UPPER GASTROINTESTINAL

BLEEDINGBernard M. Jaffe, MDProfessor of Surgery

Emeritus

UPPER GI BLEEDING• Bleeding from the • Distal Esophagus• Stomach• Duodenum• proximal Small Bowel (Rare)

CAUSES• Gastritis (Commonest)• Peptic Ulcer• Mallory-Weiss Tear (Mucosal Laceration

Near E-G Junction)• Varices (Esophageal > Gastric)• Dieulafoy’s Lesion (Tortuous Arteriole

Protruding Through Gastric Mucosa)

CAUSES OF GASTRITIS• H. Pylori Infection• NSAID’s• Atrophic Gastritis• Pernicious Anemia• Alkaline Enterogastric Reflux (Bile is

Offending Material)

UPPER GI BLEED• Vomiting Coffee Ground Material• Bright Red Blood• Per Rectum Melena• Bright Red Blood (Very

Rapid Bleeding) •

WORK-UP• History- Peptic Ulcer Disease, Liver

Disease, NSAID Use• Physical Exam- Usually Normal (Except

Features of Cirrhosis)• Lab Tests- Serum Gastrin level• Hemoglobin/Hematocrit• Type and Cross-Matching• Imaging Studies Not Helpful

NON-OPERATIVE THERAPY• Irrigation of Clots from Stomach • (May Require Ewald Tube)• Urgent EGD- Heater Probe, Cautery• Clip of Visible Vessel• Anti-Secretory Therapy • Vasopressin• Somatostatin

VISIBLE VESSEL• Gastroduodenal Artery in Posterior

Duodenum• Bleeds Massively (Arterial)• Temporize by Endoscopic Means• (Clips, Cautery)• Requires Operative Therapy• Need to Oversew Artery Above and

Below Bleeding Site

PROGNOSIS• 80% Are Self-Limiting• Mortality Rate 8-10%• Increases with Patient Age• Mortality Related to Severity• Site/Cause • High Transfusion

Rate• Shock

PROGNOSIS (2)• Bleeding in Hospital Worse Than

Bleeding Outside (33 vs. 17%)• Recurrent Bleeding Increases

Mortality from 8-30%• Visible Vessel Mortality 16%

OPERATIVE THERAPY• Gastritis- Oversew Bleeding Arreas• Vagotomy and Pyloroplasty• Ulcer- Resect the Ulcer• Definitive Ulcer Procedure• Mallory Weiss Tear- Oversew Bleeding

Area• Suture Torn Area• Dieulafoy’s Lesion- Oversew Arteriole

VARICES• Sengstaken-Blakemore Tube • Puts Pressure on Varices• Sclerotherapy• TIPS Procedure (Transjugular

Intrahepatic Portosystemic Shunt)• If Operation Unavoidable, Perform

Porta-Systemic Shunt