| GI UGI
BLEEDING SX & DX |
RX See also
Variceal Bleeding |
Capsule Endoscopy |
Upper GI bleeding is arbitrarily defined
as hemorrhage from a source proximal to the ligament of Treitz (i.e., the
esophagus, stomach, or duodenum). Hematemesis essentially always reflects
upper GI bleeding, and stools may range from black (melena) to bright red
(hematochezia), depending on rates of bleeding and intestinal transit.
Esophagitis, esophageal erosion, trauma, varices or cancer or erosion
Gastritis or Gastric Ulceration (Ulcer, Varices, Carcinoma, lymphoma,
polyps, leiomyoma, leiomyosarcoma, AV malformation,
telangiectasia/Osler-Weber-Rendu disease, Mallory-Weiss tear
Peptic Ulcer Disease: Duodenal ulcer, duodenal or jejunal diverticula; trauma
, or angiodysplasia
Crohn's Disease with Ulceration
Hematemesis, melena (>60mL of blood), decreased Hgb & Hct, decreased
NG tube aspiration & irrigation,
(Mesenteric) angiography ( for >0.5 mL/min bleed)
Radiolabeled Tc99 red cell scanning (for >0.1 mL/min) - less specific.
Blood loss of <500 mL is rarely associated with systemic signs except
in elderly or in anemic pts.
Orthostatic hyotension >10 mmHg usually indicates a >20% reduction
in blood volume.
When blood blood loss approaches 40% of blood volume, shock frequently ensues.
Upper GI endoscopy or colonoscopy - to
identify the location of the bleed.
Selective visceral angiography is considered
when endoscopic therapy for an established lesion has failed and surgery
is not an option or when the site of an active bleed remains obscure after
endoscopy. An optimal examination with a high positive yield is best obtained
when there is active bleeding at rates exceeding 0.5 to 1 ml/min. Significant
complicationsincluding contrast reaction, acute renal failure, and
femoral artery thrombosishave been reported in approximately 9% of
cases. The reported sensitivity of angiography varies from 22% to 87%.
The specificity approaches 100%.
Technetium-99m-labeled red cell Scan should be considered when
active bleeding is suspected but endoscopy has been negative. Nuclear scans
can detect bleeding at rates that exceed 0.1 ml/min. On scans, however, pooled
blood may sometimes be mistaken for active bleeding, which contributes to
a reported false positive rate of about 22%. Upper GI bleeding may
be misdiagnosed as lower because of pooling in the distal ileum or right
colon. A positive result is more reliable when the scan is done early rather
than delayed (several hours later).
Endoscopic techniques that are currently available for examination of the
small bowel include push enteroscopy, wireless
capsule endoscopy, and intraoperative
Management of UGI Bleeding
Starting 2 large-bore IV lines for fluid & medication Rx.
NG tube placement for aspiration of stomach contents , lavage & monitoring
for acute bleeding.
Frequent vital signs & urine output monitoring.
Frequent Hgb & Hct; Protime, PTT, Type & cross-match red blood for
transfusion as needed.
*Gastric lavage with ice-cold water to stop
bleeding is potentially dangerous & has no role in modern mangement of
*Avoid antacids or sucralfate before endoscopy to
prevent obscuring the endoscopic view.
No food or drink by mouth.
IV fluid (saline, fresh frozen plasma, plasma protein
solution, or dextran) or blood transfusion as needed to maintain
stable vital signs & acceptable Hgb & Hct (about Hct of 30%).
IV Protonix (pantoprazole) 40 mg IV q12h daily;
Tagamet (cimetidine) 900 mg/day infusion or Zantac (ranitidine) 50 mg q6-8h
Upper Gastroduodenal endoscopy therapy to
evaluate the source of bleeding & to apply therapy (epinephrine
1:10,000 solution, hypertonic 1.8% saline, sclerotherapy with sclerosants
for varices, thermal coagulation or cauterization, clips or banding varices,
topical cyanoacrylate/Superglue, etc.)
Interventional radiology with selective
catheterization of the celiac axis & mesenteric arteries, & infusion
of vasopressin Rx.
Selective arterial embolization and selective vasoconstriction with
intra-arterial infusion of vasopressin are the methods currently available
for the control of major nonvariceal GI bleeding.
Intra-arterial vasopressin is the drug of choice for selective
vasoconstrictive therapy and is generally infused for a minimum of 24 hours.
It is associated with a 70% rate of bleeding control and an 18% rate of
rebleeding. Vasopressin may be ineffective when bleeding arises from large
arteries that do not constrict in response to therapy. A study comparing
embolization with vasopressin showed similar initial hemostasis rates but
a higher rebleeding rate with vasopressin.
Surgical Repair to stop the bleeding.
Despite the high overall success rate of endoscopic therapy in the treatment
of major GI bleeding, surgery is still indicated when (1) initial hemostatic
control cannot be achieved,
(2) rebleeding occurs despite repeated endoscopic sessions,
(3) a large (> 2 cm) penetrating ulcer is present,
(4) a vessel larger than 2 mm in diameter is visible within the culprit lesion,
(5) the ulcer is located in the posterior duodenal bulb (this location is
associated with the large gastroduodenal artery), and
(6) the patient requires substantial transfusion (i.e., four or more units
of blood over 24 hours). The choice of surgery depends on the location of
the bleed and the presence of comorbidities. Localization of the site of
bleeding is critical for surgical planning.
ACP Med 2006
Consensus Recommendations for Managing Patients with Nonvariceal Upper
Gastrointestinal Bleeding -
Alan Barkun, MD, MSc; Marc Bardou, MD, PhD; and John K. Marshall,
MD, MSc for the Nonvariceal Upper GI Bleeding Consensus Conference Group*
Internal Medicine 18 November 2003 | Volume 139 Issue 10 | Pages
Major Causes of Upper & Lower Gastrointestinal
Peptic ulcer disease
Esophagitis or esophageal ulceration
Diaphragmatic hernia (Cameron erosions)
Inflammatory bowel disease
Cancers and neoplasms
Primary lesion at any site
Metastatic deposits at any site
Gastrointestinal stromal tumors
Nonsteroidal anti-inflammatory drugs
Management of Overt Major GI Bleeding
REF: ACP Medicine 2006
Management of Overt Minor GI Bleeding
Clinical High-Risk Criteria for Rebleeding and Mortality
Advanced age (70 yr)
Major organ comorbidities
Bright-red hematemesis in patient with liver cirrhosis
Hypotension (systolic blood pressure < 100 mg Hg)
Tachycardia (heart rate > 100 bpm)
Orthostasis (BP drop > 20 mm Hg; HR rise > 20 bpm)
Hemoglobin < 10 g/dl or drop of 2 g/dl
4 units of blood transfused in 24 hr