ACUTE UPPER GASTROINTESTINAL HEMORRHAGE Upper GI bleeding refers to bleeding that arises from the GI tract proximal to the ligament of Treitz Common Causes of Upper Gastrointestinal Hemorrhage NONVARICEAL BLEEDING (80%) Peptic ulcer disease 3050% Mallory-Weiss tears 1520% Gastritis or duodenitis 1015 Esophagitis 5-10% Arteriovenous malformations 5% Tumors 2% PORTAL HYPERTENSIVE BLEEDING (20%) Gastroesophageal varices >90% Hypertensive portal gastropathy <5% Isolated gastric varices Rare Although patients with cirrhosis are at high risk for developing variceal bleeding, even in these patients, nonvariceal sources account for most of the episodes of GI hemorrhage The foundation of diagnosis and management of patients with an upper GI bleed is an EGD. Multiple studies have demonstrated that early EGD (within 24 hours) results in reductions in blood transfusion requirements, a decrease in the need for surgery, and a shorter length of hospital stay. Endoscopic identification of the source of bleeding also permits an estimate of the risk for subsequent or persistent hemorrhage as well as facilitating operative planning, should that prove necessary. In general, 20% to 35% of patients undergoing EGD will require a therapeutic endoscopic intervention, and 5% to 10% will eventually require surgery Peptic Ulcer Disease PUD still represents the most frequent cause of upper GI hemorrhage, accounting for about 40% of all cases Bleeding develops as a consequence of acid-peptic erosion of the mucosal surface. Although chronic blood loss is common with any ulcer, significant bleeding typically results when there is involvement of an artery, either of the submucosa or, with penetration of the ulcer, an even larger vessel. . Although duodenal ulcers are more common than gastric ulcers, gastric ulcers bleed more commonly; as a result, in most series, the relative proportions are nearly equal. The most significant hemorrhage occurs when duodenal or gastric ulcers penetrate into branches of the gastroduodenal artery or left gastric artery, respectively Algorithm for the diagnosis and management of nonvariceal upper GI bleeding Indications for Surgery in Gastrointestinal Hemorrhage Hemodynamic instability despite vigorous resuscitation (>6 units transfusion) Failure of endoscopic techniques to arrest hemorrhage Recurrent hemorrhage after initial stabilization (with up to two attempts at obtaining endoscopic hemostasis) Shock associated with recurrent hemorrhage Continued slow bleeding with a transfusion requirement exceeding 3 units/day Mallory-Weiss Tears Mallory-Weiss tears are mucosal and submucosal tears that occur near the gastroesophageal junction. Classically, these lesions develop in alcoholic patients after a period of intense retching and vomiting after binge drinking, but they can occur in any patient who has a history of repeated emesis. The mechanism, proposed by Mallory and Weiss in 1929, is forceful contraction of the abdominal wall against an unrelaxed cardia, resulting in mucosal laceration of the proximal cardia as a result of the increase in intragastric pressure. Stress Gastritis Stress-related gastritis is characterized by the appearance of multiple superficial erosions of the entire stomach, most commonly in the body. It is thought to result from the combination of acid and pepsin injury in the context of ischemia from hypoperfusion states, although NSAIDs produce a very similar appearance. it was a commonly encountered lesion in critically ill patients, with significant morbidity and mortality from bleeding. These lesions are different from the solitary ulcerations, related to acid hypersecretion, that occur in patients with severe head injury (Cushing's ulcers). When stress ulceration is associated with major burns, these lesions are referred to as Curling's ulcers. In contrast to NSAID-associated lesions, significant hemorrhage from stress ulceration was a common phenomenon. Esophagitis The esophagus is infrequently the source of significant hemorrhage. When it does occur, it is most commonly the result of esophagitis. Esophageal inflammation secondary to repeated exposure of the esophageal mucosa to the acidic gastric secretions in gastroesophageal reflux disease (GERD) leads to an inflammatory response, which can result in chronic blood loss. Ulceration may accompany this process, but the superficial mucosal ulcerations generally do not bleed acutely, but rather present as anemia or guaiacpositive stools. A variety of infectious agents may also cause esophagitis, particularly in the immunocompromised host ( Fig. 46-5 ). With infection, hemorrhage can occasionally be massive. Other causes of esophageal bleeding include medications, Crohn's disease, and radiation. Dieulafoy's Lesion Dieulafoy's lesions are vascular malformations found primarily along the lesser curve of the stomach within 6 cm of the gastroesophageal junction, although they can occur elsewhere in the GI tract ( Fig. 46-6 ). They represent rupture of unusually large vessels (1-3 mm) that are found in the gastric submucosa. Erosion of the gastric mucosa overlying these vessels leads to hemorrhage. The mucosal defect is usually small (2-5 mm) and may be difficult to identify. Given the large size of the underlying artery, bleeding from a Dieulafoy's lesion can be massive. Malignancy Malignancies of the upper GI tract are usually associated with chronic anemia or hemoccult-positive stool rather than episodes of significant hemorrhage. On occasion, malignancies present as ulcerative lesions that bleed persistently. This is perhaps most characteristic of the GI stromal tumor (GIST), although it may occur with a variety of other lesions, including leiomyomas and lymphomas. Although endoscopic therapy is often successful in controlling hemorrhage, the rebleeding rate is high; therefore, when a malignancy is diagnosed, surgical resection is indicated. Gastric Antral Vascular Ectasia Also known as “watermelon stomach,” gastric antral vascular ectasia (GAVE) is characterized by a collection of dilated venules appearing as linear red streaks converging on the antrum in longitudinal fashion, giving it the appearance of a watermelon. Acute severe hemorrhage is rare in GAVE, and most patients present with persistent, iron deficiency anemia from continued occult blood loss. Aortoenteric Fistula Primary aortoduodenal fistulas are rare lesions developing in up to 1% of aortic graft cases Hemobilia Hemobilia is often a difficult diagnosis to make. It is typically associated with trauma, recent instrumentation of the biliary tree, or hepatic neoplasms. This unusual cause of GI bleeding is suspected in anyone who presents with hemorrhage, right upper quadrant pain, and jaundice. Unfortunately, this triad is seen in less than half of patients, and a high index of suspicion is required. Endoscopy can be helpful by demonstrating blood at the ampulla. Angiography is the diagnostic procedure of choice. If diagnosis is confirmed, angiographic embolization is the preferred treatment. Hemosuccus Pancreaticus Another rare cause of upper GI bleeding is bleeding from the pancreatic duct, or hemosuccus pancreaticus. This is typically caused by erosion of a pancreatic pseudocyst into the splenic artery. It presents with abdominal pain and hematochezia. As with hemobilia, it is a difficult diagnosis to make and requires a high index of suspicion in patients with abdominal pain, blood loss, and a past history of pancreatitis. Angiography is diagnostic and permits embolization, which is often therapeutic. In cases that are amenable to a distal pancreatectomy, this procedure often results in cure. Iatrogenic Bleeding Upper GI bleeding may follow therapeutic or diagnostic procedures. As described, hemobilia may be iatrogenic in nature, particularly after percutaneous transhepatic procedures. Another common cause of iatrogenic bleeding is endoscopic sphincterotomy. This can occur in up to 2% of cases. It is often mild and self-limited. Late hemorrhage usually occurs within the first 48 hours and may require injection of the area with epinephrine. Surgical intervention is rarely required. Percutaneous endoscopic gastrostomy (PEG) placement is an increasingly common procedure. Bleeding rates of up to 3% have been reported. Although most of these cases reflect bleeding from the incision site, some are due to bleeding from the gastric mucosa ( Fig. 46-8 ). This can often be controlled endoscopically.