GI - Upper GI Bleed Flashcards
Common causes of UGIB
Peptic ulcer disease (most common)
Gastro-esophageal varices
Esophagitis, Gastritis or duodenitis
Gastric malignancies
Mallory-Weiss syndrome
Rarer causes of UGIB
Oesophageal tumour
Stomach
Portal hypertensive gastropathy, GAVE, Dieulafoy’s lesion
Small bowels
Aortoduodenal fistula, angiodysplasia, GI stromal tumour (GIST), diverticular bleeding, Crohn’s disease
Biliary tree
Haemobilia, haemosuccus pancreaticus
Variceal hemorrhage
- Bleeding pattern
- Cause
- Relevant history
Bleeding pattern:
Large volume haematemesis/melena ± haematochezia (seldom coffee ground)
Cause: Liver cirrhosis, Portal hypertension leading to collateral vein distension
Relevant history:
Chronic hepatitis carrier status
Hx of cirrhosis and chronic liver disease
Hx of oesophageal varices with banding
Esophagitis causing UGIB
- Bleeding pattern
- Cause
- Relevant history
Bleeding pattern: Usually haematemesis only
Causes: Reflux, Radiation, Infection, drugs, scleroderma…etc
Relevant history:
Reflux: obesity, middle aged, Hx of heartburn, acid regurgitation, acid/water brash
Irradiation: Hx of H&N and thoracic malignancy
Infectious: usually in immunocompromised patients (Candida, HSV, CMV)
Drug-induced: NSAID, tetracyclines, alendronate, Potassium Chloride
Sclerotherapy-induced: Hx of endoscopic intervention
Mallory-Weiss tears
- Bleeding pattern
- Cause
- Relevant history
Bleeding pattern: small volume bleeding
Cause:
Longitudinal mucosal lacerations in distal oesophagus and proximal stomach
caused by violent retching
Relevant history:
Hx of repeated vomiting and its predisposing factors (alcoholism, chemotherapy)
Hx of sudden ↑intra-abd pressure¸ eg. straining, seizures, blunt abd injury
Gastritis or Duodenitis
- Bleeding pattern
- Cause
- Relevant history
Bleeding pattern: minor bleeding, self-limiting
Causes: Drugs, alcohol, stress
Relevant history:
Drug induced due to local (GI) and systemic effect (blood) of aspirin and NSAIDs
Alcohol-induced: Acute (esp after binge drinking) or chronic
Stress gastritis: ICU patients with resp failure, hypotension, sepsis, renal failure, burns
Dieulafoy’s lesion
- Bleeding pattern
- Cause
- Relevant history
Bleeding pattern: Often self-limiting bleeding but can be recurrent and profuse
Cause:
Vascular malformation with idiopathic dilated aberrant submucosal vessels eroding overlying normal mucosa, at gastric fundus
Relevant finding:
Pool of blood in stomach w/o any localizing lesion
UGIB without localization
Portal HTN gastropathy
- Bleeding pattern
- Cause
- Relevant history
Bleeding pattern: Rarely bleeds, only in severe/ late presentation
Cause: Liver Cirrhosis
Relevant history:
Endoscopy incidental finding: gastric mucosa with mosaic, snakeskin appearance
Hx of liver cirrhosis
Gastric antral vascular ectasia (GAVE)
- Bleeding pattern
- Cause
- Relevant history
Bleeding pattern:
Melena or haematochezia, not acute profuse bleeding
Cause:
- dilated antral small blood vessels of unknown cause
- giving rise to erythematous bands with watermelon appearance on endoscopy
Relevant history:
History of cirrhosis, Scleroderma, CKD,
List upper GI malignancies that can cause UGIB
Bleeding pattern
Relevant history
Examples:
CA oesophagus, adenoCA of stomach, GIST, lymphoma, duodenal CA
Bleeding pattern:
self-limiting bleed but can be severe
Relevant history:
Hx of dysphagia (CA oesophagus/cardia)
Hx of ulcer-like discomfort, early satiety, bloating (CA stomach)
Constitutional S/S, eg. loss of weight, loss of appetite
Peptic ulcer disease
- Bleeding pattern
- Ulcer sites
- Relevant history
Bleeding pattern: Variable bleeding ± prior epigastric pain
Sites: duodenal, gastric, oesophageal, stomal (eg. jejunal side of gastrojejunostomy)
Ulcers high on lesser curve and in postero-inferior wall of D1 bleed more easily
Relevant history:
Hx of dyspepsia
Hx of H. pylori infection: urea breath test, OGD, triple therapy
DHx of NSAIDs, antiplatelets, steroids, anticoagulants, TCM
Recent Hx of stress, eg. burns (Curling ulcer), ↑ICP (Cushing’s ulcer)
Angiodysplasia-caused UGIB
- Bleeding pattern
- Cause
- Site
- Relevant history
Bleeding pattern: Variable
Cause: vascular malformation
Sites: usually in colon, can occur in stomach and duodenum
Relevant history: Advanced age Hx of aortic valve disease Hx of chronic renal failure Hx of hereditary haemorrhagic telangiectasia Hx of prior RT
