Acute Upper Gastrointestinal Bleed

Chapter 8 Acute Upper Gastrointestinal Bleed



Key Points



General


1 Acute upper gastrointestinal (GI) bleed has a mortality rate of approximately 10%.

2 Gastroduodenal ulcers are the most common cause of acute upper GI bleeding.

3 Gastroesophageal variceal hemorrhage is common in patients with cirrhosis and has a high mortality rate.

Management


4 History and physical examination should focus on hemodynamic parameters and risk factors for upper GI bleeding.

5 Laboratory testing should include a complete blood count, electrolytes, blood urea nitrogen, creatinine, type and cross, prothrombin time (PT), and activated partial thromboplastin time (PTT).

6 Barium studies of the upper and lower GI tract should be avoided.

7 Use of nasogastric lavage erythromycin (1–3 mg/kg IV) or metoclopramide (10 mg IV) may improve endoscopic visualization.

8 High-dose proton pump inhibitors should be started. Octreotide should be administered if the patient has findings suggestive of cirrhosis.

9 Angiography or surgery should be considered for ulcer hemorrhage refractory to maximal medical and endoscopic therapy.

10 Transjugular intrahepatic portosystemic shunt (TIPS) placement should be considered for esophageal variceal bleeding, refractory to maximal medical and endoscopic therapy, or for isolated gastric variceal bleeding.



Definitions


Upper gastrointestinal (GI) bleeding is defined as bleeding from a source proximal to the Ligament of Treitz. Melena, the passage of black, tarry stools per rectum, is often associated with an upper GI bleed. However, melena may occur in patients with a small bowel or proximal right-sided colon bleeding source. Patients can pass bright red blood per rectum with a brisk upper GI bleed.


Upper GI bleeding occurs five times more often than lower GI bleeding, and is more common in male and elderly patients. There are 400,000 hospitalizations annually in the United States for upper GI bleeding Despite advances in therapy, the mortality rate for upper GI bleeding ranges from 4% to 14%, largely due to the higher mortality rate in elderly patients with numerous serious comorbidities (30%–44% of upper GI bleeding occurs in patients over the age of 65). Mortality from upper GI bleeding is 0.4% in patients under the age of 60 and rises to 11% in patients over the age of 80.


The major causes of upper GI bleeding are gastric and duodenal ulcers, esophageal varices, and Mallory-Weiss tears. Other less common causes are Dieulafoy’s lesions (an arterial branch protruding through a mucosal defect, most commonly found in the gastric fundus), arteriovenous malformations, esophagitis, and neoplasms (Box 8-1).



Box 8-1 Causes of Acute Upper GI Bleeding


Rockey DC. Gastrointestinal Bleeding. In: Feldman M, Friedman LS, and Sleisenger MH, editors. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 7th ed. Philadelphia. WB Saunders; 2002. p. 215. Reproduced with permission, 2005.



Common


Gastroduodenal ulcer


Esophageal varices


Mallory-Weiss tear



Less Common


Dieulafoy’s lesions


Vascular ectasia


Portal hypertensive gastropathy


Gastric antral vascular ectasia


Neoplasia


Esophagitis


Gastric erosions



Infrequent


Esophageal ulcers


Erosive duodenitis


Aortoenteric fistula


Hemobilia


Pancreatic source


Crohn’s disease



Initial Evaluation



History


The history should focus on determining risk factors and potential etiologies for gastrointestinal hemorrhage, and assessment of rebleeding risk. In addition, potential complications due to coexisting medical conditions (such as myocardial ischemia in patients with coronary artery disease) should also be evaluated.


• Potential etiologies:
image Helicobacter pylori infection or history of gastric or duodenal ulcers

image Nonsteroidal anti-inflammatory drug (NSAID) use

image Liver disease: potential sources include esophageal or gastric varices. Portal hypertensive gastropathy and gastric antral vascular ectasia usually do not present with acute upper GI bleeding.

image Nausea and vomiting prior to hematemesis suggest Mallory-Weiss tears as a potential etiology.

image Weight loss or anorexia may suggest malignancy.

Rebleeding risk is highest in elderly patients with many comorbidities, and those with persistent hypotension, hematemesis, or hematochezia (Box 8-2). There are many prognostic scoring systems, but their overall reliability remains low.



