ACUTE UPPER GASTROINTESTINAL HEMORRHAGE

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ACUTE UPPER GASTROINTESTINAL HEMORRHAGE
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• Upper GI bleeding refers to bleeding that arises
  from the GI tract proximal to the ligament of
  Treitz

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Common Causes of Upper Gastrointestinal Hemorrhage

• NONVARICEAL BLEEDING (80)
• Peptic ulcer disease 30-50
• Mallory-Weiss tears 15-20
• Gastritis or duodenitis 10-15 Esophagitis 5-10  
  
• Arteriovenous malformations 5  
• Tumors 2  
• Other 5

• PORTAL HYPERTENSIVE BLEEDING (20)
• Gastroesophageal varices gt90
• Hypertensive portal gastropathy lt5
• Isolated gastric varices Rare

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• Although patients with cirrhosis are at high risk
  for developing variceal bleeding, even in these
  patients, nonvariceal sources account for most of
  the episodes of GI hemorrhage

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• The foundation of diagnosis and management of
  patients with an upper GI bleed is an EGD.
  Multiple studies have demonstrated that early EGD
  (within 24 hours) results in
• reductions in blood transfusion requirements, a
  decrease in the need for surgery,
• and a shorter length of hospital stay.
• Endoscopic identification of the source of
  bleeding also permits an estimate of the risk for
  subsequent or persistent hemorrhage as well as
  facilitating operative planning, should that
  prove necessary.
• In general, 20 to 35 of patients undergoing
  EGD will require a therapeutic endoscopic
  intervention, and 5 to 10 will eventually
  require surgery

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Peptic Ulcer Disease

• PUD still represents the most frequent cause of
  upper GI hemorrhage, accounting for about 40 of
  all cases
• Bleeding develops as a consequence of acid-peptic
  erosion of the mucosal surface.
• Although chronic blood loss is common with any
  ulcer, significant bleeding typically results
  when there is involvement of an artery, either of
  the submucosa or, with penetration of the ulcer,
  an even larger vessel.
• .

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• Although duodenal ulcers are more common than
  gastric ulcers, gastric ulcers bleed more
  commonly as a result, in most series, the
  relative proportions are nearly equal.
• The most significant hemorrhage occurs when
  duodenal or gastric ulcers penetrate into
  branches of the gastroduodenal artery or left
  gastric artery, respectively

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Algorithm for the diagnosis and management of
nonvariceal upper GI bleeding
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Indications for Surgery in Gastrointestinal
Hemorrhage

•    Hemodynamic instability despite vigorous
  resuscitation (gt6 units transfusion)  
•   Failure of endoscopic techniques to arrest
  hemorrhage   
• Recurrent hemorrhage after initial stabilization
  (with up to two attempts at obtaining endoscopic
  hemostasis)   
• Shock associated with recurrent hemorrhage  
•   Continued slow bleeding with a transfusion
  requirement exceeding 3 units/day

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Mallory-Weiss Tears

• Mallory-Weiss tears are mucosal and submucosal
  tears that occur near the gastroesophageal
  junction. Classically, these lesions develop in
  alcoholic patients after a period of intense
  retching and vomiting after binge drinking, but
  they can occur in any patient who has a history
  of repeated emesis.
• The mechanism, proposed by Mallory and Weiss in
  1929, is forceful contraction of the abdominal
  wall against an unrelaxed cardia, resulting in
  mucosal laceration of the proximal cardia as a
  result of the increase in intragastric pressure.

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Stress Gastritis

• Stress-related gastritis is characterized by the
  appearance of multiple superficial erosions of
  the entire stomach, most commonly in the body.
• It is thought to result from the combination of
  acid and pepsin injury in the context of ischemia
  from hypoperfusion states, although NSAIDs
  produce a very similar appearance.

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• it was a commonly encountered lesion in
  critically ill patients, with significant
  morbidity and mortality from bleeding. These
  lesions are different from the solitary
  ulcerations, related to acid hypersecretion, that
  occur in patients with severe head injury
  (Cushing's ulcers).
• When stress ulceration is associated with major
  burns, these lesions are referred to as Curling's
  ulcers.
• In contrast to NSAID-associated lesions,
  significant hemorrhage from stress ulceration was
  a common phenomenon.