Aortoenteric fistula
- Bleeding pattern
- Cause
- Site
- Relevant history
Bleeding pattern: Life-threatening, severe bleed
Cause: erosion of AAA into GI tract, after graft repair as graft infection erode into duodenum and create fistula between duodenum and aorta
Site: D3/4 (aorta just behind)
Relevant history:
Hx of endovascular Tx or aortic surgery
Hx of AAA
Differentiate acute vs chronic UGIB presentation
Acute:
- Haematemesis
- Coffee ground vomiting
- Fresh blood or coffee ground vomit from NG tube
- Fresh PR bleeding/ Haematochezia
- Melaena
Chronic bleed:
- Small amount: asymptomatic iron deficiency anaemia, fecal occult blood test positive
- Moderate amount: symptomatic anaemia, melena
Differentiate ongoing/ severe UGIB vs Slow/ stopped UGIB
Ongoing/ severe:
- Hematemesis
- Fresh melena
Slow/ stopped:
- Coffee ground vomit
- Stale melena
Coffee ground vomitus
- Cause of appearance
- Associated diseases
- Bleeding severity
- Cause: UGI blood oxidized by gastric acid → vomitus containing methaemoglobin
- Associated diseases: gastric ulcers, gastritis, small amounts of variceal blood
- Bleeding severity: mild bleeding from stomach or beyond
Haematemesis
- Cause of appearance
- Associated diseases
- Bleeding severity
- Cause: vomiting of fresh, unaltered blood → increase time spent in stomach → oxidization → red colour turns brown gradually
- Associated diseases: variceal bleeding, Mallory-Weiss tears, AV malformation
- Bleeding severity: Indicates: moderate-to-severe bleeding or from a source proximal to stomach
Melena
- Distinguish fresh vs stale melena
- Cause of appearance
- Important Ddx
- Bleeding severity
Fresh melaena = haematin + Hb; jet black with tarry non-particulate liquid stools
→ indicates acute ongoing bleeding
Old (stale) melaena = haematin only; black-grey, dull and mixed with normal stools
→ indicates bleeding has stopped
Cause: blood in GI tract digested by gut bacteria enzymes → black haematin in stools → hematin is a cathartic substance that induces diarrhea
Ddx: iron stools from iron supplements, differences: - More likely to be constipated - solid, green/black stools - Not pungent smell like melena
Bleeding severity:
indicates LGIB unless very profuse UGIB
Outline history taking for UGIB
- Ascertain true UGIB: rule out hemoptysis, upper airway bleed
- Assess urgency and resuscitation: S/S of hypovolemic shock, anaemia S/S
- Characterize bleed
- Nature, number of times, amount, duration
- Bleeding history - Screen for underlying causes:
- Variceal bleed, Peptic ulcer bleed …etc - S/S of malignancies
- Constitutional symptoms
- Early satiety, dysphagia
- Signs of metastasis: liver, lungs…etc
- Family history - Associated symptoms, precipitating factors:
- Bleeding tendencies
- Alcohol use
- Caustic substance ingestion
- DRUGS
Questions to screen for variceal bleeding in history taking
□ Hx and S/S of liver disease: ascites, jaundice, hepatic encephalopathy (these pt can still have ulcers)
□ RFs of chronic liver disease: hepatitis carrier status, alcoholism, FHx of HCC/hepatitis
□ Hx of previous variceal bleeding: any previous UGIB, OGD, banding
Questions to screen for peptic ulcer bleeding in history taking
Previous dyspepsia/meal-related pain: ↑with eating (gastric) vs ↓with eating (duodenal)
Hx of peptic ulcer ± bleeding: ulcer recurrence
Hx of H. pylori testing, treatment and F/U:
→ could be Hp-negative peptic ulcers (eg. drug-induced)
Recent use of NSAIDs and TCM (some TCM may contain NSAIDs)
Recent severe metabolic stress, eg. burns, ↑ICP
Ddx the following associated symptoms with UGIB
□ Dysphagia □ Vomiting □ Heartburn, acid regurgitation □ Early satiety □ Epigastric pain
□ Dysphagia: painful (oesophagitis, ulcers), painless (malignancy)
□ Vomiting: eg. repeatedly, a/w alcohol → Mallor-Weiss tears
□ Heartburn, acid regurgitation: reflux oesophagitis
□ Early satiety: malignancy, peptic ulcer
□ Epigastric pain: peptic ulcer, gastritis, malignancy
Drug history for UGIB
Give rationale behind each drug
Aspirin - Transient gastritis, antiplatelet
NSAIDs - peptic ulcer
Anticoagulant and antiplatelets
Cardiac drugs - beta blocker - Slow HR may mask effect of hypovolemia, suppress reflex tachycardia
Iron - Black stool mimic melena
Outline physical exam for UGIB
- Confirm bleed:
- Examine vomitus/ NG tube
- Perform PR exam for melena - General exam to r/o hypovolemia and anaemia