Box 8-2 Risk Factors for Rebleeding and Prognostic Variables



• Age > 60

• Severe or numerous comorbidities, such as coronary artery disease, renal failure, congestive heart failure, or cirrhosis

• Hypotension or shock at presentation

• Requiring ≥ 6 units of packed red blood cells

• Coagulopathy

• Red blood on nasogastric lavage, hematemesis, or hematochezia

• Bleeding or rebleeding occurring during hospitalization

• Presence of a high-risk lesion on endoscopy, such as arterial bleeding, visible vessel, or clot


Physical Examination



• Orthostatic vital signs should be taken. A drop in blood pressure greater than 10 mmHg or an increase in pulse greater than 10 bpm indicates blood loss of greater than 800 mL. Resting tachycardia or hypotension suggests blood loss greater than 1500 mL.

• Cardiovascular evaluation, including electrocardiogram (EKG), should be performed, as necessary.

• Abdominal examination should focus on identifying stigmata of chronic liver disease and any focal tenderness. Digital rectal examination should be performed.


Initial Management


See Fig. 8-1 and Fig. 8-2 for an algorithmic approach to acute upper GI bleeding, with details for gastroduodenal ulcer and gastroesophageal variceal hemorrhage.


image

Figure 8-1 Algorithm for acute GI bleeding. CBC = complete blood count, PT = prothrombin time, PTT = activated partial thromboplastin time, NG = nasogastric, ICU = intensive care unit. Rockey DC. Gastrointestinal Bleeding. In: Feldman M, Friedman LS, and Sleisenger MH, editors. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 7th ed. Philadelphia. WB Saunders; 2002. p. 216. Adapted with permission, 2005.


image

Figure 8-2 Esophageal variceal hemorrhage treatment. TIPS = transjugular intrahepatic portosystemic shunt. Rockey DC. Gastrointestinal Bleeding. In: Feldman M, Friedman LS, and Sleisenger MH, editors. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease, 7th ed. Philadelphia. WB Saunders; 2002. p. 216. Adapted with permission, 2005.


Hemodynamically stable patients with acute upper GI bleeding may be managed in a telemetry unit, whereas those with hemodynamic instability or persistent bleeding should be admitted to the intensive care unit.


Placement of two large-bore IV catheters, determination of hemodynamic status, and volume resuscitation (if necessary) should be performed, and patients should be kept NPO. Laboratory testing should include:


• Type and cross for packed red blood cells, and, if necessary, platelets and fresh frozen plasma.

• Complete blood count: To determine hematocrit and rule out thrombocytopenia. The hematocrit may initially be normal, and may take 12–24 hr to reflect blood loss.
image Hematocrit should be maintained around 30%. In patients with esophageal variceal hemorrhage, the hematocrit should not exceed 30%. At higher hematocrit levels, portal pressure will rise and increase the risk of rebleeding.

image Platelet count should be kept above 50,000/μL.

• Basic metabolic panel should be obtained. A BUN: Creatinine ratio greater than 20 suggests the possibility of an upper GI source (although this may also be seen in a patient with a “pre-renal” cause of acute renal failure).

• Prothrombin time (PT) and activated partial thromboplastin time (PTT): Presence of any coagulopathy should be corrected.
image International Normalized Ratio (INR) > 1.5 should be corrected with fresh frozen plasma initially, and, if necessary (i.e., patients on Coumadin with supratherapeutic INR levels) Vitamin K1, 10 mg given intravenously over 20 to 60 minutes.

EKG and cardiac enzymes should be obtained in patients with risk factors for coronary artery disease.


Nasogastric lavage with tap water should be performed in patients with upper GI bleeding.


High-dose proton pump inhibitors, such as omeprazole 40 mg orally twice a day, should be initiated. Intravenous administration may also be used (i.e., omeprazole 80 mg bolus, then 8 mg/hr for 72 hr). A neutral pH enhances clot formation and decreases clot breakdown.



Radiologic Imaging


Plain films of the abdomen may be obtained to rule out complications, such as perforation, but have little role in the diagnosis and management of upper gastrointestinal bleeding.


Barium studies may obscure visualization of a bleeding source during upper endoscopy and should not be performed.

Related posts:

  1. Urinary Tract Infections
  2. Diabetic Ketoacidosis
  3. Anemia
  4. Cellulitis and Diabetic Foot Infections

Stay updated, free articles. Join our Telegram channel
Tags:
Mar 25, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Acute Upper Gastrointestinal Bleed

Full access? Get Clinical Tree
Get Clinical Tree app for offline access