Upper gastrointestinal haemorrhage

Causes

  • Peptic ulcer (50%)
  • Gastric erosions
  • Oesophageal or gastric varices
  • Mallory-Weiss tear
  • Angiodysplasia
  • Dieulafoy malformation
  • Gastric neoplasia

Dieulafoy malformation

Management

  • Patients should be managed according to agreed multidisciplinary protocols
  • Close collaboration between physicians and surgeons is vital
  • Aggressive fluid resuscitation is important
  • Circulating blood volume should be restored with colloid or crystalloid
  • Cross-matched blood should be given when available
  • All patients require closed monitoring
  • Possibly in an HDU or ITU environment with central and arterial pressure monitoring

Bleeding peptic ulcer

  • 80% bleeding stops spontaneously
  • 25% require intervention for recurrent bleeding within 48 hours
  • It is difficult to predict those that will continue to bleed

All patients require early endoscopy ( intervention)  to determine:

  • Site of bleeding
  • Continued bleeding
  • Features of recent bleed
    • Ooze from ulcer base
    • Clot covering ulcer base
    • Black spot in ulcer base
    • Visible vessel

Bleeding gastric ulcer

Picture provided by Mohamed Husein, University of Ottawa, Canada

Recently shown that proton pump inhibitors may improve the outcome in non-variceal upper GI haemorrhage

Endoscopic therapy

  • Laser photocoagulation using the Nd-YAG laser
  • Bipolar diathermy
  • Heat probes
  • Adrenaline or sclerosant injection
  • No technique is superior
  • Comparative trials of different techniques are inconclusive

Indications for surgery

  • Continued bleeding that fails to respond to endoscopic measures
  • Recurrent bleeding
  • Patients > 60 years
  • Gastric ulcer bleeding
  • Cardiovascular disease with predictive poor response to hypotension

Surgery for bleeding peptic ulcer

For duodenal ulcer

  • Create gastroduodenotomy between stay sutures
  • Bleeding usually from gastroduodenal artery
  • Underun vessels with 2/0 nonabsorbable suture on round body needle
  • Avoid picking up common bile duct
  • Close gastroduodenotomy as a pyloroplasty
  • Consider truncal vagotomy and pyloroplasty
  • All patients should be given H. pylori eradication therapy post operatively

  • If a pyloroplasty will be difficult because of large ulcer consider Polya gastrectomy

For gastric ulcer

  • Consider either local resection of ulcer or partial gastrectomy

Variceal upper gastrointestinal haemorrhage

  • 90% patients with portal hypertension have varices
  • 30% patients with varices will have an upper gastrointestinal bleed
  • 80% of GI bleed in patients with portal hypertension comes from varices
  • The mortality of a variceal bleed is approximately 50%
  • 70% patients will have a rebleed
  • Survival is dependent on the degree of hepatic impairment

Primary prevention

  • Bleeding from varices more likely if poor hepatic function or large varices
  • Primary prevention of bleeding is possible with β blockers
  • Reduces risk of haemorrhage by 40-50%
  • Band ligation may also be considered
  • Sclerotherapy or shunting is ineffective

Active bleeding

  • Resuscitation should be as for other causes of upper GI haemorrhage
  • Endoscopy should be performed to confirm site of haemorrhage
  • Vasopressin and octreotide decrease splanchnic blood flow and portal pressure
  • Lactulose may be used to decrease GI transit and reduce ammonia absorption
  • Metronidazole and neomycin may be used to reduce gut flora
  • Temporary tamponade can be achieved with Sengstaken-Blackmore tube
    • Should be considered as a salvage procedure
    • Tamponade is 90% successful at stopping haemorrhage
    • Unfortunately 50% patients rebleed within 24 hours of removal of tamponade

Sengstaken-Blackmore tube

  • A Sengstaken-Blackmore tube has three channels
    • One to inflate the gastric balloon
    • One to inflate the oesophageal balloon
    • One to aspirate the stomach
  • Emergency endoscopic therapy includes:
    • Endoscopic banding of varices
    • Intravariceal or paravariceal sclerotherapy
    • Sclerosants include ethanolamine and sodium tetradecyl sulphate
  • If endoscopic methods fail need to consider:
    • Transection or devascularisation
    • Porto-caval or mesenterico-caval shunting
  • Emergency shunting associated with 20% operative mortality and 50% encephalopathy
  • Shunting can also be performed non-surgically by transjugular intrahepatic porto-systemic shunting (TIPSS)
  • Reduces risk of rebleeding but increases risk of encephalopathy
  • Mortality of the procedure ~1%

Secondary prevention

  • 70% of patients with an variceal haemorrhage will rebleed
  • The following have been shown to be effective in the prevention of rebleeding
    • Beta-blockers possibly combined with isosorbide mononitrate
    • Endoscopic ligation
    • Sclerotherapy
    • TIPSS
    • Surgical shunting

Bibliography

Dagher L,  Patch D,  Burroughs A.  Management of oesophageal varices.  Hosp Med 2000;  61:  711-717.

Garcia-Tsao G,  Bosch J.  Management of varices and variceal haemorrhage in cirrhosis:  NEJM 2010;  362:  823-832.

Ghosh S. Watts D, Kinnear M.  Management of gastrointestinal haemorrhage.  Postgrad Med J 2002;  78:  4-14.

Gotzsche P C.  Somatostatin or octreotide for acute bleeding oesophageal varices.  Cochrane Database Syst Rev 2000;  2:  CD000103.

Gow P J,  Chapman R W.  Modern management of oesophageal varices.  Postgrad Med J 2001;  77:  75-81

Lau J Y W,  Sung J J Y,  Lee K K C et al.  Effects of intravenous omeprazole on recurrent bleeding after endoscopic treatment of bleeding peptic ulcers. N Eng J Med 2000;  343:  310-316.

Ohmann C,  Imhof M,  Roher H D.  Trends in peptic ulcer bleeding and surgical management.  World J Surg 2000;  24:  284-293.

Rosch J,  Keller F S.  Transjugular intrahepatic portosystemic shunt:  present status, comparison with endoscopic therapy and shunt surgery and future perspectives.  World J Surg 2001;  25:  337-346.

Sharara A I,  Rockey D C.  Gastroesophageal variceal hemorrhage.  N Eng J Med 2001;  345:  669-681.

Stabole B E,  Stamos M J.  Surgical management of gastrointestinal bleeding.  Gastroenterol Clin North Am 2000;  29:  189-222.

 
 

Last updated: 09 November 2010

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