- BP, HR, hydration status, pallor…etc - Malignancy
- Cervical LN
- Abdominal masses/ organomegaly - Liver cirrhosis and PHTN
- Caput medusae, splenomegaly, shifting dullness, peritoneal signs - Hereditary vascular anomalies
- e.g. Telecgiectasiae in HHT - Occult bleed in nose/ mouth
First-line investigations and rationale for UGIB
CBC: Hb, MCV, Platelet, Haemocue
LFT: liver diseases, Ammonia for cirrhosis
RFT: electrolytes and Urea/Creatinine
- U/C ratio >100:1 indicates breakdown of GI blood and hypovolemia
Clotting profile: bleeding tendencies
T/S, cross-match for transfusion
Erect CXR for aspiration pneumonia and perforations
NGT suction if uncertain bleeding source
Resuscitation methods for severe UGIB
Secure hypovolemic shock:
- ABC
- Nil by mouth +/- NG tube for decompression
- Large bore IV cannula (rapid fluid resuscitation)
- Group O Rh-ve blood with colloids for immediate transfusion
- T/S and cross-match + Haemocue + Basic blood panels
- Erect CXR for perforation and pneumonia
Stop bleeding:
- Medication: PPI, prokinetics, Vasoactive drugs
- Immediate OGD
- Balloon tamponade for uncontrollable variceal bleed
Monitoring of resuscitation after severe UGIB
Monitoring by:
□ Shock chart hourly
□ Vitals: BP/P, RR, body temp
□ Foley’s catheter: IV fluid to aim urine output ≥0.5mL/kg/h
□ Cardiac monitor, pulse oximetry
□ ± CVP line for PAWP (pulmonary arterial wedge pressure)
Medication before OGD to investigate UGIB
IV PPI
IV prokinetics (eg. erythromycin, metoclopramide): ↑gastric emptying → improve gastric visualization in OGD
Reversal of coagulopathy if any (eg. stopping aspirin, vitamin K + PCC for warfarin)
Immediate medical treatment of variceal bleeding
Vasoactive medications (eg. somatostatin, terlipressin) → ↓portal pressure → ↓bleeding
Abx prophylaxis (IV augmentin, IV levofloxacin) → ↓2o infection
Consider lactulose for HE
Methods to locate source of UGIB
□ Upper endoscopy (first-line)
□ Colonoscopy for LGI sources
□ ± capsule endoscopy, double/single balloon enteroscopy for small bowel sources
□ ± RBC scan, angiography for occult bleeding
Name of classification for peptic ulcer and re-bleeding chance
Function of classification?
Forrest’s classification (endoscopic stigmata of recent haemorrhage, ESRH)
Role:
- stratify endoscopic finding in bleeding peptic ulcers
- estimate chance of rebleeding
- guide whether endoscopic Tx is required
Outline the Forrest’s classification for Peptic ulcer bleeds
Endoscopic modalities of UGIB treatment
Endoscopic Tx modalities: usually dual therapy (adrenaline + another modality)
- Adrenaline injection: volume effect, induce vasoconstriction, attract platelet for thrombosis
- Thermal cauterization (with risk of perforation)
- Heat probes
- Laser coagulation
- Argon plasma coagulation - Mechanical (haemoclip) for large visible vessels, colonic diverticular bleeding and temporary control in Mallory-Weiss tears
- Haemospray: Nanopowder to induce haemostasis
- Band ligation/sclerotherapy: for varices
Complications of Endoscopic treatment of UGIB
□ Anaesthetic risk: respiratory depression, MI, CVA
□ Procedure-related: aspiration, bleeding, perforation, failure of haemostasis, failure of complete scope (to D2)
Monitoring after endoscopic treatment of UGIB
Close monitoring for rebleeding
- Inpatient care for 3 days
- Check S/S of rebleeding: ↑pulse rate, haematemesis, fresh blood from NGT, fresh melaena, sudden ↓Hb
- Second-look endoscopy if suspicious of recurrent bleed
Risk factors for recurrent UGIB
- Severity at presentation
- Patient factors
- Location of bleed
Presentation:
- Shock at presentation
- Hb <8.0g/dL at presentation
- Require Transfusion
Patient factors:
- Age >60
- Multiple comorbidities
- Coagulopathy with medication
Location of bleed:
- Large ulcer on posterior D1 > Close to gastroduodenal artery
- Large ulcer on high posterior lesser curvature > Close to left gastric artery
Open surgery for UGIB
- Indications
- Methods (3)
Indications: usually for ulcers
- Endoscopy failed/ not available
- Massive bleeding with significant haemodynamic instability
- Associated perforations
Methods:
- Plication and closure of duodenal ulcer + Truncal Vagotomy + Pyloroplasty (after vagotomy to stop pylorus spasm)
- Plication with biopsy of gastric ulcer (malignant potential)
- Gastric ulcer resection: ulcerectomy, partial gastrectomy ± reconstruction (usu Billroth I or II)
