Upper GI Bleeding
Upper GI Disease
Lori F Gentile
Upper GI Bleeding
Definitions
• UGIH = proximal to ligament of Treitz
• Hematemesis = vomiting blood - bright red or coffeeground (typically UGI source)
• Melena = black tarry stool (often UGI)
– Enzymatic breakdown
• Hematochezia = bloody stool (LGI > UGI)
– Blood as cathartic agent
• Occult blood = UGI or LGI source
Upper GI Bleeding
DDx- UGI Bleed
• Peptic Ulcer Disease (PUD) >50% cases
• Gastritis / Duodenitis (15-30%)
– Subset due to NSAID use
• Esophageal varices from portal hypertension (10-20%)
• Gastric varices
• Mallory-Weiss tears at GE junction (5%)
• Esophagitis (3-5%)
• Malignancy (3%)
• Dieulafoy’s lesion (1-3%)
• Nasopharyngeal bleed – swallowed blood
Upper GI Bleeding
Initial Evaluation
• Evaluate ABCs/PE:
– Can the pt protect his airway?
– Is the pt hemodynamically unstable?
– Does the pt have adequate IV access, Foley, NGT?
• Resuscitate as appropriate
• Orders: NPO, IVF, NGT to LCWS, Foley, HOB>30,
continuous pulse oximetry & telemetry
• Labs: type & cross, CBC, INR/PT/PTT, BMP, LFTs
• Additional question to ask yourself:
– Does the pt require a higher level of care?
Upper GI Bleeding
H&P
• Risk factors: age, oral anticoagulant use, h/o prior GIB,
PUD, NSAID use, alcohol/tobacco use, liver disease /
portal HTN, burn/trauma, severe vomiting, h/o H. pylori, GI
instrumentation, AAA repair
• History: HPI, PMHx, PSHx, Meds, ALL, SHx.
– Symptoms: none  postural hypotension, exertional dyspnea
– Coffee ground emesis (UGI)
• PE: remember to examine for signs of cirrhosis & portal
HTN (ascites, caput medusa, rectal varices)
• Tests: T&C, CBC, coags, BMP, LFT, CXR/KUB
Upper GI Bleeding
Management
• NGT/lavage -can identify UGI bleed
• Start proton pump inhibitor (PPI) infusion
• EGD-visualize bleeding source and treat
– Tx- sclerotherapy, epinephrine, banding, cautery
• For varices: octreotide infusiom -Reduces portal pressure,
vasoconstricts
• Tagged pRBC scan if cannot localize source
• More sensitive than angiography, Can detect bleeding rate >
3-10mL/hr
• AngiographyAngiography (Diagnostic & Therapeutic)
• Intra-arterial vasopressin
• Embolization
• Can detect bleeding rate > 30-50mL/hr
• If pt unstable and continues to require blood->consider OR
Upper GI Bleeding
PUD
• Most freq cause of UGI bleed
• Usually in 1st part of duodenum
– Anterior-perforate
– Posterior-bleed from GDA
• Spontaneous resolution in 80-90%
• OR – perforation, refractory bleeding, obstruction, Inability to
identify bleeding source
• Surgery –
– Duodenostomy, GDA ligation
– Truncal vagotomy and pyloroplasty
Upper GI Bleeding
Long-Term Management
• Test for H. pylori. Treatment = amoxicillin,
clarithromycin, and PPI
• Limit NSAID use
• H2B, PPI
Upper GI Bleeding
Esophagus
• Zenker’s Diverticulum – b/w cricophayngeas and pharyngeal
constrictors
– Sx- dysphagia, choking, halitosis, regurgitation of chewed food
– Dx: barium swallow
– Tx: cricopharyngeal myotomy +/- diverticulectomy
• Achalasia- failure of peristalsis and LES relaxation
– Sx- dysphagia, regurgitation, weight loss, resp sx
– Dx- manometry (inc LES pressure, incomplete LES relaxation, no
peristalsis)
– Tx- Medical- CCB, dialation, botox, Surgical-Heller myotomy
• GERD – Surgery for failure of med mgt, stricture, Barrett’s esophagus
– Dx- endoscopy, PH probe, manometry, UGI (make sure no motility
d/o)
– Tx- Nissen fundoplication 360 degree wrap
Upper GI Bleeding
Other Esophagus
• Para-esophageal hernia – 4 types, must repair
type 2. Repair with patch and Nissen
• Esophageal Cancer –
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Dx with endoscopy and biopsy followed by CT C/A
Adenocarcinoma – lower 1/3, most common
Squamous cell – upper 2/3, h/o etoh/tobacco use
Tx
• T1- esophagectomy +/- adjuvent C/R
• T2 – Gray area – If + Nodes then neoadjuvent C/R,
esophagectomy
• T3/T4 – Neoadjuvent C/R followed by esophagectomy +/adjuvent therapy