Gastrointestinal Bleedingdocx

=== Gastrointestinal bleeding ===

Ministryof Healthof theRepublic ofMoldova

State University of Medicine and Pharmacy

"Nicolae Testemițanu"

Faculty of Medicine

 Department OF surgery

License Thesis

Gastrointestinal bleeding

Student’s name and surname- Haia Abu Arkia
year , group no. 1646

Scientific coordinator’s :Conf.Univ. Dr.tinish

Chișinău, 2015

Contents

Introduction 4

I  Bibliographicanalysisof the topic

1. Incidence and Epidemiology5-6

2 .Pathogenesis and Pathophysiology 6 -7

3 . Clinical Manifestations 8- 9

4 . Diagnosis 9-12

5 .DifferentialDiagnosis 12

6. staging 12-13

7 .Treatment for chronic lymphocytic leukemia13 -22

8 . Treatment of Complications andSupportiveCare 23 -25

9. prognosis 26 -27

II

General conclusion 28

III

References 29- 34

IV

Statement 35

The purpose of the thesis : updates of data from contemporary medical literature related to gastrointestinal bleeding

The objectives of the thesis :

1. To study different epidemiological data around the world, and the increased incidence of gastrointestinal tract bleeding .

2. To learn the pathologic classification of gastrointestinal tract bleeding .

3. To investigate the molecular biology of clear gastrointestinal bleeding , in relation to different hereditary disorder.

4. Investigation of most common sings and symptoms of gastrointestinal bleeding according to clinical findings and laboratory investigation .

5. laboratory findings in relation to staging and prognosis of gastrointestinal bleeding evaluation.

6. methods of treatment gastrointestinal tract bleeding.

Introduction

GI bleed, also known asGI hemorrhage, is all forms of bleedingin the GIT from the mouth to the rectum.[1] When there is significant blood losing over a short time, symptoms may include vomiting red blood,vomiting black blood, bloody stool, or black stool. Small amounts of bleeding over a long period o f time may cause iron-deficiency anemia the result in feeling tiredor heart-related chest pain.[2] Other symptoms may include abdominal pain, shortness of breathing, pale skin,.[1][2] Sometimes in those with small amounts of bleeding no symptoms may be present.[2]

Bleeding is typically divided into two main types: upper GIT  and LOWER GIT  Causes of upper GI bleeds include: peptic ulcer disease, esophageal varices due to liver cirrhosis and cancer, among others.[4] Causes of lower GI bleeds include: hemorrhoids, cancer, and نIBD among others.[3] Diagnosis begins with a medical history and physical examination, along with blood tests. little amounts of bleeding may be detected by fecal occult blood test. Endoscopy of the lower and upper GIT may locate the area of bleeding. Medical imaging may be useful in cases that are not clear.[2]

The first therapy focuses on resuscitation which may include intravenous fluids and blood transfusions.[5] Often blood transfusions are not recommend unless the hemoglobin is less than 70 or 80 g/L.[6][7] therapy with proton pump inhibitors, octreotide, and antibiotics may be in certain cases.[8][9][10] If other measures are not effective, an esophageal balloon may be in those with persumed esophageal varices.[3] Endoscopy of the esophagogastrodudenioscopy  or endoscopy of the large bowel are generally recommended within 24 hours and may permit treatment as well as diagnosis.[5]

An upper Gastro intestinal I bleed is more common than lower GI bleed.[3] An upper GI bleed occurs in 55 to 150 per 100,000 adults per year.[11] A lower GI bleed is estimated to occur in 20 to 30 per 100,000 per year.[3] It results in about 300,000 hospital admissions a year in the United States.[2] Risk of death from a GI bleed is between 5% and 30%.  bleeding is more common in males and increases with increased age.[

1. Incidence and Epidemiology

1.1 Epidemiology of GIT BLEEDING

occurs most common in the “upper gastrointestinal tract”اا that is, from the esophagus, gastric , and proximal duodenum. The “lowerייי gastrointestinal tract” is typically considered to consist of the colon, rectum, aand anus. The incidence of upper gastrointestinal bleeding in adults is as ranging from 45 to 150 cases per 100,000 population per year. Upper gastrointestinal bleeding is more common reported than lower gastrointestinal hemorrhage, which has an incidence of 20-30 per 100,000 population per year.

