Upper GI Bleeding

Upper GI Bleeding Presenter:Dr. AbdulazizAlmusallam Moderator: Dr. Maher Morris

Objectives • To Know: • The Definition • Causes • Management Plan

Upper GI bleeding • Bleeding that arises from the GI tract proximal to the ligament of Treitz. • Accounts for nearly 80% of significant GI hemorrhage.

The causes of upper GI bleeding • Best categorized as: Nonvariceal Bleeding Or Bleeding related to portal hypertension

The nonvariceal causes account for about 80% of such bleeding • PUD is the most common cause. • In the remaining 20% of patients, most of them have cirrhosis and portal hypertension • which can lead to the development of: - Gastroesophagealvarices, -Isolated gastric varices, -Hypertensive portal gastropathy, All can be the source of an acute upper GI bleed.

The patients with cirrhosis are at high risk for developing variceal bleeding, • Even in these patients, nonvariceal sources account for most of the episodes of GI hemorrhage.[ • Because of the greater morbidity and mortality of variceal bleeding, • Patients with cirrhosis is generally assumed to have variceal bleeding and appropriate therapy initiated

NONVARICEAL BLEEDING (80%) PORTAL HYPERTENSIVE BLEEDING (20%) • Peptic ulcer disease 30-50% • Mallory-Weiss tears 15-20% • Gastritis or duodenitis 10-15% • Esophagitis 5-10% • Arteriovenous malformations 5% • Tumors 2% • Other 5% • Gastroesophagealvarices >90% • Hypertensive portal gastropathy <5% • Isolated gastric varices Rare Common Causes of Upper Gastrointestinal Hemorrhage

Upper GI Endoscopy • The foundation of diagnosis and management of patients with an upper GI bleed is an EGD. • Multiple studies have demonstrated that early EGD (within 24 hours) results in: • Reductions in blood transfusion requirement • Decrease in the need for surgery • Shorter length of hospital stay

Upper GI Endoscopy • Endoscopic identification of the source of bleeding also permits: • Estimate the risk for subsequent or persistent hemorrhage • Facilitating operative planning • 20% to 35% of patients undergoing EGD will require a therapeutic endoscopic intervention. • 5% to 10% will eventually require surgery.

Although the best tool for localization of the bleeding source is an EGD • 1% to 2% of patients the source cannot be identified • Excessive blood impair visualization of the mucosal surface. • Aggressive lavage of the stomach with room temperature normal saline solution before the procedure can be helpful.

Recent evidence has suggested that a single bolus injection of intravenous erythromycin, stimulates gastric emptying, and can significantly improve visualization. • If identification of the source is still not possible: • Angiography may be appropriate in the reasonably stable patient

Although operative intervention must be seriously considered if the blood loss is extreme or the patient hemodynamically unstable. • Tagged RBC scan is seldom necessary with a confirmed upper GI bleed. • Contrast studies are usually contraindicated because they will interfere with subsequent maneuvers.

Specific Causes of Upper Gastrointestinal Hemorrhage Nonvariceal Bleeding

Peptic Ulcer Disease • PUD is the most frequent cause of upper GI hemorrhage. • Accounting for about 40% of all cases. • About 10% to 15% of patients with PUD develop bleeding at some point in the course of their disease. • Bleeding develops as a consequence of acid-peptic erosion of the mucosal surface.

Peptic Ulcer Disease • Although chronic blood loss is common with any ulcer, • Significant bleeding results when there is involvement of an artery: • Either of the submucosa • Or, penetration of the ulcer a larger vessel.

Peptic Ulcer Disease • Duodenal ulcers are more common • But gastric ulcers bleed more commonly • The most significant hemorrhage occurs when: • duodenal or gastric ulcers penetrate into branches of the gastroduodenal artery or left gastric artery.

Management • Management Strategies depend on the appearance of the lesion at endoscopy. • Endoscopic therapy is instituted if: • Bleeding is active • Bleeding has already stopped but there is a significant risk for rebleeding.

