TOC |  STAT | GI UGI BLEEDING    SX & DX  |  RX    See also  Variceal Bleeding  |  Capsule Endoscopy  | ugi_bleedingRx2008.pdf  

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.

Diff-Dx:
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

SX & Dx:

Diagnostic Tests:

  1. Upper GI endoscopy or colonoscopy - to identify the location of the bleed.
  2. 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 complications—including contrast reaction, acute renal failure, and femoral artery thrombosis—have been reported in approximately 9% of cases.  The reported sensitivity of angiography varies from 22% to 87%. The specificity approaches 100%.
  3. Radionuclide 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).
  4. Endoscopic techniques that are currently available for examination of the small bowel include push enteroscopy, wireless capsule endoscopy, and intraoperative enteroscopy.

Management of UGI Bleeding

  1. No food or drink by mouth.
  2. 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%).
  3. IV Protonix (pantoprazole) 40 mg IV q12h daily; Tagamet (cimetidine) 900 mg/day infusion or Zantac (ranitidine) 50 mg q6-8h IV
  4. 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.)
  5. 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.  
  6. 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.

Ref:
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*
Annal of Internal Medicine  18 November 2003 | Volume 139 Issue 10 | Pages 843-857

              

Major Causes of Upper & Lower Gastrointestinal Bleeding

Inflammatory

Cancers and neoplasms

Vascular anomalies

Drugs

Miscellaneous

Management of Overt Major GI Bleeding                                   REF:  ACP Medicine 2006

Management of Overt Minor GI Bleeding         

Clinical High-Risk Criteria for Rebleeding and Mortality

          

                                                                                                               

2006