UGIB


DEFINITIONS
Hematemesis: Vomiting of blood)
  • UGIB proximal to ligament of Treitz

Hematochezia (fresh blood thorugh anus)

  • Maroon: transverse and right colon
  • Bright red: anus, rectum, sigmoid
  • 10% due to rapid UGIB

Melena (Dark sticky feaces containing partly digested blood)

  • Usually due to UGIB
  • Iron and bismuth ingestion causes black, heme-negative stool

Etiology

Common Causes
  • Peptic Ulcer disease (55%)

    1. H. pylori infection
    2. NSAID use
    3. Stress
    4. Gastric acid
      • A factor in all of the above
      • Rarely the sole factor
        • Zollinger-Ellison syndrome
  • Esophageal varices (14%)

    1. Cirrhosis of liver
    2. Portal vein pressure increases
    3. Pressure causes shunting to collateral vessels
      • Esophageal veins dilate (varices)
    4. Causes
      • Alcoholic liver disease
      • Chronic hepatitis
      • Budd-Chiari syndrome
      • Portal vein thrombosis
  • Arteriovenous malformations (6%)

    1. Collections of ectatic, thin-walled vessels
      • Vessels lined w/ only endothelium, may have minimal amount of smooth muscle
    2. Arteriovenous connections can occur
      • Precapillary sphincter incompetent
    3. Pathogenesis unclear
      • May be due to chronic low-grade venous obstruction
      • May be complication of chronic mucosal ischemia
        • Straining at stool
        • Bowel obstruction
      • May be due to local ischemia
        • Cardiac/pulmonary disease
      • May be congenital (younger patients)
  • Mallory-Weiss tears (5%)

    1. Mucosal tear
      • Caused by transmural pressure gradient esophagogastric junction
      • 80% along lesser curvature of stomach
      • 10% involve esophagus
  • Tumors (3-4%)
    1. Late stage of dz
      • Tumor outgrows blood supply
      • Erodes mucosa
      • May erode into vessel
  • Erosions

    1. Esophagitis
      • From reflux peptic acid
      • Infection
        • CMV, candida
        • Herpes simplex
      • Toxins
        • EtOH
        • Caustics
        • Medications
          • Tetracycline
          • Quinidine
          • Potassium
    2. A factor in ulcers
    3. Also seen in
      • Henoch-Schönlein purpura
      • Barrett's esophagus
      • Other diseases
Uncommon Causes
  • Tumors (3-4 %)

    1. Late stage of disease
      • Tumor outgrows blood supply
      • Erodes mucosa
      • May erode into vessel
    2. AVM
    3. Hereditary hemorrhagic telangiectasia
    4. Hemangioma
    5. Crohn's disease
       
  • Erosions
    1. Esophagitis
      • From reflux peptic acid
      • Infection
        • CMV, candida
        • Herpes simplex
      • Toxins
        • EtOH
        • Caustics
        • Medications
          • Tetracycline
          • Quinidine
          • Potassium
    2. A factor in ulcers
    3. Also seen in
      • Henoch-Schönlein purpura
      • Barrett's esophagus
      • Other diseases
         
  • Dieulafoy's Lesion (1%)

    • Etiology unknown
    • Dilated aberrant submucosal vessel
      • Erodes overlying epithelium
        • No primary ulcer
      • Erodes into submucosal artery
      • Usually located in upper stomach
        • Along high lesser curvature, near gastroesophageal junction
      • Have been found in all areas of GI tract
         
  • Gastric Antral Vascular Ectasia (GAVE)

    • AKA "watermelon stomach"
    • Rows of ectatic, sacculated, submucosal vessels
    • Usually idiopathic
    • May also be due to cirrhosis and systemic sclerosis
       
  • Portal Hypertensive Gastropathy (Congestive Gastropathy)

    • Diffuse mucosal oozing - no other lesions
    • Gastric mucosa is friable
    • Bleeding begins when ectatic vessels rupture
    • May be due to cirrhosis/portal hypertension
      • Congestion & hyperemia of stomach
    • NO relation to H. pylori infection
       
  • Hemobilia

    • Bleeding from the hepatobiliary tract
    • Very rare cause of UGI bleeding
    • "Classic triad"
      • Biliary colic
      • Obstructive jaundice
      • Occult or acute GI bleeding
    • Consider if
      • UGI bleeding AND recent hepatic parenchymal/biliary tract injury
        • Percutaneous and transjugular liver biopsy
        • Percutaneous transhepatic cholangiogram
        • Gallstones, cholecystitis, cholecystectomy
        • Endoscopic biliary biopsies/stenting
        • TIPS
        • Hepatic/ bile duct tumors
        • Intrahepatic stents
        • Hepatic artery aneurysms
        • Hepatic abscesses
        • Obstructive jaundice
        • Biliary sepsis
           