The ability to predict the risk for rebleeding permits: • Prophylactic therapy • Closer monitoring • Earlier detection of hemorrhage in high-risk patients. • The Forrest classification assess the risk based on endoscopic findings, and stratify the patients into low-, intermediate-, and high-risk groups

CLASSIFICATION REBLEEDING RISK • Grade Ia: Active, pulsatile bleeding • Grade Ib: Active, nonpulsatile bleeding • Grade IIa:Nonbleeding visible vessel • Grade IIb: Adherent clot • Grade IIc: Ulcer with black spot • Grade III: Clean, nonbleeding ulcer bed • High • High • High • Intermediate • Low • Low Forrest Classification of Endoscopic Findings and Rebleeding Risks in Peptic Ulcer Disease

Algorithm for the diagnosis and management of nonvariceal upper GI bleeding

Endoscopic therapy • Recommended in: 1)active bleeding 2)visible vessel (Forrest I to IIa). • In cases of an adherent clot (Forrest IIb): the clot is removed and the underlying lesion evaluated.

Endoscopic therapy • Ulcers with a clean base or a black spot, secondary to hematin deposition, are generally not treated endoscopically.

Medical Management In cases of an acute peptic ulcer bleed • PPIs: • reduce the risk for rebleeding • the need for surgical intervention • patients with a suspected or confirmed bleeding ulcer are started on a PPI.

Association between H. pylori infection and bleeding • Unlike perforated ulcers, which are commonly associated with H. pylori infection, • the association between H. pylori infection and bleeding is less strong. • Only 60% to 70% of patients with a bleeding ulcer test positive for H. pylori.

Association between H. pylori infection and bleeding • This has generated some controversy as to the importance of H. pylori treatment in patients with a bleeding peptic ulcer. However, • several studies and a large meta-analysis have shown that H. pylori treatment and eradication, in patients who test positive for the infection, results in decreased rebleeding.

Importantly • After the H. pylori has been eradicated: • No need for long-term acid suppression. • No increased risk for further bleeding.

Patients taking ulcerogenic medications • Such as NSAIDs or SSRIs, • Who present with a bleeding GI lesion • These medications are stopped, and • The patient is started on a nonulcerogenic alternative.

Endoscopic options Available endoscopic options include: • Epinephrine injection • Heater probes and coagulation • Application of hemoclips.

Epinephrine injection • Epinephrine injection (1:10,000) to all four quadrants of the lesion is very successful in controlling the hemorrhage. • It has been shown that large-volume injection (>13 mL) is associated with better hemostasis, • This suggesting that the endoscopic injection works in part by compressing the bleeding vessel and inducing tamponade.

Combination therapy • Epinephrine injection alone is associated with a high rebleeding rate • The standard practice is to provide combination therapy. • This usually means the addition of thermal therapy to the injection.

The thermal energy • A combination of injection with thermal therapy achieves hemostasis in 90% of bleeding PUD cases. • The sources of thermal energy can be heater probes, monopolar or bipolar electrocoagulation, laser, or argon plasma coagulator.

The thermal energy • The most commonly used therapies are :- • Electrocoagulation for bleeding ulcers • Argon plasma coagulator for superficial lesions.

Hemoclips • The role of hemoclips is less clear • Several studies have reported mixed results. • Hemoclips, which can be difficult to apply, may be particularly effective when dealing with a spurting vessel because they provide immediate control of hemorrhage.

Rebleeding of an ulcer • Rebleeding of an ulcer is associated with a significant increase in mortality • Careful observation of patients at high risk for rebleeding is important.

Second Endoscopy • In those that rebleed, the role of a second attempt at endoscopic control has been controversial but recently validated. • Recent study demonstrated that a second attempt at endoscopic hemostasis is successful in 75% of patients.Although this will fail in 25% of patients who will then require emergent surgery • There is no increase in morbidity or mortality. Therefore, most clinicians would now encourage a second attempt at endoscopic control before surgical intervention.