1.2 Incidence

the incidence of clinically gastrointestinal bleeding increases with advanced age, particularly in those over 60, and is more common in men than women .

Mortality associated with gastrointestinal bleeding seems to be more related to advanced age and coexisting illness than to bleeding,. The authors of a Dutch study went so far as to report that only one third of the mortality associated with upper gastrointestinal bleeding was directly leading to bleeding, while tow thirds of the patients were thought to die from other causes.  conditions including malignancy, cirrhosis, and chronic respiratory illnesses are particularly bad prognostic factors.

2. Pathophysiology

Esophageal Varices

Esophageal varices are a particularly lethal source of upper gastrointestinal bleeding. They are associated with so severe liver disease, in which sclerotic tissue replaces normal liver parenchyma; this subsequently blocks blood flow, raises portal pressure, and thereby provides stimulus for the formation of collateral circulation(., varices). Alcoholic liver disease and viral hepatitis (B.;C, and D) are among the most common causes of cirrhosis. Less common precursors to the formation of varices are nonalcoholic steatohepatitis, primary biliary cirrhosis, secondary biliary cirrhosis (complication of cholecystectomy), hepatotoxic medications, environmental toxins,اا schistosomiasis, and congestive heart failure with liver congestion. Inheritable etiologies include autoimmune hepatitis, alpha-1 antitrypsin deficiency, hemochromatosis,ا Wilson’s disease, galactosemia, and glycogen storage disease.

Peptic Ulcer Disease

The discovery the roles of Helicobacter pylori infection in the development of PU disease has revolutionized our understanding of peptic ulcer disease, the most common cause of upper gastrointestinal bleeding.י H. pylori is a gramnegative, spiral, flagellated bacterium that survives in the acidity environment of theי Gastric by virtue of a urease drivenי process in which it produces an alkaline local environment. Gastritis is found in all patients infected with H. pylori—ייin factי the bacterium has such a strong causal relationship with the disease that peptic ulcer disease is thought to be uncommon in H. pylorinegative individuals who are not taking NSAIDs.י Smoking has been found to be an independent risk factor forי GI bleeding from peptic ulcers,י and a recent study found a synergistic relationship between smoking and concomitant H. pylori infection.

Colonic Disease

There are some diseases of the large intestine that can cause bleeding, and the pathophysiology of each is somewhat the same . The common however, is that there is mucosal disruption, which allows the lumen of blood vessels to communicate with the lumen of the gut. The blood vessels can be so small, as might be seen in radiation colitis, malignancy , or infectious colitis y. Alternatively, the blood vessels may be larger, as might be seen in diverticulosis. The most dramatic example of this process may be an aortoenteric fistula, whereby the lumen of the aorta communicates with the lumen of the gut.

Drug-Related Causes

There is clearly an increased incidence of ggastrointestinal bleeding among patients who uses certain medications. Non steroidal anti inflammatory including aspirin, have most commonly been implicated. יי However, the average patient with NSAID-associated bleeding is older at age of onset and has an related decreased risk in mortality compared to non-NSAID-related bleeding. This phenomenon is thought to be subclinical disease by widespread NSAID use. Patients at risk for gastrointestinal bleeding who require NSAID treatment are frequently put on the new selective cox -2 inhibitors. As advertised, these drugs are associated with a decreased risk of GI bleeding compared to conventional NSAIDs.

The use of daily aspirin among the elderly makes this non-steroidal anti-inlammatory of particular interest to epidemiologists. A recent study by the U.S. Preventive Services Task Force on the daily use of aspirin for the primary prevention of cardiovascular events found an odds ratio of 1.7 for ייmajorייGI bleeding in daily aspirin users over individuals not taking aspirin. Even with enteric coating or in the 81 mg daily dose, aspirin is related with an increased incidence of gastrointestinal bleedingיי—and the bleeding is not just from ulcers, as had been previously thought. Aspirin has also been associated with an increased incidence of variceal bleeding in patients with cirrhosis.45Patients intolerant of aspirin therapy may be placed on alternative platelet inhibitors (e.g., ticlopidine) that appear to have a lower incidence of bleeding when compared with aspirin. Other medications with a definite association with GI bleeding include chemotherapeutic agents,oral anticoagulants, and steroids.

