Upper GI Bleeding Protocols

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Upper GI Bleeding

Protocols:4B Ri


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Epidemiology:

Upper: Lower GI bleeding = 5:1

Incidence: 50-100 per 100,000 pts. 100 per

100,000 hospital admission.

30% pts are older than 65 years.

80% are self-limited.

20% of pts who have recurrent bleeding(within 48-72 hrs) have poor prognosis.


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Why upper GI bleeding?

More than 75% of ICU patient will have

gastroduodenal lesions by endoscopy.

Highest risk are: intubated patients; multi-

organ failure, coagulopathy, sepsis, or

extensive burns; head trauma or neurosurgery.

Decreased mucosal blood flow mucosa to

develop erosions or ulcerations.


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Prophylaxis to stress ulcer:

Frequency declined over the past 20 years. (but

not because of prophylaxis)

Prophylaxis:-- H2 receptor antagonist: (Zantac, Gaster)

-- Sucralfate (Ulsanic): lower incidence of

nosocomial pneumonia.-- Proton Pump Inhibitor: (Losec, Pantoloc)

higher incidence of nosocomial pneumonia.


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Acute GI bleeding:

Immediate Assessment

Stabilization of hemodynamic status

Identify the source of bleeding

Stopping the active bleeding

Treat the underlying

Prevent recurrent blee


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Initial assessment:

1. Orthostatic changes of BP and HR.

2. History: Drugs history (NSAID, anti-

thrombotic agents, Calcium channel blocker)

3. P.E.:heart, lung, and abdominal examinations,

skin and mucus membranes.

4. Lab: CBC, Plt, coagulation profile.5. Significant of GI blood loss: hematemesis,

melena, or hematochezia.


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Initial resuscitation + stabilization:

1. IV route in unstable patient for colloid

solution.

2. Oxygen support.

3. Monitor urine output.

4. Blood transfusion. (maintain Hct at 30% in the

elderly, 20-25% in younger pt, 25-28% inportal HTN.)


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Identify bleeding source:

1. N-G tube differentiate between upper/lower

GI bleeding.

2. Lavage color and rapidity of clearing; clear

the field for esophagogastroduodenoscopy

(EGD).

3. Initial EGD: within 24 hrs of bleeding.


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Stopping the active bleeding:

Most effective method: endoscopic therapy

Laser therapy: requires significant training.

Thermal contact: mono- (greater tissue injury)and bipolar electrocautery, heater probes.Widely available and require minimal training.

Injection therapy: epinephrine (1:10,000

dilution) with or without various sclerosantsolutions. ( or + thermal contact).

Rubber band ligation, metal clips.


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Treating the underlying

Causes of acute Upper GI bleedingUlcers: duodenal, gastric, esophageal

Varices: esophageal, gastric, duodenal

Mallory-Weiss tear

Dieulafoy's lesionsArteriovenous malformations

Portal hypertensive gastropathy

Gastric antral vascular ectasias (watermelon stomach)

ErosionsAorto-enteric fistula

Crohn's disease Malignancy Hemobilia Pancreaticsource Foreign body ingestion or bezoar Causticingestion No site found


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Ulcers:


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Ulcers:

High Risks:

1. active bleeding

2. visible vessels

3. recent bleeding

(overlying clot)

Lower Risks:

1. flat red or black spot

2. clean based ulcer


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Ulcers:

1. Two separate EGD.

2. Angiography with embolization: empirical

embolization can be done.

3. Surgical therapy: oversewing and resection of thebleeding site.

4. Medications to heal ulcers:

PPI-- decrease recurrent bleeding rate.H2 receptor antagonist not beneficial..

H. pylori present antibiotics, prevent rebleeding.


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Varices:

Hepatic venous pressuregradient > 12 mmHg.

In esophageal variceal ,

prefer variceal ligation (withmultiband ligator) overendoscopic sclerotherapy.

In gastric varices, injectionwith a sclerosing agent willbe more beneficial thanband ligation.


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Varices:

Medical therapy (could combine endoscopy):

1. Vasopressin: side effect-- Myocardial

infarction 25%. Combine with NTG.

2. Octreotide (somatostatin analog)

3. Nonselective -blockers, (haldolol or

propranolol) decreased rebleeding rate.4. -blockers with nitrates in stable pt.


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Varices:

TIPS (transjugular intrahepatic porto-systemic shunt):

transjugular approach connect portal v. and hepatic

v. reduce portal v. pressure gradient to < 12-15

mmHg. Patent a repeat endoscopy should be done to

evaluate for an alternative source of bleeding.

Complications include: bleeding, dye-induced renal

failure, hemolysis, stent migration, and puncture of

the gallbladder or other organs adjacent to the liver.


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Varices:

Balloon tamponade:

1. Intubation

2. Gastric balloon

3. Esophageal balloon Balloon should be inflated for less than 24 hrs.

75% rebleeding rate after balloon deflation.

Antibiotic prophylaxis for cirrhosis pt: norfloxacin,ciprofloxacin.

Maintain Hct at 25-28 %.


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Preventing recurrent bleeding:

Predictors of Rebleeding:1. Older age

2. Shock/hemodynamic instability/orthostasis

3. Comorbid disease states (e.g., coronary artery

disease, congestive heart failure, renal and hepaticdiseases, cancer)

4. Specific endoscopic diagnosis (e.g., GI malignancy)

5. Use of anticoagulants/coagulopathy

6. Presence of a high-risk lesion (e.g., arterialbleeding, nonbleeding, visible vessel and clot)


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References:

Critical issues in digestive diseases

Clinics in Chest Medicine

Volume 24 Number 4 December 2003

An annotated algorithmic approach to upper gastrointestinal bleeding

Gastrointestinal Endoscopy Volume 53 Number 7 June 2001

Management principles of gastrointestinal bleeding

Primary Care; Clinics in Office Practice

Volume 28 Number 3 September 2001


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attention!!

Upper GI Bleeding Protocols

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