Surgical Management • Despite significant advances in endoscopic therapy, about 10% of patients with bleeding ulcers still require surgical intervention for effective hemostasis • several clinical and endoscopic parameters have been employed to identify patients at high risk for failed endoscopic therapy

Indications for Surgery in Gastrointestinal Hemorrhage • Hemodynamic instability despite vigorous resuscitation (>6 units transfusion) • Failure of endoscopic techniques to arrest hemorrhage • Recurrent hemorrhage after initial stabilization (with up to two attempts at obtaining endoscopic hemostasis) • Shock associated with recurrent hemorrhage • Continued slow bleeding with a transfusion requirement exceeding 3 units/day

Surgical Management • The first priority at operation is control of the haemorrhage. • Then • A decision must be made regarding the need for a definitive acid-reducing procedure.

Surgical Management(Duodenal Ulcer) • The first step in the operation for duodenal ulcer is exposure of the bleeding site. • Because most of these lesions are in the duodenal bulb, longitudinal duodenotomyor duodenal pyloromyotomyis performed. • Hemorrhage can typically be controlled initially with pressure and thendirect suture ligation with nonabsorbable suture.

Surgical Management(Duodenal Ulcer) • When ulcers are positioned anteriorly, typically four-quadrant suture ligation suffices. • A posterior ulcereroding into the pancreaticoduodenal or gastroduodenal artery may require suture ligature of the vessel proximal and distal to the ulcer.

Surgical Management(Duodenal Ulcer) • After the bleeding has been addressed, a definitive acid-reducing operation is considered. • With the identification of the role of H. pylori infection in the pathogenesis of duodenal ulcers • There is an argument that simple closure and subsequent treatment for H. pylori is sufficient to prevent recurrence.

Surgical Management(Duodenal Ulcer) • At the present time an acid-reducing procedure still appears appropriate in most patients. • The choice between various operative procedures has been based on the hemodynamic condition of the patient and whether there is a long-standing history of refractory ulcer disease.

Surgical Management(Duodenal Ulcer) • As the pylorus has often been opened in a longitudinal fashion to control the bleeding, • Closure as a pyloroplasty combined with truncalvagotomyis the most frequently used operation for bleeding duodenal ulcer.

Truncalvagotomy

Surgical Management(Duodenal Ulcer) • There is some evidence to suggest that parietal cell vagotomy may represent a better therapy for a bleeding duodenal ulcer in the stable patient • Surgeon experience with this procedure may be the determining factor.

Surgical Management(Duodenal Ulcer) • In a patient who has a known history of refractory duodenal ulcer disease or who has failed more conservative surgery, antrectomy with truncalvagotomy may be more appropriate. • This procedure is more complex and is rarely undertaken in a hemodynamically unstable patient.

Surgical Management(Bleeding gastric ulcers) • Similar to bleeding duodenal ulcers, control of bleeding is the immediate priority • This may require gastrotomy and suture ligation, which, if no other procedure is performed, is associated with about a 30% risk for rebleeding. • In addition, because of the approximate 10% incidence of malignancy, gastric ulcer resection is generally indicated.

Surgical Management(Bleeding gastric ulcers) • Simple excision alone is associated with rebleeding in as many as 20% of patients, • so that distal gastrectomy is generally preferred, • although excision combined with vagotomy and pyloroplasty may be considered in the high-risk patient.

Surgical Management(Bleeding gastric ulcers) • Bleeding ulcers of the proximal stomach near the gastroesophageal junction are more difficult to manage. • Proximal or near-total gastrectomy is associated with a particularly high morbidity in the setting of acute hemorrhage.

Surgical Management(Bleeding gastric ulcers) • Options include: • Distal gastrectomycombined with resection of a tongue of proximal stomach to include the ulcer Or • Vagotomy and pyloroplasty combined with either wedge resection or simple oversewing of the ulcer.

Upper GI Bleeding