Physiologic Stress

The critical care experience with gastrointestinal bleeding has led intensivists to study the various physiologic contributors to GI bleeding. Stressors identified as most strongly predisposing factors to GI bleeding include radiation therapy ; hypothermia; sepsis;, treatment for heart failure or diabetes, renal failure; and graft-versus-host disease.

Symptoms and signs of gastrointestinal bleeding

gastrointestinal bleeding symptoms are consistent depending on the bleeding is acute or chronic.

Signs of GI bleeding that is considered chronic, or long period , can be so small that it isn’t easy to detect without a medical test, such as a fecal occult blood test. If Untreated, this slow bleed can cause anemia or low blood counts. On the other hand, acute gastrointestinal bleeding can occurs suddenly and can be life threatening. The acute gastrointestinal bleeding symptoms are usually very noticed .

Signs of Gastrointestinal Bleeding:

Blood in the stool

Hematemesis or like coffee grounds

So Dark, tarry stools

Diarrhea and or Abdominal cramps

Paleness appearance

Anemia

These symptoms point serious issue in the GI tract. Reasons for blood in stool can include hemorrhoids, (IBD), stomach ulcers or even cancer.

If you experience any; GIB; symptoms, seek medical help immediately, since the condition can be life threatening.

Physical examination

General examination on vital signs and other indicators of shock or hypovolemia (tachycardia; pallor ;tachypnea diaphoresis;oliguria; confusion) and anemia (pallor, diaphoresis). Patients with lesser degrees of bleeding may have mild tachycardia (heart rate > 100).

Orthostatic changes in pulse (change of > 10 beats/min) or Bp (a drop of ≥ 10 mm Hg) often develops after acute loss of ≥ 2 units of blood. orthostatic measurements are in patients with severe bleeding ;possibly causing syncope;and generally lack specificity and sensistivty as a measure of intravascular volume; especially in elderly patients.

bleeding disorders (eg, petechiae, ecchymoses) are sought, as are signs of chronic liver disease (spider angiomas, ascites, palmar erythema) and portal hypertension (י splenomegalyי dilated abdominal wall veins).

Digital rectal examination is necessary to search for masses , stool coulor , and fissures. Anoscopy is done to diagnose hemorrhoids. Chemical testing of a stool specimen for occult blood completes the examination if gross blood is not present.

Red flags

Several findings suggest hypovolemia or hemorrhagic shock:

Syncope

Pallor

Tachycardia

Diaphoresis

Hypotensions

Clinical Calculator:; Lower gastrointestinal Bleeding and Risk of Severe Bleeding

Interpretation of findings

The physical examination and history suggest a diagnosis in about 55% of patients, but findings are rarely diagnostic and confirmatory testing is required.

Epigastric abdominal discomfort relieved by food or antacids suggests peptic ulcer disease. However, many patients with bleeding ulcers have no history of pain. Weight loss and anorexia, with or without a change in stool, suggest a GI cancer. A history of cirrhosis or chronic hepatitis suggests esophageal varices. Dysphagia suggests esophageal cancer or stricture. Vomiting and retching before the onset of bleeding suggests Mallory-Weiss tear of the esophagus, although about 55% of patients with Mallory-Weiss tears do not have this history.

A history of bleeding (purpura, ecchymosis, hematuria) may indicate a bleeding diathesis (hemophilia, hepatic failure). Bloody diarrhea, fever, and abdominal pain suggest ischemic colitis, inflammatory bowel disease (ulcerative colitis, Crohn disease), or an infectious colitis ( Shigella , Salmonella , Campylobacter ,amebiasis). Hematochezia suggests diverticulosis or angiodysplasia. Fresh blood only on toilet paper or the surface of formed stools suggests internal hemorrhoids or fissures, whereas blood mixed with the stool indicates a more proximal source. Occult blood in the stool may be the first sign of colon cancer or a polyp, particularly in patients > 45 yr.

