Massive Upper GI Bleeding John Meisel MD

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Massive Upper GI BleedingJohn Meisel MD

• 28 year old man presented with hematemesis of 1
  liter of blood one hour ago
• He was weak and sweaty
• Physical examination was otherwise normal no
  jaudice, ascites, abdominal mass, cachexia,
  telangectasia,
• Lecture will discuss how to deal with him and
  patients with similar problems
• Copy of lecture at www.drmeisel.com

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Massive Upper Gastro-intestinal Bleeding

• A medical emergency mortality 8-9
• Upper GI bleeding 5X more common than lower
• Good treatment improves outcome

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Chronic Upper GI Bleeding (will not discuss)

• Presents often with Microcytic anemia in the
  absence of pain
• Usually some symptom to suggest diagnosis weight
  loss, dysphagia, abdominal pain, vomiting
• Most common cause in the world of GI bleeding and
  Microcytosis is Hookworm!

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Massive Upper GI BleedingClinical Presentation

• Sudden Weakness, sweating, nausea, syncope
• Postural Hypotension before tachycardia
• Blood Loss Hematemesis or melena
• Iron and Bismuth cause black stools
• Stools may not be seen for 4-6 hours because of
  slow GI transit in some patients
• It takes 100 cc blood to produce melena, which
  can come from nose to right colon.

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Upper GI BleedingCommon Causes

• Peptic Ulcers 1/3 have no preceding pain before
  bleeding
• Esophageal Varices from cirrhosis
• Mallory Weiss Tear gastroesophageal junction
  injury from vomiting or wretching
• Gastritis usually from anti inflammatories,
  alcohol,
• Cancer of esophagus, stomach
• Many rare causes, including Dieulafoys(superficia
  l pseudoanurysem of mucosa without ulcer
  intermittent arterial bleeding)

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EvaluationThe medical History

• Exact description of events, including number and
  volume of stools or vomitus
• Medicines, including anything taken except food.
  (Baby Aspirin often forgotten)
• Other illnesses clues to severity, possible
  cause
• Prior GI complaints pain, trouble swallowing,
  weight loss,
• During history, IVs are being started, blood is
  being drawn(rapid treatment improves outcome

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Physical Examination

• Vital Signs BP initially low, then tachycardia,
  check repeatedly
• Pallor(only if anemic), lymph nodes, abdominal
  mass, liver or spleen, rectal to test stool for
  blood
• Rarer findings bruising with coagulopathy,
  arthritis as clue for anti inflammatories,
  telangectasia, abdominal scars of trauma or
  surgery, bruits of vascular disease, ascites from
  liver disease

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Immediate Treatment

• IV fluids or sips of liquids in emergency
• Bed rest with legs up
• Check Blood counts remember with acute bleeding
  counts unchanged till diluted with IV fluids or
  time
• Type and Cross match Blood do not give unless
  under 24 unless heart/lung disease

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Immediate Treatment

• Naso-gastric tube ? can tell if active bleeding
  or not, reliable if bile obtained. Only used 50
  Unless vomiting persistent
• If bright red blood, urgent endoscopy
• Benefits of Endoscopy Not just because we want
  to know, but does it really help the patient?
• The characteristics of the ulcer will define
  prognosis, need for hospitalization (Visible
  vessel or active bleeding 90 vs. clean ulcer 5
  chance of re-bleeding( Lee,JG, Gastro Endo 1999)
  
• Decrease the need for transfusion
• Decrease the need for surgery
• (Injection of Erythromycin will help clear
  stomach before endo(Gastro 20212317)
• If endoscopy delayed 12-24 hours, use only if
  dysphagia, continued bleeding, weight loss or
  other alarm symptoms present

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Endoscopic TherapyStopping Ulcer Bleeding

• Electrocautery monopolar or bipolar(Bicap)
• Bipolar safer because injury more superficial
• Clips
• Injection 110,000 epinephrine or other solution
  (works by vasospasm and tamponade
• Banding. May cause bowel necrosis if applied to
  deeper
• Combination Treatment most common Epinephrine
  and Bicap
• Argon Plasm Coagulation Deeper, controlled burn
  Expensive
• Fibrin Sealant Experimental, but seals fistulae

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Endoscopic TherapyResults

• About 1/25 bleeders can not be stopped and
  require surgery
• Some require second endoscopy, and 75 are
  successfully treated
• IV Omeperazole by Infusion may be helpful but
  very expensive
• Surgery is usually over sew ulcer in USA(where
  availability and cost of medicines better than
  long term side effects of ulcer surgery(diarrhea,
  weight loss) Definitive ulcer operation sensible
  elsewhere to avoid lifetime medications.

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Common Causes of Bleeding

• Gastric or Duodenal Ulcers In USA 50
  Helicobacter, 50 Anti inflammatories
• A very good medication history
• Blood test for antibodies, Stool for Antigen,
  Biopsy or assume everyone positive (Cambodia)
• Esophagitis from reflux plus anti inflammatories
  can be focal ulcer
• Tear at GE junction from Vomiting Mallory Weiss
  tear sometimes needs clips, injection

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Common Causes of Bleeding

• Gastritis from drugs, alcohol, stress, cannot be
  focally treated endoscopically,usually not
  massive
• Cancer Temporarily stopped endoscopically
• Esophageal Varices from Cirrhosis Banding better
  than sclerotherapy
• Multiple Rare causes

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Other Issues GI Bleeding

• No need to treat Helicobacter acutely
• Transfusion Hct lt22, elderly lt26
• Endoscopy also allows us to triage
• Clean based ulcer watch 24 Hr, or discharge, the
  chance of rebleeding ,5
• Clot, visible vessel rebleeding 12-20
• Actively Bleeding higher, surgery possible

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Prevention of Bleeding

• Identified Cause will allow for Prevention
• If anti inflammatories the cause, treat with
  alternative medicine for headaches/arthritis, etc
  or the patient will start taking them again
• Adequate treatment duration Duodenal ulcers
  treat for 6 weeks Gastric ulcers for 3 months
• Treat Helicobacter Test for cure Stool or Breath
  test (Blood antibodies will persist)
• Some Patients will re-bleed without
  antiinflammatories and Helicobacter treated
  about 20 of ulcers Other causes yet to be
  discovered.