Textbook Reading Upper Gastrointestinal Bleeding dr. Mohamad Ananto dr. Syifa Mustika, SpPD Division of Gastroentero Hepatology Medical Faculty of Brawijaya University - Saiful Anwar HospitalIntroduction e Upper Gastrointestinal bleeding (UGIB) ---> bleeding from a source proximal to the ligament of Treitz, associated with melena, hematemesis, coffee ground emesis, or aspiration of ted blood from a nasogastric tube e Three major groups : 1. UGI hemorrage due to direct bleeding into the gut 2. Transpapillary hemorrage ( comprising hemobilia and transpancreatic duct hemorrage ) e UGIB more commonly in men, the overall mortality rate of 5% to 10% is similar for both sexes. e Severe UGIB generally neccessitates admission to an Intensive Care Unit ( ICU )Assessment e Patients presents with GI bleeding, the initial management should focus on two main aspects : 1. Volume resuscitation with appropriate iv fluids and blood products. 2. Identification of the bleeding source, to allow selective therapy.Causes of Upper Gastrointestinal bleeding in their Frequency =e Fee aoe a ae an Varices (esophageal, gastric) 15.4% Esopheattis 128% ee Be oe ae oe ie iad ae icra = a; = From SWverstan FE, Gilbert DA, Tedesco WF ef at The national ASGE survey an upper gastatestinat bleoding. 1 Study desin and basalne data. Gastrointest Endove 27:73-79, 1981Indications for Admission to the Intensive Care Unit for Upper Gastrointestinal bleeding Active bleeding Hemodynamically unstable Known or suspected portal hypertension Significant comorbid disease Coagulopathy (e.g., prothrombin time elevated with INR > 2) Posi cl bleed (previous abdominal aortic graft) INR, international normalized ratio,History Taking Prior history of GI bleeding, Peptic Ulcer Disease, Bleeding diathesis or chronic anticoagulation, renal or liver disease, alcohol abuse, NSAID use. Assess the possibility of cirrhosis or other cause of portal hypertension Retching or vomiting episodes immediately preceding the onset of UGIB suggest Mallory Weiss Tear Recent instrumentation of the pancreas, liver, or biliary tract --> suspicion of hemobilia or hemosuccus pancreaticus Chronic epistaxis and skin teleangiectasias potential hereditary hemorragic teleangiectasia (HHT, also known as Osler-Weber-Rendu syndrome)Physical Examination and Laboratory evaluation Begins with evaluating the patient's hemodynamic status, initial vital signs have prognotic importance ; 50% of patients presenting with shock have rebleeding episodes Survey for the stigmata of chronic liver disease or findings suggestive of an underlying malignancy. Initial Laboratory evaluation include CBC, PT, PTT, SE, BUN, bilirubin and liver-associated enzyme levels Intestinal metabolism of blood raises serum BUN ( BUN: Creatinin ratio > 20) supports the diagnosis of UGIBInitial Management of Patient with Upper Gastrointestinal Bleed in the Intensive Care Unit Secure two wide-bore intravenous (IV) access lines (preferably two 16-gauge peripheral IV lines or one 16- or 18-gauge peripheral IV line and one central venous catheter) Give volume replacement, initially with crystalloid ‘Monitor central venous pressute if patient has underlying cardiac, renal disease, or shock Send hemoglobin (High) and hematocrit, platelet count, coagulation studies (PT, PTT) stat; follow Heb frequently ‘Type and cross-match or type and screen for at least six units of packed red blood cells For patients in shock with exsanguinating hemorrhage, give unmatched O-negative blood (and other blood products that are available from the blood bank as part of their exsanguination protocol (see Chapter 19 for details) via short 7-8 French rapid infusion catheters (also called érawma fines) via a blood warming device with wide-bore stop-cocks and tubing Insert Foley catheter to monitor urinary output Obtain abdominal radiograph Consult gastroenterologist, interventional radiologist, and general surgeon early PT; prothrombin time; PTT, partial thromboplastin time.Gastric Lavage An obvious history of UGIB, Gastric lavage is indicated to clear the stomach in anticipation of endoscopy. Decrease the risk of aspiration for the patient and improves endoscopic visualization. No therapeutic