Blood in the nose or trickling down the pharynx suggests the nasopharynx as the source. Spider angiomas, hepatosplenomegaly, or ascites is consistent with chronic liver disease and hence possible esophageal varices. Arteriovenous malformations, especially of the mucous membranes, suggest hereditary hemorrhagic telangiectasia (Rendu-Osler-Weber syndrome). Cutaneous nail bed and GI telangiectasia may indicate systemic sclerosis or mixed connective tissue disease.

Testing

Several tests are done to help confirm the suspected diagnosis.

CBC, coagulation profile, and often other laboratory studies

NGT for all but those with minimal rectal bleeding

Upper endoscopy for suspected upper GI bleeding

Colonoscopy for lower GI bleeding (unless clearly caused by hemorrhoids)

CBC should be obtained in patients with large-volume or occult blood loss. Patients with more significant bleeding also require coagulation studies (platelet count, יPTh, PTT) and liver function tests (eg, bilirubin, alkaline phosphatase, albumin, AST, ALT). Type and cross-match are done if bleeding is ongoing. Hb and Hct may be repeated up to every 6 h in patients with severe bleeding. Additionally, one or more diagnostic procedures are typically required.

Nasogastric aspiration and lavage should be done in all patients with suspected upper GI bleeding (eg, hematemesis, coffee-ground יemesis, melena, massive rectal bleeding). Bloody nasogastric aspirate indicates active upper GI bleeding, but about 10% of patients with upper GI bleeding have no blood in the nasogastric aspirate. Coffee-ground material indicates bleeding that is slow or stopped. If there is no sign of bleeding, andי bile is returned, the NGT is removed; otherwise, it is left in place to monitor continuing or recurrent bleeding. Nonbloody, nonbiliousי return is considered a nondiagnostic aspirate.

Upper endoscopy (exam of the esophagus, gastric , and duodenum) should be done for upper gastrointestinal bleeding. Because endoscopy may be therapeutic as well as diagnostic, it should be done rapidly for significant bleeding but may be deferred for 24 h if bleeding stops or is minimal. Upper gastrointestinal barium x-rays have no role in acute bleeding, and the contrast used may obscure subsequent attempts at angiography. Angiography is useful in the diagnosis of upper GI bleeding and permits certain therapeutic maneuvers (vasoconstrictor inusion, embolization).

Flexible sigmoidoscopy and anoscopy may be all that is required acutely for patients with symptoms typical of hemorrhoidal bleeding. All other patients with hematochezia should have colonoscopy, which can be done electively after routine preparation unless there is significant ongoing bleeding. In such patients, a rapid prep (5 to 6 L of polyethylene glycol solution delivered via NGT or by mouth over 3 to 4 h) often allows adequate visualization. If colonoscopy cannot visualize the source and ongoing bleeding is sufficiently rapid (> 0.5 to 1 mL/min), angiography may localize the source. Some angiographers first take a radionuclide scan to focus the examination, because angiography is less sensitive than the radionuclide scan.

Diagnosis of occult bleeding can be hard to diagnose , because heme-positive stools may result from bleeding any place in the GI tract. Endoscopy is the preferred method, with symptoms determining the upper or lower gastrointestinal tract is examined at the first. Double-contrast barium enema and sigmoidoscopy can be used for the lower tract when colonoscopy is unavailable or the patient refuses it.

If the results of upper endoscopy and colonoscopy are minus negative and occult blood conteniue s in the stool, an upper gastrointestinal series with small-bowel follow-through, CT enterography, small-bowel endoscopy ;enteroscopy;;, capsule endoscopy (which uses a small pill-like camera that is swallowed), technetium-labeled colloid or RBC scan, and angiography should be considered. Capsule endoscopy is of limited value in an actively bleeding patient.

