Upper GI Bleeding Protocols:

4B Ri

Epidemiology:

Upper: Lower GI bleeding = 5:1 Incidence: 50-100 per 100,000 pts. 100 per 100,000 hospital admission. 30% pts are older than 65 years. 80% are self-limited. 20% of pts who have recurrent bleeding (within 48-72 hrs) have poor prognosis.

Why upper GI bleeding?

More than 75% of ICU patient will have gastroduodenal lesions by endoscopy. Highest risk are: intubated patients; multiorgan failure, coagulopathy, sepsis, or extensive burns; head trauma or neurosurgery. Decreased mucosal blood flow mucosa to develop erosions or ulcerations.

Prophylaxis to stress ulcer:

Frequency declined over the past 20 years. (but not because of prophylaxis) Prophylaxis: -- H2 receptor antagonist: (Zantac, Gaster) -- Sucralfate (Ulsanic): lower incidence of nosocomial pneumonia. -- Proton Pump Inhibitor: (Losec, Pantoloc) higher incidence of nosocomial pneumonia.

Acute GI bleeding:
Immediate Assessment

Stabilization of hemodynamic status

Identify the source of bleeding

Stopping the active bleeding

Treat the underlying

Prevent recurrent bleed

Initial assessment:
1. Orthostatic changes of BP and HR. 2. History: Drugs history (NSAID, antithrombotic agents, Calcium channel blocker) 3. P.E.:heart, lung, and abdominal examinations, skin and mucus membranes. 4. Lab: CBC, Plt, coagulation profile. 5. Significant of GI blood loss: hematemesis, melena, or hematochezia.

Initial resuscitation + stabilization:

1. IV route in unstable patient for colloid solution. 2. Oxygen support. 3. Monitor urine output. 4. Blood transfusion. (maintain Hct at 30% in the elderly, 20-25% in younger pt, 25-28% in portal HTN.)

Identify bleeding source:

1. N-G tube differentiate between upper/lower GI bleeding. 2. Lavage color and rapidity of clearing; clear the field for esophagogastroduodenoscopy (EGD). 3. Initial EGD: within 24 hrs of bleeding.

Stopping the active bleeding:

Most effective method: endoscopic therapy Laser therapy: requires significant training. Thermal contact: mono- (greater tissue injury) and bipolar electrocautery, heater probes. Widely available and require minimal training. Injection therapy: epinephrine (1:10,000 dilution) with or without various sclerosant solutions. ( or + thermal contact). Rubber band ligation, metal clips.

Treating the underlying

Causes of acute Upper GI bleeding Ulcers: duodenal, gastric, esophageal Varices: esophageal, gastric, duodenal Mallory-Weiss tear Dieulafoy's lesions Arteriovenous malformations Portal hypertensive gastropathy Gastric antral vascular ectasias (watermelon stomach) Erosions Aorto-enteric fistula Crohn's disease Malignancy Hemobilia Pancreatic source Foreign body ingestion or bezoar Caustic ingestion No site found

Ulcers:

Ulcers:

High Risks: 1. active bleeding 2. visible vessels 3. recent bleeding (overlying clot) Lower Risks: 1. flat red or black spot 2. clean based ulcer

Ulcers:
1. Two separate EGD. 2. Angiography with embolization: empirical embolization can be done. 3. Surgical therapy: oversewing and resection of the bleeding site. 4. Medications to heal ulcers: PPI-- decrease recurrent bleeding rate. H2 receptor antagonist not beneficial.. H. pylori present antibiotics, prevent rebleeding.

Varices:

Hepatic venous pressure gradient > 12 mmHg. In esophageal variceal , prefer variceal ligation (with multiband ligator) over endoscopic sclerotherapy. In gastric varices, injection with a sclerosing agent will be more beneficial than band ligation.

Varices:

1.
2. 3.

4.

Medical therapy (could combine endoscopy): Vasopressin: side effect-- Myocardial infarction 25%. Combine with NTG. Octreotide (somatostatin analog) Nonselective -blockers, (haldolol or propranolol) decreased rebleeding rate. -blockers with nitrates in stable pt.

Varices:

TIPS (transjugular intrahepatic porto-systemic shunt): transjugular approach connect portal v. and hepatic v. reduce portal v. pressure gradient to < 12-15 mmHg. Patent a repeat endoscopy should be done to evaluate for an alternative source of bleeding. Complications include: bleeding, dye-induced renal failure, hemolysis, stent migration, and puncture of the gallbladder or other organs adjacent to the liver.

Varices:

Balloon tamponade: 1. Intubation 2. Gastric balloon 3. Esophageal balloon Balloon should be inflated for less than 24 hrs. 75% rebleeding rate after balloon deflation. Antibiotic prophylaxis for cirrhosis pt: norfloxacin, ciprofloxacin. Maintain Hct at 25-28 %.

Preventing recurrent bleeding:

Predictors of Rebleeding: 1. Older age 2. Shock/hemodynamic instability/orthostasis 3. Comorbid disease states (e.g., coronary artery disease, congestive heart failure, renal and hepatic diseases, cancer) 4. Specific endoscopic diagnosis (e.g., GI malignancy) 5. Use of anticoagulants/coagulopathy 6. Presence of a high-risk lesion (e.g., arterial bleeding, nonbleeding, visible vessel and clot)

References:

Critical issues in digestive diseases Clinics in Chest Medicine Volume 24 Number 4 December 2003 An annotated algorithmic approach to upper gastrointestinal bleeding Gastrointestinal Endoscopy Volume 53 Number 7 June 2001 Management principles of gastrointestinal bleeding Primary Care; Clinics in Office Practice Volume 28 Number 3 September 2001

Thank you for your attention!!