NON-VARICEAL UPPER GI HEMORRHAGE –ADVANCES IN DIAGNOSIS AND TREATMENT

SPEAKER – IPSEET MISHRA

CHAIRPERSONS – PROF. N. C. NATH DR. A. MAJI

ACUTE GASTROINTESTINAL HEMORRHAGE

UPPER GI HEMORRHAGE LOWER GI HEMORRHAGE

NON-VARICEAL VARICEAL COLONIC SMALL INTESTINAL BLEEDING BLEEDING BLEEDING BLEEDING

1. PEPTIC ULCER DISEASE2. MALLORY-WEISS TEARS3. GASTRITIS OR DUODENITIS4. ESOPHAGITIS5. ARTERIOVENOUS MALFORMATION6. TUMOURS

1. GASTRO-ESOPHAGEAL VARICES2. HYPERTENSIVE PORTAL GASTROPATHY3. ISOLATED GASTRIC VARICES

1. DIVERTICULAR DISEASE2. ISCHEMIA3. ANORECTAL DISEASE4. NEOPLASIA5. INFECTIOUS COLITIS6. POST-POLYPECTOMY7. IBD8. ANGIODYSPLASIA9. RADIATION COLITIS

1. ANGIODYSPLASIAS2. EROSIONS,ULCERS3. CROHN’S DISEASE4. RADIATION5. MECKEL’S

DIVERTICULUM6. NEOPLASIA7. AORTOENTERIC

FISTULAS

Upper GI bleeding refers to bleeding that arises from the GI tract proximal to the ligament of Treitz; it accounts for almost 80% of significant GI hemorrhage.

The nonvariceal causes account for approximately 80% of this bleeding, with peptic ulcer disease being the most common.

In the remaining 20% of patients, most of whom have cirrhosis, portal hypertension can lead to the development of gastroesophageal varices, isolated gastric varices, or hypertensive portal gastropathy.

Although patients with cirrhosis are at high risk of developing variceal bleeding, nonvariceal sources account for most upper GI bleeds,even in these patients.

CAUSESCause of Bleeding Relative Frequency(%)

Peptic Ulcer 30-50

Mallory Weiss tear 15-20

Gastritis/Duodenitis 10-15

Oesophagitis 5-10

Vascular Malformation 5

Tumours 2

Other (e.g. Aortoenteric fistula) 5

Takes priority over determining the diagnosis/cause

• ABC (main focus is ‘C’)• Oxygen: Non-rebreathing mask• 2 large bore cannula into both ante-cubital fossa

• Take bloods at same time for CBC, Urea/Crt, LFT, BT/CT/PT, X match 6Units

• Catheterise• IVF initially then blood as soon as available (depending on urgency: O-, Group

specific, fully X-matched)• Monitor response to resuscitation frequently (HR, BP, urine output, level of

consciousness, peripheral temperature, CRT)• Stop anti-coagulants and correct any clotting derangement• NG tube and aspiration (will help differentiate upper from lower GI bleed)• Organise definitive treatment (endoscopic/radiological/surgical)

Emergency Resuscitation

RR, HR, BP, Urine output and Mental status can be used to estimate degree of blood loss/hypovolaemia

ESTIMATING DEGREE OF BLOOD LOSS

Class I Class II Class III Class IV

Volume Loss (ml)

0-750 750-1500 1500-2000 >2000

Loss (%) 0-15 15-30 30-40 >40

RR 14-20 20-30 30-40 >40

HR <100 >100 >120 >140

BP Unchanged Unchanged Reduced Reduced

Urine Output (ml/hr)

>30 20-30 5-15 Anuric

Mental State Restless Anxious Anxious/confused

Confused/ lethargic

ACUTE UPPER GI HEMORRHAGE

DIAG

NO

SIS

Upper GI Endoscopy or Esophagogastroduodenoscopy (EGD) is the key to the diagnosis of Upper GI Hemorrhage.

Early EGD within 24 hrs results in – identification of the lesion - reduction in blood transfusion

requirement - decrease in need for surgery - shorter hospital stay - estimation of risk of subsequent or

persistent hemorrhage

Studies have shown that early EGD sooner than within 24 hrs has no extra benefit due to increased risk and poor visualization.

For improving visualization – aggressive lavage of stomach with room temp normal saline

- single bolus injection of erythromycin for gastric emptying

DIAGNOSTIC ALGORITHM

FORREST CLASSIFICATION FOR ENDOSCOPIC FINDINGS AND RE-BLEEDING RISK

Grade Ia Grade IIa

Grade IIb Grade IIc Grade III

Radionuclide Scanning

Radionuclide scanning with 99mTc–labeled RBC is the most sensitive but least accurate method for localizing GI bleeding.

With this technique, the patient’s own red cells are labeled and reinjected. The labeled blood is extravasated into the GI tract lumen, creating a focus that can be detected scintigraphically. Initially, images are obtained frequently and then at 4-hour intervals, for up to 24 hours.

The RBC scan can detect bleeding as slow as 0.1 mL/min and is reported to be more than 90% sensitive. Reported accuracy of localization is in the range of only 40% to 60% and it is particularly inaccurate for distinguishing right-sided from left-sided colonic bleeding.

The RBC scan is not usually used as a definitive study before surgery but instead as a guide to the usefulness of angiography; if the RBC scan is negative or only positive after several hours, angiography is unlikely to be revealing. Such an approach avoids the significant morbidity of angiography.

