Upper GI Bleeds

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75% of all gastrointestinal bleeds are classified as upper GI bleeds. An upper GI bleed is defined as a bleeding taking place proximal to the ligament of Treitz, a suspensory ligament where the fourth portion of the duodenum transitions to the jejunum.

Etiology

·      Above the GE junction

o   Epistaxis

o   Esophageal varices (10~30%)

o   Esophagitis

o   Esophageal cancer

o   Mallory-Weiss tear (10%)

·      Stomach

o   Gastric ulcer (20%)

o   Gastritis (20%)

o   Gastric cancer

o   Gastric antral vascular ectasia (rare condition where small blood vessels are dilated around the antrum of the stomach—resulting in “watermelon stomach”; associated with cirrhosis, chronic kidney failure, and collagen vascular disease.)

o   Dieulafoy’s lesion (very rare where a large, tortuous arteriole in the submucosa of the stomach erodes and bleeds)

·      Duodenum

o   Ulcer in bulb (25%)

o   Aortoenteric fistula: rare and lethal; usually only if previous aortic graft has been done

·      Coagulopathy (drugs, renal disease, liver disease)

·      Vascular malformation

Clinical features includes patient noticing blood is coming out his/her GIT. This can be in a variety of forms. In order of decreasing severity of the bleed: hematochezia (blood—usually fresh—passed through anus, can be along with or mixed in stools), hematemesis (vomiting up blood—usually fresh), coffee ground emesis (vomiting old blood), melena (old blood passed through anus), and occult blood in stool.

ALWAYS ask about NSAID, aspirin, or anticoagulant drug use!

Initial management

1.     Resuscitate patient with 2 large bore IVs, IV fluids, monitor vital signs

2.     Send blood for CBC, cross and type, platelets, prothrombin time (PT), partial thromboplastin time (PTT), electrolytes, BUN, creatinine, and liver function tests.

3.     Keep the patient fasting

4.     NGT can be considered to determine upper vs. lower GIT bleeding

5.     Endoscopy is done to establish bleeding site and treat lesion

·      For bleeding peptic ulcers, the most commonly used method of controlling bleeding is injection of epinephrine around bleeding point and thermal hemostasis via bipolar electrocoagulation or heater probe. Less often thermal hemostasis may be used alone. Injection alone is not recommended

·      Endoclips

·      Hemospray—mineral blend powder specifically used for endoscopic hemostasis. It absorbs water to form a cohesive and adhesive mechanic barrier around the bleeding site.

6.     Administer PPI (IV) to decrease the risk of rebleeding if endoscopic predictors of rebleeding are seen

·      PPI is given to stable the clot, not to accelerate ulcer healing

·      If given before endoscopy, it decreases need for endoscopic therapeutic intervention

7.     For variceal bleeds, administer octreotide 50 micrograms loading dose followed by constant infusion of 50 micrograms/hour

8.     Consider IV erythromycin or metoclopramide to accelerate gastric emptying prior to gastroscopy to remove clots from stomach.

Review—PT vs. PTT

Both PT and PTT are tests done to assess whether the patient has a coagulation problem. PTT stands for partial thromboplastin time (sometimes also called activated partial thromboplastin time APTT) and measures the function of the intrinsic coagulation pathway; PT stands for prothrombin time and measures the function of the extrinsic coagulation pathway. The way to remember the difference is this: the 2 T are no longer together à they are “exes” à PT measures extrinsic pathway. Why are they not together anymore? Because one of them got the “7 year itch” à PT/extrinsic pathways deals with factor VII while PTT deals with all other factors.

Prognosis

·      80% stop spontaneously

·      Peptic ulcer rebleeding occurs in 25% of patients. If there is no rebleeding, mortality is low 2%; however, it rises to 10% if rebleeding occurs.

·      Endoscopic predictors of rebleeding includes: spurt or ooze, visible vessel, or fibrin clot

·      H2-antagonists have little impact on rebleeding rates and need for surgery

·      Esophageal varices have a high rebleeding rate (55%) and mortality (29%)

·      Patients can be sent home if:

o   They are clinically stable

o   Bleeding was minor

o   No comorbidities

o   Endoscopy shows clean ulcer with no predictors of rebleeding