Acute UGI Bleeding

Stephen Matarazzo MD Hillmont G.I. p.c.

Acute UGI Bleeding

Common cause of hospitalization Appropriate resuscitation effects outcome Endoscopic intervention is highly successful Management decisions based on Endoscopic findings

Acute UGI Bleeding

Presentation Hematemesis

Vomiting BRB or coffee ground material Black tarry stool Bright red or maroon rectal discharge 11% are UGI Bleeding Positive result

Melena

Hematochezia

NG Lavage

Blood or coffee ground material Bile with no blood Bleeding stopped Bleeding beyond closed pylorus

Negative Result

Acute UGI Bleeding

Approach to the patient

Assess hemodynamic stability Resuscitation Diagnostic studies Treatment

Acute UGI Bleeding

Hemodynamic Instability

Shock Orthostatic hypotension Profuse active bleeding Decrease in HCT 10% Anticipated transfusion > 2 units RBCs

Acute UGI Bleeding

Resuscitation

Large bore I.V. NSS Blood Transfusions Correct coagulopathy INR > 1.5 FFP Vitamin K Correct thrombocytopenia < 50,000 NG Lavage to remove blood & clots Protect airway if necessary with elective intubation PPI Octreotide GI and Surgical Consults

Acute UGI Bleeding

Diagnostic Studies

Endoscopy Tagged red cell bleeding scan Angiography

Acute UGI Bleeding

Differential Diagnosis

PUD

H. Pylori NSAIDS Z.E. Stress Idiopathic

ESO / gastric varices Portal gastropathy Mallory Weiss tear Esophagitis

Peptic Pill Infectious Adeno Ca Lymphoma

Gastric Malignancy

AVM Dieulafoy

Acute UGI Bleeding

Endoscopy

Gold standard for Dx Most sensitive study Therapeutic potential is major asset Decrease re-bleeding Fewer blood transfusions Decreases LOS Reduces mortality Reduces surgical procedure Pre-Endoscopy Emycin

Acute UGI Bleeding

Risks of Endoscopy

Aspiration Hypoventilation Perforation Co-Morbid Events

AMI COPD

Acute UGI Bleeding

Risk of Stratification of PUD

Major Stigmata

Bleeding visible vessel re-bleeds 80-90% Non-bleeding visible vessel re-bleeds 45-50% Adherent clot re-bleeds 25-30% Oozing without visible vessel re-bleeds 10-15% Flat spot re-bleeds 7-10% Clean ulcer base re-bleeds 3-5%

Minor Stigmata

Acute UGI Bleeding

Risk Stratification of PUD

Clean ulcer base

Ok to discharge after Endoscopy Re-admission rate 1% Exceptions

Severe Anemia Serious co-morbid diseases Anticoagulation therapy Coagulopathy

46% of patients discharge in ER or 12-24hrs.

Acute UGI Bleeding

Endoscopic treatment of PUD

Epinephrine injection initial Rx only Heater probe Bipolar electro-coagulation Endo clips 15-20% of ulcers cannot be clipped Use double channel scope Re-bleeding occurs 15-20% of non-variceal lesions Re-bleeding usually occurs in 24-48 hrs. Re-scope successful 50%

Acute UGI Bleeding

PPI Treatment

Decreases re-bleeding in PUD Decreases blood transfusions and LOS High risk ulcers; use PPI infusion

80 mg IV bolus 8 mg 1 hr. infusion

Switch to PPI BID orally in 72 hrs. Positive H. pylori; treat as outpatient

Variceal Bleeding

Prediction of patients at risk Prophylaxis against first bleed Treatment of active bleeding Prevention of re-bleeding

Variceal Bleeding

30-40% mortality Directly related to portal hypertension 70% risk of re-bleeding in 1 year Occurs in 25-40% of patients with cirrhosis most common etiology Portal pressure flow X resistance Normal portal pressure 5mm Hg

Variceal Bleeding

Treatment of Active Bleeding

Current Options

Octreotide Endoscopy Surgery TIPS

Variceal Bleeding

Octreotide Splanchnic vasoconstriction by inhibiting glucagon Decrease portal flow Rapid onset of action Magic number; 12mm Hg portal pressure Absent side-effects Initial hemostasis > 75% 50ug bolus followed by 50ug/hr x5 days Endoscopy Endoscopic Variceal Ligation EVL Endoscopic Variceal Sclerosis EVS Current Recommendations Octreotide plus EVL Antibiotics improve survival in cirrhotics with hemorrhage

Prevention of Variceal Re-bleeding

70% re-bleeding rate after index bleed Risk of re-bleeding greatest immediately after cessation of index bleeding 70% of untreated patients die in 1 year EVL treatment of choice EVS less successful with higher morbidity and mortality Requires at least 4-6 bandings Medical treatment

Propanolol

Decreases portal pressure Titrate dose to decrease heart rate by 25% Reduces risk of re-bleeding by 40% Reduces mortality by 20%

Propanolol plus oral nitrates

Increase side effects Not routinely used unless you fail beta blocker Rx

Transjugular Intrahepatic Porto Systemic Shunts

Functions similar to surgical shunts No surgery, done transjugular Re-bleed rate 20% in first year Major drawback is hepatic encephrlopathy Shunt stenosis common Very expensive Best used as salvage procedure