Upper GI Bleeding in a 58-Year-Old Male (Case 24)

Chapter 39 Upper GI Bleeding in a 58-Year-Old Male (Case 24)



Veeraiah Siripurapu, MD, Robert B. Noone, Jr., MD




Differential Diagnosis













Gastric ulcer/erosion Duodenal ulcer Gastritis
Esophageal varices Mallory-Weiss tear Gastric neoplasm



Speaking Intelligently


When I’m asked to see a patient with GI bleeding, I begin with resuscitation first. I follow the ABC’s, protect the airway from aspiration, obtain large bore IV access, and administer volume (crystalloid 3 : 1 for blood). I consider central monitoring with a central venous pressure (CVP) catheter, and I place a Foley catheter for monitoring urine output. I insert an NG tube for gastric lavage (if bloody, approximately 93% predictive of upper GI source), remembering that a duodenal site of bleeding may still be possible with a negative gastric lavage.


Endoscopy is the initial diagnostic test and may be therapeutic. The three most popular methods to achieve hemostasis via endoscopy are injection therapy, coaptive coagulation, and laser phototherapy. The need for surgical intervention and timing will depend on endoscopic findings.



PATIENT CARE



Clinical Thinking



• When suspecting a GI bleed, ask yourself, is this an upper or a lower GI bleed? An upper GI bleed is defined as proximal to the ligament of Treitz. Upper GI bleeding is four times as common as lower GI bleeding. While evaluating the source of bleeding, remember to stabilize the patient.


History



• Explore the bleeding hx: Is there frank bloody emesis, coffee ground emesis, melanotic stool, or hx of chronic anemia?

• Is there associated abdominal pain?

• Explore the past medical hx with attention to the differential:
• Find out about a hx of NSAID use or Helicobacter pylori infection.

• Alcohol abuse or other conditions that cause cirrhosis (HepC/Hep B/genetic conditions) could result in varices.

• Forceful emesis or sharp thoracic pain could suggest a Mallory-Weiss tear.

• Early satiety or weight loss may be a clue to a cancer dx.

• Note that melena (70%) and hematemesis (50%) are the most obvious presentations of the upper GI bleed; other symptoms include epigastric pain (40%), presyncope (40%), heartburn (20%), and weight loss (10%).


Physical Examination


There is no definitive trademark sign that suggests an etiology for upper GI bleed; the following findings may suggest a disease process:


• Inspection: Is the patient thin or malnourished (think cancer/alcohol) or jaundiced, or are there stigmata of chronic liver disease such as spider angiomas, asterixis, or clubbing (think cirrhosis with varices)?

• Abdominal scars may suggest past gastric or aortic surgery.

• Palpation: Assess for epigastric tenderness. Is the liver edge palpable or nodular? Always examine for lymphadenopathy. Supraclavicular adenopathy (Virchow’s node) or periumbilical adenopathy (Sister Mary Joseph’s nodule) may be a sign of advanced gastric cancer.


PATIENT CARE



Tests for Consideration
























• CBC: Hemoglobin and platelet count
 $35

• BUN/creatinine: A ratio >36 in the absence of renal failure is suggestive of upper GI bleeding
 $45

• LFTs: May give an idea of hepatic cirrhosis
 $65

• Amylase/lipase: Elevated with pancreatitis and intestinal perforation
 $25

• PT/INR/PTT: Check for coagulopathy: medication related or from hepatic failure.
 $55

• Type and cross-match: Blood needs to be available for resuscitation. [Note: Transfusion requirement is a criterion for surgical intervention and a risk factor for mortality (>5 units = 57% likelihood of surgery, 43% risk of mortality).]
 $68



IMAGING CONSIDERATIONS









→ Barium swallow/upper GI study: Can show erosive esophagitis, gastric mass, or peptic ulceration. May be able to show esophageal varices. Has largely been replaced by upper endoscopy.
 $500





















Clinical Entities Medical Knowledge
Peptic Ulcer Disease
PΦ Peptic ulcer disease is caused by a hyperacidic state or by weakened mucosal defenses; usually associated with the presence of helicobacter pylori bacteria.
TP Both gastric and duodenal ulcers are likely to present with melena, hematemesis, and/or epigastric pain. Duodenal ulcers are most common, but incidence of bleeding identical for either. Arterial erosion in ulcer base with vessel greater than 1.5 mm increases mortality.
Dx Endoscopy findings. Biopsies performed to rule out malignant potential. Obtain H. pylori titers/biopsy sample to initiate medication if so required.
Tx 80% of ulcer bleeds will stop spontaneously. Endoscopic therapy with injection, heater probe, bipolar cautery, or clip application may be effective. Proton pump inhibitors used as adjunct for active healing and prevention. Rebleeds can be treated with endoscopy, but failure of such demands surgical intervention. Choices would be selective vagotomy, vagotomy and pyloroplasty, or vagotomy and antrectomy. Choice depends on speed with which operation can be performed, stability of patient, rate of recurrence, and experience of the surgeon. See Sabiston 46, Becker 26.


















Variceal Bleeds
PΦ Increased portal vein pressure greater than 10 mmHg defines portal hypertension. Varices arise from the diverted flow to portosystemic shunts. A shunt through the coronary vein/esophageal submucosal plexus off the portal vein results in esophageal varices. 50% bleed at some point in a patient’s lifetime, with a mortality rate of 30% to 50%. Patients with normal liver function have better survival rates. Four recognized collateral sites from the portal vein are (1) esophageal submucosal plexus, (2) coronary vein of stomach, (3) retroperitoneal-umbilical system, and (4) the hemorrhoidal system.
TP Typically painless hematemesis. May present as a massive hemorrhage with signs of shock, necessitating aggressive resuscitation.
Dx Dx is by endoscopy in a patient with a clinical suspicion of cirrhosis.
Tx Tx is broadly summarized as (a) pharmacologic therapy, (b) endoscopic therapy, (c) tamponade, (d) decompressive therapy (radiological, surgical), and (e) liver transplantation. The modalities include:
a. IV vasopressin, terlipressin, or somatostatin or one of its analogs.

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Mar 20, 2017 | Posted by in GENERAL SURGERY | Comments Off on Upper GI Bleeding in a 58-Year-Old Male (Case 24)

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