Upper gastrointestinal haemorrhage
Causes
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Peptic ulcer (50%)
Gastric erosions
Oesophageal or gastric varices
Mallory-Weiss tear
Angiodysplasia
Dieulafoy malformation
Gastric neoplasia
Management
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Patients should be managed according to agreed multidisciplinary protocols
Close collaboration between physicians and surgeons is vital
Aggressive fluid resuscitation is important
Circulating blood volume should be restored with colloid or crystalloid
Cross-matched blood should be given when available
All patients require closed monitoring
Possibly in an HDU or ITU environment with central and arterial pressure monitoring
Bleeding peptic ulcer
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80% bleeding stops spontaneously
25% require intervention for recurrent bleeding within 48 hours
It is difficult to predict those that will continue to bleed
All patients require early endoscopy (± intervention) to determine:
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Site of bleeding
Continued bleeding
Features of recent bleed
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Ooze from ulcer base
Clot covering ulcer base
Black spot in ulcer base
Visible vessel
Picture provided by Mohamed Husein, University of Ottawa, Canada
Recently shown that proton pump inhibitors may improve the outcome in non-variceal upper GI
haemorrhage
Endoscopic therapy
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Laser photocoagulation using the Nd-YAG laser
Bipolar diathermy
Heat probes
Adrenaline or sclerosant injection
No technique is superior
Comparative trials of different techniques are inconclusive
Indications for surgery
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Continued bleeding that fails to respond to endoscopic measures
Recurrent bleeding
Patients > 60 years
Gastric ulcer bleeding
Cardiovascular disease with predictive poor response to hypotension
Surgery for bleeding peptic ulcer
For duodenal ulcer
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Create gastroduodenotomy between stay sutures
Bleeding usually from gastroduodenal artery
Underun vessels with 2/0 nonabsorbable suture on round body needle
Avoid picking up common bile duct
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Close gastroduodenotomy as a pyloroplasty
Consider truncal vagotomy and pyloroplasty
 All patients should be given H. pylori eradication therapy post operatively
If a pyloroplasty will be difficult because of large ulcer consider Polya gastrectomy
For gastric ulcer
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Consider either local resection of ulcer or partial gastrectomy
Variceal upper gastrointestinal haemorrhage
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90% patients with portal hypertension have varices
30% patients with varices will have an upper gastrointestinal bleed
80% of GI bleed in patients with portal hypertension comes from varices
The mortality of a variceal bleed is approximately 50%
70% patients will have a rebleed
Survival is dependent on the degree of hepatic impairment
Primary prevention
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Bleeding from varices more likely if poor hepatic function or large varices
Primary prevention of bleeding is possible with β blockers
Reduces risk of haemorrhage by 40-50%
Band ligation may also be considered
Sclerotherapy or shunting is ineffective
Active bleeding
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Resuscitation should be as for other causes of upper GI haemorrhage
Endoscopy should be performed to confirm site of haemorrhage
Vasopressin and octreotide decrease splanchnic blood flow and portal pressure
Lactulose may be used to decrease GI transit and reduce ammonia absorption
Metronidazole and neomycin may be used to reduce gut flora
Temporary tamponade can be achieved with Sengstaken-Blackmore tube
o Should be considered as a salvage procedure
o Tamponade is 90% successful at stopping haemorrhage
o Unfortunately 50% patients rebleed within 24 hours of removal of tamponade
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A Sengstaken-Blackmore tube has three channels
o One to inflate the gastric balloon
o One to inflate the oesophageal balloon
o One to aspirate the stomach
Emergency endoscopic therapy includes:
o Endoscopic banding of varices
o Intravariceal or paravariceal sclerotherapy
o Sclerosants include ethanolamine and sodium tetradecyl sulphate
If endoscopic methods fail need to consider:
o Transection or devascularisation
o Porto-caval or mesenterico-caval shunting
Emergency shunting associated with 20% operative mortality and 50% encephalopathy
Shunting can also be performed non-surgically by transjugular intrahepatic porto-systemic
shunting (TIPSS)
Reduces risk of rebleeding but increases risk of encephalopathy
Mortality of the procedure ~1%
Secondary prevention
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70% of patients with an variceal haemorrhage will rebleed
The following have been shown to be effective in the prevention of rebleeding
o Beta-blockers possibly combined with isosorbide mononitrate
o Endoscopic ligation
o Sclerotherapy
o TIPSS
o Surgical shunting
Bibliography
Dagher L, Patch D, Burroughs A. Management of oesophageal varices. Hosp Med 2000; 61: 711717.
Ghosh S. Watts D, Kinnear M. Management of gastrointestinal haemorrhage. Postgrad Med J
2002; 78: 4-14.
Gotzsche P C. Somatostatin or octreotide for acute bleeding oesophageal varices. Cochrane
Database Syst Rev 2000; 2: CD000103.
Gow P J, Chapman R W. Modern management of oesophageal varices. Postgrad Med J
2001; 77: 75-81
Lau J Y W, Sung J J Y, Lee K K C et al. Effects of intravenous omeprazole on recurrent bleeding
after endoscopic treatment of bleeding peptic ulcers. N Eng J Med 2000; 343: 310-316.
Ohmann C, Imhof M, Roher H D. Trends in peptic ulcer bleeding and surgical management. World J
Surg 2000; 24: 284-293.
Rosch J, Keller F S. Transjugular intrahepatic portosystemic shunt: present status, comparison with
endoscopic therapy and shunt surgery and future perspectives. World J Surg 2001; 25: 337-346.
Sharara A I, Rockey D C. Gastroesophageal variceal hemorrhage. N Eng J Med 2001; 345: 669681.
Stabole B E, Stamos M J. Surgical management of gastrointestinal bleeding. Gastroenterol Clin
North Am 2000; 29: 189-222.