  • Hemosuccus Pancreaticus
    • Bleeding from the pancreatic duct
    • Pseudocyst/tumor erodes into vessel
      • Direct connection between duct & vessel
    • Usually seen with
      • Chronic pancreatitis
      • Pancreatic pseudocysts
      • May be seen following endoscopy of pancreas or duct
        • Stone removal
        • Sphincterotomy
        • Pseudocyst drainage
        • Duct stenting
           
  • Aortoenteric Fistula
    • Direct communication between aorta and GI tract
    • HIGH mortality if not diagnosed/treated correctly
    • Causes
      • Atherosclerotic aneurysm (US)
      • Prosthetic abdominal aortic graft
      • Infectious aortitis
        • TB, syphilis
        • NOT common in US
      • Penetrating ulcer, tumor invasion
      • Trauma, foreign body perforation
      • Radiation therapy
         
  • Cameron Lesions
    • Erosion/ulcer in the sac of a hiatal hernia

 

DDx

  • PUD
  • Esophagitis
  • Tumors
  • Colitis
  • Ischemia
  • Esophageal varices
  • Angiodysplasia
  • Diverticulitis
  • Angiodysplasia
  • Malignancy
  • Hemorrhoids
  • Mallory-Weiss tear
  • Aortoentiric fistula
  • Gastric vascular telangiectasia

Diagnosis

  • History
    • Duration/quantity of bleeding
    • Previous Hx of bleeds
    • Current medications
      • ASA, NSAIDs
      • Anticoagulants
    • Alcohol use
    • Associated symptoms
    • Prior medical conditions
      • Bleeding diathesis
      • Cardiac conditions
      • Prior abdominal surgeries
    • Prehospital Tx, if any & response to Tx
    • Patients may C/O
      • Dizziness, weakness
      • Syncope (w/standing)
      • Dyspnea
      • Confusion
      • Abdominal pain
      • Chest pain
        • Think cardiac ischemia from anemia in elderly
           
  • Physical exam
    • Vital signs
      • Postural hypotension suggests significant blood loss
      • Normal vitals do NOT R/O significant bleed
    • General exam
      • Overall appearance
      • Mental status
      • Skin signs
        • Pallid, sweaty
        • Color, warmth
        • Bruising/telangiectasia
    • Signs of liver disease
      • Jaundice, cutaneous angiomata
      • Palmar erythema, gynecomastia, testicular atrophy
    • Signs of coagulopathy
      • Multiple ecchymoses, petechiae, telangiectasia
    • Abdominal exam
      • Check masses, ascites & hepatosplenomegaly
      • Look for surgical scars, listen for bruit
        • Aorticoenteric fistula
      • Rectal exam
      • Masses, stool color, hemoccult
         
  • Diagnostic testing
    • CBC
      • Hgb & Hct may be nl during acute bleed
        • May take up to 6 hrs to equilibrate
      • If Hgb < 8g/dl (Hct < 25%)
        • Usually require transfusion
    • PT/PTT
      • Increase PT
        • Coumadin, liver dz, fat malabsorption, antibiotics
      • Incr PTT
        • Congenital (factor VIII deficiency, von Willebrand's dz) or acquired (DIC)
    • Electrolytes
      • Lactic acidosis
        • From hypotension and shock
      • Hypochloremic alkalosis
        • From vomiting or NG tube
      • BUN
      • Creatinine > 20:1 suggests upper GI source or severe dehydration
      • LFT's
    • Type & Cross x 6U PRBC if
      • Active bleed, signs of shock, elderly
      • Transfuse type-spec blood if possible
      • If not possible
        • O (-) for fertile women
        • All others O (+)
           
  • Diagnostic Studies
    • Confirmation of UGI source
      • Witnessed bloody or coffee-ground emesis OR
      • NGT aspirate
    • Endoscopy can more accurately pinpoint source
      • 78-95% of time
      • Good for
        • Ulcers
        • Varices
        • AE fistulas
        • Dieulafoy's lesion
        • Erosions, neoplasms
    • Plain X-ray
      • No role in acute UGI bleed
      • Exception is if suspect perforated viscus
    • Angiography
      • Limited use from ED(1%)
      • Better for LGIB
    • CT scan
      • May be useful in some rare forms of UGIB
        • Hemosuccus pancreaticus
    • Tagged red cell scans
 

Acute Management

  1. Airway, Consider intubation for airway protection
  2. NPO
  3. 2 large bore IVs
  4. STOP all meds causing bleeding (ASA, Plavix, warfarin etc.)
  5. +/- NG tube (NOT in pt with Varices)
    • Recommended in most patients with significant GI bleeding regardless of source
    • * Negative aspirate does not rule out upper GI source
       
  6. Fluid and blood resuscitation
    • Treat coagulopathy with 2-4 Units FFP +/- Vitamin K (until PTT normalizes in cirrhotic pt)
    • Vitamin K if INR is high
      • 5-9: 1-2.5mg PO
      • >9: 5-10mg PO
      • Any bleed: 10mg by slow IV infusion
    • Treat thrombocytopenia
    • Platelet transfusion if < 50K
       
  7. PPI: reduce rebleeding and the need for subsequent surgery
    • Esomeprazole 80 mg IV bolus, followed by 8 mg/hr -OR-
    • Pantoprazole 80 mg IV bolus, followed by 8 mg/hr
      • Continue PO BID x 4-8 weeks for peptic ulcer disease
      • Assess for H.pylori infection & treat if present.
         