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Esophagitis

• The esophagus is infrequently the source of
  significant hemorrhage. When it does occur, it is
  most commonly the result of esophagitis.
  Esophageal inflammation secondary to repeated
  exposure of the esophageal mucosa to the acidic
  gastric secretions in gastroesophageal reflux
  disease (GERD) leads to an inflammatory response,
  which can result in chronic blood loss.
  Ulceration may accompany this process, but the
  superficial mucosal ulcerations generally do not
  bleed acutely, but rather present as anemia or
  guaiac-positive stools. A variety of infectious
  agents may also cause esophagitis, particularly
  in the immunocompromised host ( Fig. 46-5 ). With
  infection, hemorrhage can occasionally be
  massive. Other causes of esophageal bleeding
  include medications, Crohn's disease, and
  radiation.

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Dieulafoy's Lesion

• Dieulafoy's lesions are vascular malformations
  found primarily along the lesser curve of the
  stomach within 6 cm of the gastroesophageal
  junction, although they can occur elsewhere in
  the GI tract ( Fig. 46-6 ). They represent
  rupture of unusually large vessels (1-3 mm) that
  are found in the gastric submucosa. Erosion of
  the gastric mucosa overlying these vessels leads
  to hemorrhage. The mucosal defect is usually
  small (2-5 mm) and may be difficult to identify.
  Given the large size of the underlying artery,
  bleeding from a Dieulafoy's lesion can be massive.

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Malignancy

• Malignancies of the upper GI tract are usually
  associated with chronic anemia or
  hemoccult-positive stool rather than episodes of
  significant hemorrhage.
• On occasion, malignancies present as ulcerative
  lesions that bleed persistently.
• This is perhaps most characteristic of the GI
  stromal tumor (GIST), although it may occur with
  a variety of other lesions, including leiomyomas
  and lymphomas.
• Although endoscopic therapy is often successful
  in controlling hemorrhage, the rebleeding rate is
  high therefore, when a malignancy is diagnosed,
  surgical resection is indicated.

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Gastric Antral Vascular Ectasia

• Also known as watermelon stomach, gastric
  antral vascular ectasia (GAVE) is characterized
  by a collection of dilated venules appearing as
  linear red streaks converging on the antrum in
  longitudinal fashion, giving it the appearance of
  a watermelon. Acute severe hemorrhage is rare in
  GAVE, and most patients present with persistent,
  iron deficiency anemia from continued occult
  blood loss.

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Aortoenteric Fistula

• Primary aortoduodenal fistulas are rare lesions
  developing in up to 1 of aortic graft cases

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Hemobilia

• Hemobilia is often a difficult diagnosis to make.
• It is typically associated with trauma, recent
  instrumentation of the biliary tree, or hepatic
  neoplasms.
• This unusual cause of GI bleeding is suspected
  in anyone who presents with hemorrhage, right
  upper quadrant pain, and jaundice.
• Unfortunately, this triad is seen in less than
  half of patients, and a high index of suspicion
  is required. Endoscopy can be helpful by
  demonstrating blood at the ampulla.
• Angiography is the diagnostic procedure of
  choice. If diagnosis is confirmed, angiographic
  embolization is the preferred treatment.

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Hemosuccus Pancreaticus

• Another rare cause of upper GI bleeding is
  bleeding from the pancreatic duct, or hemosuccus
  pancreaticus.
• This is typically caused by erosion of a
  pancreatic pseudocyst into the splenic artery.
• It presents with abdominal pain and
  hematochezia.
• As with hemobilia, it is a difficult diagnosis to
  make and requires a high index of suspicion in
  patients with abdominal pain, blood loss, and a
  past history of pancreatitis.
• Angiography is diagnostic and permits
  embolization, which is often therapeutic. In
  cases that are amenable to a distal
  pancreatectomy, this procedure often results in
  cure.

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Iatrogenic Bleeding

• Upper GI bleeding may follow therapeutic or
  diagnostic procedures. As described, hemobilia
  may be iatrogenic in nature, particularly after
  percutaneous transhepatic procedures. Another
  common cause of iatrogenic bleeding is endoscopic
  sphincterotomy. This can occur in up to 2 of
  cases. It is often mild and self-limited. Late
  hemorrhage usually occurs within the first 48
  hours and may require injection of the area with
  epinephrine. Surgical intervention is rarely
  required.
• Percutaneous endoscopic gastrostomy (PEG)
  placement is an increasingly common procedure.
  Bleeding rates of up to 3 have been reported.
  Although most of these cases reflect bleeding
  from the incision site, some are due to bleeding
  from the gastric mucosa ( Fig. 46-8 ). This can
  often be controlled endoscopically.

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