advantage derives from the use of iced saline ( versus room temperature or saline ) for the lavage fluid.Management General Care Initial Management is based on _ the patient's hemodynamics, bleeding rate and comorbidities. For hypotensive patients, use short large-bore (7-8 Fr) catheters in peripheral veins, initially give normal saline or Ringer’s lactate solution, titrated to keep heart rate at less than 100 beats per minute and SBP > 100 mmHg or mean BP> 60 - 65 mmHg, if possible. Replace lost blood volume by transfusing pRBCs Maintaining Hb at 10 g/dl was the traditional target for most patients with UGIBs, recent large clinical trial in 2013 by Villanueva 2013 et al indicated using 7g/dL was superior than 10 g/dl In cases with known portal hypertension and bleeding from gastric or esophageal varices, Hb 7-8g/dl adequately resuscitates blood volume.Endoscopic and angiographic interventions Endoscopy is indicated in resucitated patients with active hemorrhage, blood product transfusion requirements, sistent hypovolemia, known or suspected portal ypertension, or suspected aortaenteric fistula. The accuracy in identifying the bleeding source is highest within the first 12 to 18 hours of hospital admission { spproximately 90% ) and falls by 30% or more after 24 ours. When endoscopic diagnosis or therapy is unsuccessful because of obscured visibility or persistent bleeding, angiography comprises an alternative to emergency surgery Angiography vascular embolization may effective in patients who fail endoscopic therapy or are poor surgical candidates.Endoscopic Findings in Peptic Ulcers and Their Risk of Endoscopic Finding Arterial (pulsatile) bleeding Nonbleeding visible vessal ‘Adherent olot ozing without visible vessel Flat blood spot at uloer base Clean base Rebleeding Risk of Rebleeding 85% 40%-60% 20%-30% 20% 10% 5% From Siverstein FE, Gilbert DA, Tedesco Jf; et at The national ASGE survey on upper gastrointestinal bleeding. |. Study design and baseline data. Gastrointest Endosc 27:73-79, 1981.Evaluation and Management of UGIB Gastric And Duodenal Peptic Ulcers © Gastric ulcers have a higher overall rebleeding rate than duodenal ulcers. e Adherent clots should be gently washed; clots washing off easily reveal active bleeding or a visible vessel warrant therapeutic intervention. e 80% of all upper GI bleeds stop spontaneously, only lesions predisposed to rebleeding should be treated endoscopically.Gastric And Duodenal Peptic Ulcers e Endoscopic interventions of proven benefit include contact thermal devices, injection with epinephrine, hemoclip application, and argon plasma coagulation. e Transcatheter angiography remains a treatment option for refractory UGIB. Infection by H.pylori should assessed in a all patients with UGIB from peptic ulcersStress Ulcer and Gastritis Commonly in critically ill patients admitted to the ICU for other diagnosis Multifactorial, and causes include hypersecretion of acid, altered mucosal defenses and drug-induced injury. Typically occur in fundus or body of the stomach, but can arise int the distal stomach and duodenum PPI preventive therapy significantly more effective than H2RA, potentially harmful side effect exist, nonetheless the risk does not outweigh the potential benefit of UGIB prophylaxis in high risk ICU patientsIndications for Prophylaxis against Stress Ulceration for patients in the Intensive Cared Unit Any One of the Following: Mechanical ventilation for 2 48 hours Coagulopathy. —Platelet count < 50,000 —INR>15 —PTT>2 x normal control value History of gastrointestinal (Gl) ulceration or bleeding within the last year Or Any Two of the following: Sepsis ICU admission lasting > 1week, Occult GI bleeding > 6 days, Glucocorticoid therapy (> hydrocortisone 250 mg or equivalent) From ASHP therapeutic guidelines on stress uleer prophylaxis. ASHP Commission on Therapeuties and approved by the ASHP Board of Directors on November 14, 1998. Am J Health Syst Pharm $6:347, 1999.Esophageal and Gastric Varices © Gastroesophageal varices exist in 50% of patients with cirrhosis and correlate with the severity of liver disease. e Many therapeutic modalities for bleeding esophageal are