Upper GI Bleeding Protocols:

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Upper GI Bleeding Protocols

• 4B Ri ???

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Epidemiology

• Upper Lower GI bleeding 51
• 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
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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 in portal
  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 (110,000
  dilution) with or without various sclerosant
  solutions. ( or thermal contact).
• Rubber band ligation, metal clips.

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Treating the underlying

• Causes of acute Upper GI bleeding
•     Ulcers duodenal, gastric, esophageal   
• Varices esophageal, gastric, duodenal   
• Mallory-Weiss tear   
• Dieulafoy's lesions   
• Arteriovenous malformations   
• Portal hypertensive gastropathy   
• Gastric antral vascular ectasias (watermelon
  stomach)   
• Erosions   
• Aorto-enteric fistula   
• Crohn's disease   Malignancy   Hemobilia   Pancre
  atic source   Foreign body ingestion or
  bezoar   Caustic ingestion   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
  the bleeding 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 pressure gradient gt 12 mmHg.
• In esophageal variceal , prefer variceal ligation
  (with multiband ligator) over endoscopic
  sclerotherapy.
• In gastric varices, injection with a sclerosing
  agent will be more beneficial than band 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 ß-blockers, (haldolol or
  propranolol) decreased rebleeding rate.
• 4. ß-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 lt 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 hepatic diseases, cancer)
• 4. Specific endoscopic diagnosis (e.g., GI
  malignancy)
• 5. Use of anticoagulants/coagulopathy
• 6. Presence of a high-risk lesion (e.g.,
  arterial bleeding, nonbleeding, visible vessel
  and clot)

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References

• Critical issues in digestive diseasesClinics in
  Chest MedicineVolume 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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Thank you for your attention!!