Upper GI Bleeding.pdf

5 Gastrointestinal Bleeding ILOs At the end of this session, the student will be able to:  Classify the types of GIT bleeding.  Define upper GIT bleeding and its epidemiology.  Enumerate different etiologies and presentation of UGIB.  Discus the updated guidelines recommen...

5 Gastrointestinal Bleeding ILOs At the end of this session, the student will be able to:  Classify the types of GIT bleeding.  Define upper GIT bleeding and its epidemiology.  Enumerate different etiologies and presentation of UGIB.  Discus the updated guidelines recommendation for treatment algorithm of variceal and non-variceal UGIB GASTROINTESTINAL BLEEDING (GIB) Acute gastrointestinal bleeding is one of the most common medical emergencies with 250,000 to 300,000 hospitalizations annually. The mortality rate is about 6- 8%. The risk of mortality is highest in patients of advanced age or those with severe co-morbidities. Gastrointestinal bleeding is managed by many clinicians across many specialties, including emergency room physicians, hospitalists, internists, gastroenterologists, surgeons, interventional radiologists, and hematologists. The types of GIB: According to the site: Upper and lower GI bleeding is based on location in relation to the ligament of trietz (at the junction of the 2nd and 3rd parts of the duodenum). Figure 1. UGI bleeding is more common than LGI bleeding. According to the Severity, it can be divided into: Acute-chronic-intermittent- occult Upper GI bleeding (UGIB): is defined as bleeding derived from a source proximal to the ligament of Treitz. Bleeding from the upper GI tract is approximately 4 times more common than bleeding from the lower GI tract. UGIB can be divided according to its source into non-variceal and variceal. Page 1 of 12 Clinical manifestations: It might be presented by the finding of melena, hematemesis (vomiting of fresh blood), or can present with coffee ground vomitus according to the rate of blood loss. The most severe form presents with hematemesis with blood clots representing a rapid rate of bleeding which disables the dissolution of blood clots. Hematochezia (fresh bleeding per rectum) if associated with upper GI bleeding presents rapid and huge blood loss (about 1 liter). Melena is a dark tarry blackish stool with an offensive odor that presents slow upper GIT bleeding, usually occurring after hematemesis or even gum bleeding for a few days. It is rarely associated with very slow bleeding from lower GIT. Melena develops after as little as 50–100 mL of blood loss in the upper gastrointestinal tract. Etiology of GIT bleeding: Table 1, Figure 2  Peptic ulcers account for 40% of major upper gastrointestinal bleeding with an overall mortality rate of less than 5%. The incidence of bleeding from ulcers is declining due to the eradication of H pylori and prophylaxis with proton pump inhibitors in high-risk patients.  Portal hypertension accounts for 10–20% of upper gastrointestinal bleeding. Bleeding usually arises from esophageal varices and less commonly gastric or duodenal varices or portal hypertensive gastropathy.  Vascular anomalies are found throughout the gastrointestinal tract and may be the source of chronic or acute gastrointestinal bleeding. They account for 7% of cases of acute upper tract bleeding. The most common are Angio ectasias (angiodysplasias), which are 1–10 mm distorted, aberrant submucosal vessels caused by chronic, intermittent obstruction of submucosal veins. They have a bright red stellate appearance and occur throughout the gastrointestinal tract but most commonly in the right colon. Telangiectasias are small, cherry red lesions caused by dilation of venules that may be part of systemic conditions (hereditary hemorrhagic telangiectasia, CREST syndrome) or occur sporadically. The Dieulafoy lesion is an aberrant, large-caliber submucosal artery, most commonly in the proximal stomach that causes recurrent, intermittent bleeding.  Gastric neoplasms result in 1% of upper gastrointestinal hemorrhages.  Erosive gastritis is superficial, so it is a relatively unusual cause of severe gastrointestinal bleeding (less than 5% of cases) and more commonly results in chronic blood loss. Gastric mucosal erosions are due to NSAIDs, alcohol, or Page 2 of 12  severe medical or surgical illness (stress-related mucosal disease). Severe erosive esophagitis due to chronic gastroesophageal reflux may rarely cause significant upper gastrointestinal bleeding, especially in patients who are bedbound long-term. An aorto-enteric fistula complicates 2% of abdominal aortic grafts or, rarely, can occur as the initial presentation of a previously untreated aneurysm.  Unusual causes of upper gastrointestinal bleeding include hemobilia (from the hepatic tumor, angioma, penetrating trauma), pancreatic malignancy, and pseudoaneurysm (hemosuccus pancreaticus). Initial Evaluation & Treatment: In all GIT bleeding we should answer the following questions: How should patients with GOT bleeding be stratified according to the severity? What should be the initial assessment of these patients according to the severity and types of the bleeding? When the patient with acute bleeding can be discharged and followed up as an outpatient? What are the indications for admission to the hospital? Where in the hospital should be admitted (ward/ICU)? Management of Non-Variceal UGIB A. Pre-endoscopy management: 1. Patient assessment & risk stratification: The use of the Glasgow–Blatchford Score (GBS) (Table 2) is highly recommended for pre-endoscopy risk stratification. Patients with GBS ≤ 1 are at very low risk of rebleeding, mortality within 30 days, or needing hospital-based intervention and can be safely managed as outpatients with outpatient endoscopy. Patients with active bleeding manifested by hematemesis or bright red blood on nasogastric aspirate, shock, persistent hemodynamic derangement despite fluid resuscitation, serious comorbid medical illness, or evidence of advanced liver disease require admission to an ICU. The GBS was reported to have the highest accuracy for predicting the need for hospital-based intervention (RBC transfusion, endoscopic treatment, arterial embolization, surgery) or death. Page 3 of 12  2. Hemodynamic stabilization and resuscitation: Early intensive hemodynamic resuscitation of patients with acute UGIH has been shown to significantly decrease mortality, correct intravascular hypovolemia, restore adequate tissue perfusion, and prevent multiorgan failure. The ideal crystalloid fluid type to be used in hemodynamic resuscitation is either saline 0.9% sodium chloride or balanced crystalloids (e.g. ringer’s lactate which showed reduced both mortality and major adverse renal events in critically ill patients. Placement of a nasogastric tube is not routinely recommended. It might help for the initial assessment and triage of selected patients with suspected active upper tract bleeding. The aspiration of red blood or “coffee grounds” confirms an upper gastrointestinal source of bleeding. A restrictive red blood cell (RBC) transfusion strategy is considered standard of care in non-massive, acute UGIH both in variceal or non-variceal. It is associated with lower hospital mortality, a more liberal hemoglobin threshold (> 8 g/dL) to prompt RBC transfusion should be used for patients with both acute or chronic cardiovascular disease. Packed RBCs transfusion is recommended if Hb