5. Differential Diagnoses

upper gastrointestinal tract

Abdominal Aortic Aneurysm

Acute Gastritis

Barrett Esophagus

Esophageal Cancer

Esophageal Varices

Esophagitis

Gastric Cancer

Gastric Obstruction

Gastric ulcer

Gastrinoma

Peptic Ulcer Disease

Lower gastrointestinal tract bleeding

Chronic radiation enteritis/proctitis

Ischemic colitis/mesenteric vascular insufficiency

Small bowel diverticulosis

Meckel diverticulum

Colonic/rectal varices

Portal colopathy

Solitary rectal ulcer syndrome

Diversion colitis

Dieulafoy lesion of colon

Dieulafoy lesion of small bowel

Vasculitides

Small bowel ulceration

Intussusception

Endometriosis

GI bleeding in runners

Diagnostic approach

Diagnosis is n based on direct observation of blood in the vomit or in stool . This can confirmed with a fecal occult blood test. Differentiating between upper and lower gastrointestinal bleeding in some cases can be so hard . The severity of upper gastrointestinal bleeding can based on the Blatchford score[ or Rockall score. The Rockall score is the more accurate of the two. As of 2008 there is no scoring system useful for lower gastrointestinal bleedings.

Clinical

Lavage or gastric aspirationיייwhere a tube is inserted into the gastric by the nose in an attempt to determine and recognizing if there is blood in the gastric ; if minus negative does not rule out anי upper gastrointestinal bleeding  but if plus positive is useful for ruling in.Clots in the stool indicate a lower GI source while melana stools an upper one.

Laboratory testing

Recommended laboratory blood testing includes;;cross matching blood, hemoglobin, hematocrit, platelets, coagulation time, and electrolytes. If the ratio of blood urea nitrogento creatinine is greater than 30 the source is more likely from the upper GI tract.

Imaging

CT angiography is useful for determining the exact location of the bleeding within the gastrointestinal tract.Nuclear scintigraphy is a sensitive test for detecting occult gastrointestinal bleeding when direct imaging with upper and lower endoscopies are minus negative. Direct angiography allows for embolization of a bleeding source, but requires a bleeding rate faster than 1mL/minute.

Classification of gastrointestinal bleeding

Gastrointestinal (GI) bleedingاا Classification •Upper GI hemorrhage = bleeding upper the Ligament of Treitz.

•Lower GI bleeding = bleeding below Ligament of Treitz Gastrointestinal bleeding

•Upper GI bleeding = bleeding upper the ampulla of Vater

•Mid GI bleeding = bleeding from the ampulla of Vater to the terminal ileum •

Lower gastrointestinal bleeding = colonic bleeding

1ייHematemesis / Melena

2ייInitial Assessment and Resuscitation

3יי Risk Stratification

a-low risk b-high risk

Rockall scoring system for risk of rebleeding and death after admission to hospital for acute UGIB score

Interpretation;

Total score is calculated by simple addition. A score less than 3 carries good prognosis but total score more than 8 carries high risk of mortalityייץץייייייי

Abstract ;
AIM: To validate the clinical Rockall score in predicting outcomes (rebleeding, surgery and mortality) in elderly patients with acute upper gastrointestinal bleeding יייי(AUGIB).

METHODS: A retrospective analysis was undertaken in 344 patients admitted to the emergency room and Intensive Care Unit of Xuanwu Hospital of Capital Medical University with noייייvariceal upper gastrointestinal bleeding. The Rockall scores were calculated, and the relation between clinical Rockall scores and patient outcomes (rebleeding, surgery and mortality) was confirmed . Based on the Rockall scores, patients were divided into three risk categories: low risk ≤ 3, moderate risk 3-4, high risk ≥ 4יייי, and the percentages of rebleeding/death/surgery in each risk category were compared. The area under the receiver operating characteristic (ROC) curve was calculated to assess the validity of the Rockall system in predicting rebleeding, surgery and mortality of patients withיי AUGIB.

RESULTS: A positive linear correlation between clinical Rockall scores and patient outcomes in terms of rebleeding, surgery and mortality was observed (r = 0.962, 0.955 and 0.946, respectively, P = 0.001). High clinical Rockall scores > 3 were associated and related with adverse outcomes ;;;;rebleeding, surgery and death;;;. There was a significant correlation between high Rockall scores and the occurrence of rebleeding, surgery and mortality in the entire patient population (χ2 = 49.29, 23.10 and 27.64, respectively, P = 0.001). For rebleeding, the area under the ROC curve was 0.788 (95%CI: 0.726-0.849, P = 0.001); For surgery, the area under the ROC curve was 0.752 (95%CI: 0.679-0.825, P = 0.001) and for mortality, the area under the ROC curve was 0.787 (95%CI: 0.716-0.859, P = 0.001).