endoscopic, mechanical, pharmacologic, radiologic, and surgical therapy e The two major endoscopic techniques used to stop esophageal variceal bleeding are endoscopic variceal ligation (EVL) and sclerotherapy.Endoscopic Hemostasis Techniques Mechanical Hemoclips Banding Staplesisutures Endoloops Injection Epinephrine (Adrenalin) Thrombin (human) Alcohol Fibrin glue ‘Sclerosants ‘Thermal Heater probe Argon plasma coagulation Bicap probe Gold probe Laser therapyEVL -> tight rubber bands are applied directly onto a varix, thereby strangulating and eventually inducing sloughing of the varix Sclerotherapy --> a sclerosant solution is injected directly into and around a varix to stop bleeding Patients who fail endoscopic therapy and require stabilization --> temporary use of a tamponading tube (| Stengstaken-Blakemore or Minesota tube ) is recommended. Both tube have major complication : aspiration, esophageal necrosis, perforation, and tracheal compression.Pharmacologic therapy Somatostatin and octreotide, reduce portal pressure by indirectly causing splanchnic vasoconstriction and decreased portal inflow, without changing systemic blood pressure or cardiac ischemia. Octreotide is given 50 yg, followed by a continuous iv infusion at 50 ug/h for 5 days. Vasopressin and terlipressin --> reduce blood flow and control hemorrage patient wih variceal bleeding Nonselective beta blockers --> effective prophylaxis against variceal hemmorage. Cirrhotic patient with variceal bleeding --> prophylactic antibiotic Quinolones or 3 cephalosporins used for 7 dayMulti Detector Computed Tomographic Angiography (MD -CTA) © Diagnostic catheter angiography is highly sensitive in detecting active GI bleeding than obscure GI bleeding o The imaging investigation of choice in cases of suspected GI bleeding with negative or failed endoscopy e Recurrent UGIB with no cause seen at repeated endoscopy or on MD-CTA is a difficult clinical problem, such a transpapillary cause or reflux from brisk lower GI bleeding should be suspectedEquipment Variety catheter shapes : Cobra, sidewinder, visceral hook Embolic agent : Metallic coils, PVA ( Polyvinyl Alcohol ), Gelatin sponge (gelfoam or spongstan), Cyanoacrylate (“glue”) The choice of embolic agent depends on a combination of the abnormality being treated, vascular anatomy, achievable catheter position, and operator preference.JRE 53-1. Acialunenhanced (A) arterial: phate contrast-enhancad mulidetector computed tomographic angiography (B), and abique coronal maximum intensity projection (C) demonstrate active bleeding from gastroduodenal artery (arows) in 2 patient who presented with melena. Upper gastrointestinal ‘endoscopy was incomplete owing to a duodenal sticure. Comesponding catheter angjoaram (D) and successul coil embolization (arow) distal and then proximal to site of hemorrhage ().FIGURE 53-4. Geffam enbolzaton of gastroduodenal ater (GDA) hemorhage via a SF catheter. Ths procedure was performed before avalably ot microcatheter. Aor fash un showing pseudoaneurysm (arrow). 8, Active exravasaton farow) on a selectve GDA injection. c, Catheter could not be ‘adranced beyond the bleeding point. D, Completion angiogram post Geli embolization with technical and dnl success.Embolization Technique Catheters are flushed with non-heparinized salined. Check arteriograms are obtained frequently. Non radiopaque particulate embolic material (gelatin sponge and PVA particles) must be mixed with 50% ICM and injected under continuous high-quality fluoroscopic In hemodynamically unstable patient, gastric and duodenal hemorrhage --> coil embolization combined particulate agents or glue to achieve thrombosis Diffuse bleeding requires sufficient reduction in _perfussion pressure in all vessels --> gelfoam slurry or larger PVA particles All potential feeding arteries to the site hemorrage must be imaged.Contraindication Absolute contraindications to embolization are rare, alternative contrast agents ( co2 and gadolinium) can be used in severe reactions to iodinated contrast media Relative : - Previous extensive UGI surgery or radiotherapy in which embolization associated with increased gastric or duodenal infarction - Severe visceral artery atherosclerosis