  8. Consider Erythromycin 3 mg/kg IV over 20-30 mins before endoscopy to help clear blood
     
  9. If known or suspected Variceal bleeding or Cirrhosis
    • Octreotide 50 mcg bolus, followed by 25-50 mcg/hr infusion x1-5 days
      AND
    • Antibiotics (eg, Ceftriaxone, Amoxicillin-clavulanate, or Quinolone)
    • B-Blocker: Propranolol
    • Nitrates: Imdur 30 mg PO qd; added to serial endoscopic variceal ligation & B-Blocker.
    • TIPS for gastric varices or recurrent esophageal variceal bleed.
       
  10. Balloon tamponade may be performed as a temporizing measure (eg, Sengstaken-Blakemore tube, Minnesota tube)
    • Requires intubation
       
  11. Emergent EGD

 

Disposition

  1. Risk of rebleed or shock w/even minimal bleed, mandates admit for work up & serial CBC
  2. Admit
    • ICU
      • Unstable patients, persistent bleeds
      • Persistent tachycardia
      • Severe anemia w/unstable comorbid dz
      • Age>75
    • Floor
      • Stable patients w/ clearing melena or hematemesis
         
  3. Discharge home
    • Lowest risk patients
      • No comorbid diseases
      • Normal vital signs
      • Normal or trace positive stool guaiac
      • Negative gastric aspirate, if done
      • Normal/near normal hemoglobin/hematocrit
      • No problem home support
      • Proper understanding of signs & symptoms of significant bleeding
      • Immediate access to emergent care if needed
      • Follow-up arranged w /in 24 hours

Admit Orders: GI Bleed

1. Admit to: Consider ICU

2. Diagnosis: Upper/lower GI bleed

3. Condition:

4. Vital Signs: q30min. Call physician if BP >160/90, <90/60; P >120, <50; R>25, <10; T >38.5°C; urine output <15 mL/hr for 4h.

5. Activity: Bed rest

6. Nursing: Place nasogastric tube, then lavage with 2 L of room temperature normal saline, then connect to low intermittent suction. Repeat lavage q1h. Inputs and outputs.

7. Diet: NPO

8. IV Fluids: Two 16 gauge IV lines. 1-2 L NS wide open; transfuse 2-6 units PRBC to run as fast as possible, then repeat CBC.

9. Special Medications:

-Oxygen 2 L by NC.

-Pantoprazole (Protonix) 80 mg IV over 15min, then 8 mg/hr IV infusion 80 mg IV q12h OR


Esophageal Variceal Bleeds:

-Somatostatin (Octreotide) 50 mcg IV bolus, followed by 50 mcg/h IV infusion (1200 mcg in 250 mL of D5W at 11 mL/h).
 

Vasopressin/Nitroglycerine Paste Therapy:

-Vasopressin (Pitressin) 20 U IV over 20-30 minutes, then 0.2-0.3 U/min [100 U in 250 mL of D5W (0.4 U/mL)] for 30 min, followed by increases of 0.2 U/min until bleeding stops or max of 0.9 U/min. If bleeding stops, taper over 24-48h AND

-Nitroglycerine paste 1 inch q6h OR nitroglycerin IV at 10-30 mcg/min continuous infusion (50 mg in 250 mL of D5W).

-Norfloxacin (Noroxin) 400 mg twice daily OR

-Ciprofloxacin (Cipro) 400 mg IV q12h.

-Thiamine 100 mg PO/IV qd.
 

10. Extras: Portable CXR, upright abdomen, ECG. Surgery and GI consults.

Upper GI Bleeds: Esophagogastroduodenoscopy with coagulation or sclerotherapy; Linton-Nachlas tube for esophageal varices.

Lower GI Bleeds: Sigmoidoscopy/colonoscopy (after a GoLytely purge 6-8 L over 4-6h), technetium 99m RBC scan, angiography with embolization.


11. Labs:
 Repeat hematocrit q2h; CBC with platelets q12-24h. Repeat INR in 6 hours. chem 7&12, ALT, AST, alkaline phosphatase, INR/PTT, type and cross for 3-6 U PRBC and 2-4 U FFP.

 





Source: Tintinalle ED 7th