CONCLUSION: The Rockall score is clinically useful, rapid and accurate in predicting rebleeding, surgery and mortality outcomes in elderly patients with AUGIB.

Keywords: Rockall score, Acute upper gastrointestinal bleeding, Prognosis, old patients.

PREVENTION;;

those with varices or cirrhosis nonselective β-blockers decreased the risk of future bleeding.יי With a aim heart rate of 55 beats per minute they reduce the absolute risk of bleeding by 10%.Endoscopic band ligation (EBL) is also effective at improving outcomes.ייי Either B-blockers or EBL are recommended as initial preventative measures.  In those who have had a previous varcial bleed both treatments are recommendedיי With some evidence supporting the addition ofisosorbide mononitrate.יי Testing for and treating those who are positive for H. pyloriis recommended.יי Transjugular intrahepatic portosystemic shunting (TIPS) may be used to prevent bleeding in people who re-bleed despite other measures.יי

Treatment:

7. treatment and management of upper gastrointestinal bleeding

Approach :

The goal of medical therapy in upper gastrointestinal bleeding (UGIB) is to correct shock and coagulation abnormalities and to stabilize the patient so that further evaluation and treatment can proceed. So High doses may decreased the need for endoscopic therapy (ייtreatment with proton pump inhibitorsיי).

Various methodologies have been proposed to quantitate rebleeding risk (Baylor score , Rockall scoreיי).

The 2007 Scottish Intercollegiate Guidelines Network (SIGN) guideline on the management of acute upper and lower ;GI ;recommends that an initial (pre-endoscopic) Rockall score be calculated for all patients presenting with acute UGIB. In patients with an initial Rockall score more than zero, endoscopy is recommended for a full assessment of bleeding risk.

Resuscitation of a hemodynamically unstable patient begins with assessing and addressing the ABCs (breathing & airway& circulation) of initial and first management. (Baradarian et al demonstrated that early, aggressive resuscitation can reduce mortality in acute UGIB.[

Patients presenting with so severe blood loss and hemorrhagic shock present with mental status changes and confusion. In circumstances, patients cannot protect their airway, especially when hematemesis is present. In these cases, patients are at increased risk for aspiration, which is a potentially avoidable complication that can affect morbidity and mortality. This situation must be recognized early, and patients should be electively intubated in a controlled setting.

Intravenous access must be obtained. Bilateral, 16-gauge (minimum), upper extremity, peripheral intravenous lines are adequate for volume resuscitative efforts. Poiseuille’s law states that the rate of flow through a tube is proportional to the fourth power of the radius of the cannula and is inversely related to its length. Thus, short, large-bore, peripheral intravenous lines are adequate for rapid fluid infusion.

According to the 2008 SIGN guideline, either colloid or crystalloid solutions may be used to attain volume restoration prior to administering blood products. A rough guideline for the total amount of crystalloid fluid volume needed to correct the hypovolemia is the 3-for-1 rule. Replace each milliliter of blood loss with 3 mL of crystalloid fluid. This restores the lost plasma volume. Patients with severe coexisting medical illnesses, such as cardiovascular and pulmonary diseases, may require pulmonary artery catheter insertion to closely monitor hemodynamic cardiac performance profiles during the early resuscitative phase.

Once the ABCs have been addressed, assess the patient's response to resuscitation, based on evidence of end organ perfusion and oxygen delivery.

A study published by Kaplan et al indicated that skin temperature upon physical examination in combination with serum bicarbonate levels correlated well with the level of systemic perfusion.

Pulmonary artery catheters may be helpful to guide therapy. Foley catheter placement is mandatory to allow a continuous evaluation of the urinary output as a guide to renal perfusion. This labor-intensive management should be performed only in an ICU setting.

Once the maneuvers to resuscitate are underway, insert a nasogastric tube and perform an aspirate and lavage procedure. This should be the first procedure performed to determine whether the GI bleeding is emanating from above or below the ligament of Treitz. If the stomach contains bile but no blood, UGIB is less likely. If the aspirate reveals clear gastric fluid, a duodenal site of bleeding may still be possible.

In a retrospective review of 1190 patients, Luk et al found that positive nasogastric-tube aspirate findings were 93% predictive of an upper GI source of bleeding.

