythromycin intravenous bolus infusion in acute UGI bleeding: A randomized, controlled, double-blind trial. Gastroenterology 2002; 123:17.
Erythromycin improves the quality of EGD in patients with acute UGI bleeding: A randomized controlled study. Gastrointest Endosc 2000;
56:174
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Multiple trials evaluating the effectiveness of
prophylactic antibiotics in cirrhotic patients
admitted with GI bleeding.
Suggest an overall reduction in infections
complications and possibly decreased
mortality.
Patient with cirrhosis and upper GI bleeding
should be given prophylactic antibiotics,
preferably before endoscopy.
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Focused history and physical exam is essential in the
initial evaluation:
- Nature and duration of bleeding,
including stool color and frequency.
- Associated symptoms; abdominal pain
fever, wt loss, urgency/tenesmus.
- Current medications (NSAIDs/ASA
and anticoagulation).
- Relevant PMH: previous bleeding, abdominal
surgeries, PUD, IBD, pelvic radiation.
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Resuscitative measures and an appropriate level of
patient monitoring must be established before specific
therapeutic intervention.
The goal of resuscitation is the restoration of euvolemia
and resultant stability in vital signs.
Resuscitative measures include initial fluid
administration via large bore IV catheters, PRBCs/FFP
as indicated.
Admission to ICU is appropriate for those not
responding to initial resuscitative measures (persistent
hypotension, tachycardia).
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As many as 11% of patients suspected initially
to have LGIB are ultimately found to have an
UGI source.
In patients with apparent massive LGIB and
hemodynamic compromise, it is important to
include UGIB in the DD and placement of NG
tube should be considered.
While the presence of frank blood from the
aspirate confirms an UGIB, a negative aspirate
does not rule this out.
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Arteriography should be reserved for those patients
with massive, persistent or recurrent hematochezia
when colonoscopy has not revealed a source.
The overall yield of angiography is 40%-78%.
Diverticular disease and vascular ectasia are the most
common findings.
Intra-arterial injection therapy using vasopressin is
associated with a major complication rate 10-20%.
Transcatheter embolization has also been used for the
control of massive LGIB.
Embolic therpy may have utility in patients with CAD
and those at high risk for surgery.
Angiographic diagnosis and management of gastrointestinal hemorrhage: current concepts. Radiol Clin
North Am 1994;32:951-67
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Pre-operative localization of LGIB (endoscopic,
angio) is crucial to avoiding extensive surgical
intervention (blind colectomy) and to ensure
that the bleeding is truly arising from LGIT.
Segmental resection is possible when the
bleeding site is identified (diverticular disease
limited to L colon with persistent or recurrent
bleeding)
Transfusion greater than 6 units of PRBCs in a
24H and recurrent diverticular bleeding are
common indications for surgical intervention.
Bleeding colonic diverticula: a reappraisal of natural history and management. Ann Surg
1994;220:653-6.
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Assessment of hemodynamic stability.
Resuscitation.
Localization: upper vs. lower
Consider possible etiologies.
Endoscopy to diagnose and treat.
Consider other modalities (angiography,
surgery) if endoscopic therapy fails.
Thank You