Mesenteric Angiography

Selective angiography, using the superior or inferior mesenteric arteries, can detect hemorrhage in the range of 0.5 to 1.0 mL/ min but is generally only used for the diagnosis of ongoing hemorrhage.

It can be particularly useful in identifying the vascular patterns of angiodysplasias. It may also be used for localizing actively bleeding diverticula.

Catheter-directed vasopressin infusion can provide temporary control of bleeding, permitting hemodynamic stabilization, although as many as 50% of patients will rebleed when the medication is discontinued. It can also be used for embolization. Typically, such therapy is reserved for patients whose underlying condition precludes surgical therapy.

Unfortunately, angiography is associated with a significant risk of complications, including hematoma, arterial thrombosis, contrast reaction, and acute renal failure.

• Emergency resuscitation • Esophagoduodenoscopy – urgent (within 24 hrs of admission)• Pharmacology

• PPI (infusion) – pH >6 stabilises clots and reduces risk of re-bleeding following endoscopic haemostasis

- PPI @ 8mg/hr is indictated.• Tranexamic acid (anti-fibrinolytic) – maybe of benefit (more

studies needed)• If H pylori positive → eradication therapy (only 60-70% of

patients with bleeding ulcer are H.pylori positive unlike perforated ulcers)

• Stop NSAIDs/aspirin/clopidogrel/warfarin/steroids/SSRIs if safe to do so (risk:benefit analysis)

MANAGEMENT

Endoscopic therapy - Epinephrine injection (1 : 10,000) - to all four quadrants of the lesion. - Large-volume injection (>13 mL) gives better hemostasis - Associated with high rebleeding rate;

standard practice is combination therapy. - Thermal energy - can be heater probes, monopolar or bipolar electro-

coagulation, or laser or argon plasma coagulation (APC). - The most commonly used energy sources are electro- coagulation for bleeding ulcers and APC for superficial lesions.

- Hemoclips - studies have reported mixed results. - may be particularly effective when dealing with a spurting vessel because they provide immediate control of hemorrhage.

Second attempt at Endoscopic hemostasis is successful in 75% patients before subjecting to surgery without any increase in morbidity or mortality and thus, should be encouraged.

Ag Plasma Coagulation

Hemoclip

Endoscopic Injection

Angiographic techniques

- Are somewhat more generic and include selective angiography with infusion of a vasoconstrictor, typically vasopressin, or embolization.

-Embolic agents include temporary materials such as gelatin sponge (Gelfoam; Pharmacia & Upjohn, Pfizer, New York) and autologous clot or permanent devices such as coils.

- There are few data comparing the efficacy of these techniques.

Surgical therapy

- Approx. 10% of patients with bleeding ulcers still require surgery. - Indications - Hemodynamic instability despite vigorous

resuscitation (>6 U transfusion) - Failure of endoscopic techniques to arrest hemorrhage - Recurrent hemorrhage after initial stabilization (with up

to two attempts at obtaining endoscopic hemostasis) as in >2cm ulcers, posterior duodenal ulcers or gastric ulcers

- Shock associated with recurrent hemorrhage - Continued slow bleeding with a transfusion requirement >3 U /day

The first priority at operation should be control of the hemorrhage. Oncethis is accomplished, a decision must be made regarding the need for adefinitive acid-reducing procedure.

Definitive surgical therapy

1. Duodenal Ulcer - longitudinal duodenotomy or duodenopyloromyotomy - Control initially with pressure and then direct suture ligation with nonabsorbable suture.

- Four-quadrant suture ligation for anterior ulcer. - suture ligation of the vessel proximal and distal to the ulcer, as

well as placement of a U stitch for posterior ulcers eroding into pancreaticoduodenal or gastroduodenal artery

- pyloroplasty or antrectomy combined with truncal vagotomy

2. Gastric ulcer - gastrotomy and suture ligation - distal gastrectomy combined with resection of a tongue of proximal stomach to include the ulcer - vagotomy and pyloroplasty combined with wedge resection - Proximal or near-total gastrectomy for bleeding ulcers of the

proximal stomach near the gastroesophageal junction.

3. Mallory-Weiss Tears - high gastrotomy and suturing of the mucosal tear is indicated if all other measures fail.

4. Stress Gastritis - vagotomy and pyloroplasty with oversewing of the hemorrhage or near-total gastrectomy.

5. Dieulafoy’s Lesion – gastrostomy with oversewing of ulcer or partial gastrectomy in patients in whom the bleeding point is not

identified

6. Gastric Antral Vascular Ectasia – Antrectomy for patients failing endoscopic therapy

7. Malignancy - surgical resection when a malignancy is diagnosed. - The extent of resection is dependent on the specific lesion,

whether the resection is believed to be curative or palliative and the hemodynamic stablity of the patient.

Identifies patients at risk of adverse outcome following acute upper GI bleed

Score <3 carries good prognosis Score >8 carries high risk of mortality

Risk stratification: ROCKALL SCORE

Variable Score 0 Score 1 Score 2 Score 3

Age <60 60-79 >80 -

Shock Nil HR >100 SBP <100 -

Co-morbidity Nil major - IHD/CCF/major morbidity

Renal failure/liver failure

Diagnosis Mallory Weiss tear

All other diagnoses

GI malignancy -

Endoscopic Findings

None - Blood, adherent clot, spurting vessel

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Thank

you !