Upper GI Bleeding

Upper GI Disease Lori F Gentile

Upper GI Bleeding

Definitions

• UGIH = proximal to ligament of Treitz • Hematemesis = vomiting blood - bright red or coffee ground (typically UGI source) • Melena = black tarry stool (often UGI)

– Enzymatic breakdown

• Hematochezia = bloody stool (LGI > UGI) – Blood as cathartic agent • Occult blood = UGI or LGI source

Upper GI Bleeding

DDx- UGI Bleed

• Peptic Ulcer Disease (PUD) >50% cases • Gastritis / Duodenitis (15-30%) – Subset due to NSAID use • Esophageal varices from portal hypertension (10-20%) • Gastric varices • Mallory-Weiss tears at GE junction (5%) • Esophagitis (3-5%) • Malignancy (3%) • Dieulafoy’s lesion (1-3%) • Nasopharyngeal bleed – swallowed blood

Upper GI Bleeding

Initial Evaluation

• Evaluate ABCs/PE: – Can the pt protect his airway?

– Is the pt hemodynamically unstable?

– Does the pt have adequate IV access, Foley, NGT?

• Resuscitate as appropriate • Orders: NPO, IVF, NGT to LCWS, Foley, HOB>30, continuous pulse oximetry & telemetry • Labs: type & cross, CBC, INR/PT/PTT, BMP, LFTs • Additional question to ask yourself: – Does the pt require a higher level of care?

Upper GI Bleeding

H&P

• Risk factors: age, oral anticoagulant use, h/o prior GIB, PUD, NSAID use, alcohol/tobacco use, liver disease / portal HTN, burn/trauma, severe vomiting, h/o H. pylori, GI instrumentation, AAA repair • History: HPI, PMHx, PSHx, Meds, ALL, SHx.

– Symptoms: none  postural hypotension, exertional dyspnea – Coffee ground emesis (UGI) • PE: remember to examine for signs of cirrhosis & portal HTN (ascites, caput medusa, rectal varices) • Tests: T&C, CBC, coags, BMP, LFT, CXR/KUB

Upper GI Bleeding

Management

• NGT/lavage -can identify UGI bleed • Start proton pump inhibitor (PPI) infusion • EGD-visualize bleeding source and treat – Tx- sclerotherapy, epinephrine, banding, cautery • For varices: octreotide infusiom -Reduces portal pressure, vasoconstricts • Tagged pRBC scan if cannot localize source • More sensitive than angiography, Can detect bleeding rate > 3-10mL/hr • AngiographyAngiography (Diagnostic & Therapeutic) • Intra-arterial vasopressin • Embolization • Can detect bleeding rate > 30-50mL/hr • If pt unstable and continues to require blood->consider OR

Upper GI Bleeding

PUD

• Most freq cause of UGI bleed • Usually in 1 st part of duodenum – Anterior-perforate – Posterior-bleed from GDA • Spontaneous resolution in 80-90% • OR – perforation, refractory bleeding, obstruction, Inability to identify bleeding source • Surgery – – Duodenostomy, GDA ligation – Truncal vagotomy and pyloroplasty

Upper GI Bleeding

Long-Term Management • Test for H. pylori. Treatment = amoxicillin, clarithromycin, and PPI • Limit NSAID use • H2B, PPI

Upper GI Bleeding constrictors

Esophagus

• Zenker’s Diverticulum – b/w cricophayngeas and pharyngeal – Sx- dysphagia, choking, halitosis, regurgitation of chewed food – Dx: barium swallow – Tx: cricopharyngeal myotomy +/- diverticulectomy • Achalasia- failure of peristalsis and LES relaxation – Sx- dysphagia, regurgitation, weight loss, resp sx – Dx- manometry (inc LES pressure, incomplete LES relaxation, no peristalsis) – Tx- Medical- CCB, dialation, botox, Surgical-Heller myotomy • GERD – Surgery for failure of med mgt, stricture, Barrett’s esophagus – Dx- endoscopy, PH probe, manometry, UGI (make sure no motility d/o) – Tx- Nissen fundoplication 360 degree wrap

Upper GI Bleeding

Other Esophagus

• Para-esophageal hernia – 4 types, must repair type 2. Repair with patch and Nissen • Esophageal Cancer – – Dx with endoscopy and biopsy followed by CT C/A – Adenocarcinoma – lower 1/3, most common – Squamous cell – upper 2/3, h/o etoh/tobacco use – Tx • T1- esophagectomy +/- adjuvent C/R • T2 – Gray area – If + Nodes then neoadjuvent C/R, esophagectomy • T3/T4 – Neoadjuvent C/R followed by esophagectomy +/ adjuvent therapy