According to a study performed by the ASGE, however, a nasogastric-tube aspirate finding can be negative even in the setting of a large duodenal bleeding ulcer. The study compared nasogastric-tube aspirate findings with endoscopic findings of the bleeding source. The investigation revealed that 15.9% of patients with a clear nasogastric-tube aspirate, 29.9% of patients with coffee-ground aspirate, and 48.2% of patients with red blood aspirate had an active upper GI source of bleeding at the time of endoscopy.

A study correlated mortality with the color of the fluid from the nasogastric-tube aspirate and the color of the stool. As shown in the following table, the color of the nasogastric-tube aspirate can be a prognostic indicator.

Effect of the Color of the Nasogastric Aspirate and of the Stool on UGIB Mortalitיy Rate 

First surjery should be considered in patients with a perforated viscus (from perforated duodenal ulcer, יperforated gastric ulcer,י or Boerhaave syndrome). In patients who are poor operative candidates, יconservative therapy with nasogastric suction and broad-spectrum antibiotics can be instituted. Endoscopic sewing or clipping techniques have also been used in such patients.

Emergency surgery intervention in UBIG tentails oversewing the bleeding vessel in the gastric or duodenum (usually preoperatively identified by endoscopy), vagotomy with pyloroplasty, or partial gastrectomy. Angiographic obliteration of the bleeding vessel is considered in patients with poor prognoses.

Treatment-related contraindications and precautions

upper endoscopy contraindicated include an uncooperative or obtunded patient, severe cardiac decompensation, acute myocardial infarction (unless active, life-threatening hemorrhage is present), and perforated viscus (gastric ;esophagus;, intestine).

emergency surgery contraindication including bleeding daithesis impairment cardiopulmonary status ;

Esophagogastroduodenoscopy may be so sever and more difficult or impossible if the patient had previous radiation therapy to the oropharynxand oropharyngeal surgery..

When we found a Zenker diverticulum can make intubation of the esophagus more hard and diicult.

Patients presents with Down syndrome are more sensitive to conscious sedation, or they should be monitored by an anesthesiologist and/or intubated prophylactically prior to the procedure.

Hypotension can be be exacerbated by sedation/ therefore, patients who are unstable should be given less sedation.

Patients with large amount and aggresivly massive bleeding should be considered for intubationע to decrease the increased risk of aspiration. Such patients should be treated in an intensive care setting.יייייייי

the patient must be stabilized before to endoscopy and abnormalities in coagulation problem and pathologgy should be corrected. When this is impossible, the judgment of an experienced endoscopist is vital.

PPIs

The relative efficacy of the PPIs may be due to the ability to maintain a stomach pH at a level above 6.0, thereby protection an ulcer clot from fibrinolysis.יייייי Considering the available data, the ideal and eact pharmacologic therapy for patients with acute ulcer bleeding appears to be an intravenous PPI whether the patient is NPO or not. This is confirmed in the 2009 SIGN guidelines, which recommend soייי high-dose intravenous PPIs in patients with maior peptic ulcer bleeding or not bleeding present and visible vessels after endoscopic bleeding controling. Lansoprasole , esomeprazole , and plantoprazole are the only PPIs available as intravenous formulation in the יייUnited Statesייי but omeprazole is used in other countries intravenously.

We know that high-dose omeprazole intravenosly can accelerate the resolution of stigmata of recent bleeding and decreased the need for endoscopic therapy.

The suggested dose of pantoprazole intravenously and esomeprazole is 80-mg bolus followed by 8-mg/h infusion. The infusion is continued for 48-72 hours. This treatment has been shown to be cost-effective by Barkun et al Laine et al has demonstrated that intravenous high-dose lansoprazole, as well as orally administered so high-dose lansoprazole, can maintain the intragastric pH above 6.

A meta-analysis of 24 randomized controlled trials that evaluated proton יי pump יי inhibitors for bleeding ulcers (with or without endoscopic therapy) found a significant decreasing and reduction in the risk ofייי rebleeding ייי another time the needing for repeat endoscopic hemostasis, and surgery. An enhancement and improvement in mortality was seen in Asian tand in patients with active nonbleeding or bleeding visible vessels.

