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Massive Upper GI Bleeding John Meisel MD 28 year old man presented with hematemesis of 1 liter of blood one hour ago He was weak and sweaty Physical examination was otherwise normal: no jaudice, ascites, abdominal mass, cachexia, telangectasia, Lecture will discuss how to deal with him and patients with similar problems Copy of lecture at: www.drmeisel.com Massive Upper Gastro- intestinal Bleeding A medical emergency; mortality 8-9% Upper GI bleeding 5X more common than lower Good treatment improves outcome Chronic Upper GI Bleeding (will not discuss) Presents often with Microcytic anemia in the absence of pain Usually some symptom to suggest diagnosis: weight loss, dysphagia, abdominal pain, vomiting Most common cause in the world of GI bleeding and Microcytosis is Hookworm! Massive Upper GI Bleeding Clinical Presentation Sudden Weakness, sweating, nausea, syncope Postural Hypotension before tachycardia Blood Loss: Hematemesis or melena Iron and Bismuth cause black stools Stools may not be seen for 4-6 hours because of slow GI transit in some patients It takes 100 cc blood to produce melena, which can come from nose to right colon. Upper GI Bleeding Common Causes Peptic Ulcers: 1/3 have no preceding pain before bleeding Esophageal Varices from cirrhosis Mallory Weiss Tear: gastroesophageal junction injury from vomiting or wretching Gastritis: usually from anti inflammatories, alcohol, Cancer of esophagus, stomach Many rare causes, including Dieulafoy’s(superficial pseudoanurysem of mucosa without ulcer: intermittent arterial bleeding) Evaluation The medical History Exact description of events, including number and volume of stools or vomitus Medicines, including anything taken except food. (Baby Aspirin often forgotten) Other illnesses: clues to severity, possible cause Prior GI complaints: pain, trouble swallowing, weight loss, During history, IVs are being started, blood is being drawn(rapid treatment improves outcome Physical Examination Vital Signs: BP initially low, then tachycardia, check repeatedly Pallor(only if anemic), lymph nodes, abdominal mass, liver or spleen, rectal to test stool for blood Rarer findings: bruising with coagulopathy, arthritis as clue for anti inflammatories, telangectasia, abdominal scars of trauma or surgery, bruits of vascular disease, ascites from liver disease Immediate Treatment IV fluids: or sips of liquids in emergency Bed rest with legs up Check Blood counts: remember with acute bleeding counts unchanged till diluted with IV fluids or time Type and Cross match Blood: do not give unless under 24% unless heart/lung disease Immediate Treatment Naso-gastric tube ?: can tell if active bleeding or not, reliable if bile obtained. Only used 50%; Unless vomiting persistent If bright red blood, urgent endoscopy Benefits of Endoscopy: Not just because we want to know, but does it really help the patient? The characteristics of the ulcer will define prognosis, need for hospitalization (Visible vessel or active bleeding 90% vs. clean ulcer 5% chance of re-bleeding:( Lee,JG, Gastro Endo 1999) Decrease the need for transfusion Decrease the need for surgery (Injection of Erythromycin will help clear stomach before endo(Gastro 202;123:17) If endoscopy delayed 12-24 hours, use only if dysphagia, continued bleeding, weight loss or other alarm symptoms present Endoscopic Therapy Stopping Ulcer Bleeding Electrocautery: monopolar or bipolar(Bicap) Bipolar safer because injury more superficial Clips Injection: 1;10,000 epinephrine or other solution (works by vasospasm and tamponade Banding. May cause bowel necrosis if applied to deeper Combination Treatment: most common Epinephrine and Bicap Argon Plasm Coagulation: Deeper, controlled burn: Expensive Fibrin Sealant: Experimental, but seals fistulae Endoscopic Therapy Results About 1/25 bleeders can not be stopped and require surgery Some require second endoscopy, and 75% are successfully treated IV Omeperazole by Infusion: may be helpful but very expensive Surgery is usually over sew ulcer in USA(where availability and cost of medicines better than long term side effects of ulcer surgery(diarrhea, weight loss); Definitive ulcer operation sensible elsewhere to avoid lifetime medications. Common Causes of Bleeding Gastric or Duodenal Ulcers: In USA 50% Helicobacter, 50% Anti inflammatories A very good medication history Blood test for antibodies, Stool for Antigen, Biopsy or assume everyone positive (Cambodia) Esophagitis from reflux plus anti inflammatories: can be focal ulcer Tear at GE junction from Vomiting: Mallory Weiss tear: sometimes needs clips, injection Common Causes of Bleeding Gastritis: from drugs, alcohol, stress, cannot be focally treated endoscopically,usually not massive Cancer: Temporarily stopped endoscopically Esophageal Varices from Cirrhosis: Banding better than sclerotherapy Multiple Rare causes Other Issues GI Bleeding No need to treat Helicobacter acutely Transfusion: Hct <22%, elderly <26% Endoscopy also allows us to triage Clean based ulcer: watch 24 Hr, or discharge, the chance of rebleeding ,5% Clot, visible vessel: rebleeding 12-20% Actively Bleeding: higher, surgery possible Prevention of Bleeding Identified Cause will allow for Prevention If anti inflammatories the cause, treat with alternative medicine for headaches/arthritis, etc or the patient will start taking them again Adequate treatment duration: Duodenal ulcers treat for 6 weeks; Gastric ulcers for 3 months; Treat Helicobacter; Test for cure Stool or Breath test (Blood antibodies will persist) Some Patients will re-bleed without antiinflammatories and Helicobacter treated: about 20% of ulcers: Other causes yet to be discovered.
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