What are the 3 different types of GI bleeding?
Overt – acute bleeding, presenting with either hematemesis, ‘coffee ground’ emesis, melena or hematochezia; angiography and radionuclide imaging (tagged RBC scan performed in nuclear medicine) are most widely utilized for acute overt bleeding
Occult – chronic bleeding; resulting from microscopic hemorrhage; may present with Hemoccult + stools with or without iron deficiency anemia
Obscure – initially presenting with a + fecal occult blood test (FOBT) and/or iron deficiency anemia when there is no evidence of visible blood loss; recurrent bleeding without identification of a source even after upper endoscopy and colonoscopy; can be either overt or occult; capsule endoscopy and deep enteroscopy are utilized in the diagnosis of obscure bleeding originating from the small bowel
What classifies an upper GI bleed?
Refers to intraluminal blood loss from any location between the upper esophagus to the duodenum at the ligament of Treitz
What are common causes of upper GI bleeds?
- Gastric and/or duodenal ulcers
- Severe or erosive gastritis/duodenitis
- Severe or erosive esophagitis
- Esophagogastric varices
- Portal hypertensive gastropathy
- Angiodysplasia (vascular ectasia)
- Mallory-Weiss syndrome
- Mass lesions (polyps/cancers)
- Dieulafoy’s Lesions – vascular malformation of the submucosal artery located in the proximal stomach abnormally close to the mucosa that erodes the epithelium and can result in massive UGIB
How can PUD cause upper GI bleeding?
There are 4 major risk factors for bleeding peptic ulcers:
H.pylori infection - spiral bacterium that infects superficial gastric mucosa and disrupts mucous layers making it more susceptible to acid damage; h.pylori infection is associated in most patients with duodenal ulcers that are NOT related to NSAID use
NSAID’s - including low-dose aspirin
Excess gastric acid - control of gastric acidity is considered an ESSENTIAL therapeutic maneuver in patients with active UGIB
How can Esophagitis lead to upper GI bleeding?
1. Gastroesophageal reflux disease (GERD)
2. Medication use: NSAIDs, oral bisphosphonates
3. Infections (Candida, herpes simplex virus
How does Gastritis/Duodenitis lead to upper GI bleeding?
Predominantly inflammatory processes; rarely leads to significant UGIB; commonly identified at time of endoscopy; risk factors include:
1. risk factors for peptic ulcer disease above, plus
2. excessive alcohol consumption
3. radiation injury
4. obesity surgery
5. chronic bile reflux
How does Portal Hypertensive Gastropathy lead to upper GI bleeding?
While most patients with portal hypertension have cirrhosis and esophageal varices; portal hypertension DOES EXIST WITHOUT CIRRHOSIS and is termed non-cirrhotic portal hypertension; causes of non-cirrhotic portal hypertension include:
1. portal vein thrombosis
3. idiopathic non-cirrhotic portal hypertension
4. thrombosis of mesenteric vessels
What are the clinical manifestations associated with upper GI bleeding?
- Abdominal pain/discomfort
- Hematemesis- either bright red blood or coffee ground emesis
- Hypovolemic shock with acute blood loss
- Orthostatic changes – noted with a 20% or more loss of blood volume
- Skin pallor
- Spider angiomas
- NGT aspirate: bright red blood indicates active bleeding and is associated with a higher mortality than melena alone
What labs/diagnostic tests are used to diagnose an upper GI bleed?
- Type and Cross for at least 4 unit PRBCs
- CBC, Coagulation panel, electrolytes, BUN/creatinine, liver enzymes
- Endoscopy – both diagnostic and therapeutic; should be considered in asymptomatic patients who present with a high suspicion for cirrhosis and esophageal varices who have a + fecal occult blood test
- Capsule endoscopy – small camera ingested to examine entire length of small bowel; provides direct visualization of mucosa; diagnostic only
- Nuclear medicine bleeding scan (Tagged RBC scan) and/or Angiography
How do you manage a patient with an upper GI bleed?
1. Primary survey: Airway, Breathing, Circulation
2. Endotracheal intubation if required
3. STAT GI and Surgery consult
4. If acute significant blood loss, place 2 large bore IV lines or a central line for fluid resuscitation
5. Blood transfusion if warranted – Keep Hematocrit above 30%
- Patients with coagulopathies (elevated INR); 1-2 units FFP and 2.5-10 mg vitamin K IM or IV
- Low platelet count- transfuse platelets if actively bleeding
6. NGT placement – tap water gastric lavage
- If aspirate does not clear after 2-3 liters, continued active bleeding is assumed
- More urgent resuscitation and endoscopic interventions are indicated
7. Endoscopy – consider in all patients with UGIB
- Emergently indicated with active UGIB after stabilization
- Active, self-limited bleeds – perform within 24 hours, unless bleeding re-occurs
- Chronic blood loss – may undergo elective endoscopy
- Treatment options with EGD include:
- Thermal coagulation, i.e. cauterization
- Injection therapy with epinephrine or sclerosant
- Band ligation
8. Balloon Tamponade (i.e. Blakemore tube) if EGD fails to stop bleeding
What medications are used to manage patients with upper GI bleeding?
IV proton pump inhibitors- for acute bleeds
- Pantoprazole (Protonix) 80mg IV bolus, followed by continuous infusion OR
- Octreotide IV continuous infusion
- Single dose prior to endoscopy promotes gastric emptying and clearance of blood, clots and food
- Metoclopramide (Reglan) IV
- Ciprofloxacin IV OR Ceftriaxone 1 gm/day IV
- 7-day maximum course
- Shown to significantly reduce bacterial infections
- May reduce mortality, re-bleeding events and hospitalization length
When is surgery indicated for upper GI bleeding?