The 2010 international consensus guidelines on UGIB recommend the use of ייי proton ייי pump ייי inhibitors ייי intravenously in all patients with high-risk lesions post-endoscopic therapy proton ייי pump ייי inhibitors therapy might downgrade the lesion if given pre-endoscopy. The 2008 SIGN guideline agrees thatייי proton ייי pump ייי inhibitors ייי should not be used pre-endoscopy in patients presenting with acute UGIB.

So High-dose proton pump inhibitors intravenously may be used in patients who don’t have active bleeding or other high-risk stigmata for rebleeding or recurrent bleeding (יייvisible vesselייי adherent cloting יייin such ptients, the risk of recurrent bleeding is low. The goal of treatment in these patients (following resuscitation) should be directed at stage of healing the presentation o ulcers and at eliminating precipitating factors (nonייי steroidal ייי anti-inlammatory and hיי pylori ).

The 2008 SIGN guideline recommends taking Hיי pylori biopsy samples to test at the initial endoscopy procedure before starting proton pump inhebitors such as omeprazole lansoprazole…….. therapy. Histologically Biopsy specimens should be evaluated when the rapid urease test is minus negative.

A combined analysis of 5 studies that evaluated oral dosing with proton pump inhebitors (ייייwith or without endoscopic therapyיייי) found a significant decreasing in the risk of rebleeding and surgery.

Endoscopy therapiotically

In 1980s, endoscopic techniques to achieve hemostasis for bleeding ulcers and varices have progressive and continued to evolve. Endoscopy is now the method of choice for controlling active ulcer bleeding.

Several randomized clinical trials and meta-analyses have demonstrated and supported the idea that early endoscopic hemostatic therapy significantly reduces rates of recurrent bleeding, the need for emergent surgery, and mortality in patients with acute nonvariceal upper gastrointestinal bleeding (UGIB).

In the early history of endoscopy for UGIB, multiple published studies questioned the cost-effectiveness of endoscopy in this setting, because it was unclear whether the outcome was changed. In a setting in which 80% of patients respond to conservative medical management, studies were hampered by type 2 errors because of the large number of patients needed to demonstrate statistical significance.

In 1989, a National Institutes of Health (NIH) consensus conference on UGIB concluded that effective therapy was needed in the presence of active bleeding or a visible vessel. The conference affirmed that the treatment, when performed by an experienced endoscopist using 1 of 4 techniques (ie, injection of epinephrine or sclerosants, heater-probe coagulation, bipolar electrode coagulation, laser coagulation), was proven effective by the published evidence.

Three other techniques have since been developed: (1) endoscopic application of clips, (2) use of banding devices, and (3) argon plasma coagulation. Aside from ulcer hemorrhaging, other causes of gastrointestinal bleeding, including mucosal tears in the esophagus or upper stomach due to vomiting (Mallory-Weiss tears), venous blebs, and vascular ectasias, can also be treated with endoscopic coagulation.

The bleeding from gastric cancers and ulcers in leiomyomas does not usually respond to endoscopic therapy; surgical or radiologic intervention is needed.

Much debate has focused on the significance of the nonbleeding visible vessel (ie, color, size, diagnostic characteristics, risk of rebleeding) in ulcer hemorrhage. These matters became clarified after the characteristics and significance of the visible vessel in the ulcer crater were defined and the evidence for endoscopic therapy was established, demonstrating that patients requiring therapy to control bleeding or rebleeding could be diagnosed and treated at the time of the upper endoscopy.

Doctors considered for upper endoscopy if blood loss from the upper GIT bleeding is presented .

The patient should made endoscopy for the upper section before to operation to diagnose and localize the bleeding site. Mostly . patients (86-90%) respond to endoscopic therapy.

In the time of endoscopy procedurs , the patient is monitored according to sedation guidelines and analgesia formulated by the American Society of Anesthesiology. The features of the bleeding lesion are clearly noticed , and the matching therapy is applied when necessary for high-risk lesions or active bleeding.

Urgent endoscopy

Endoscopy uregent type is indicated when patients present with vomitting blood , or presented of blood in stools that called melena , or if present changes in blood pressure. a lower rate of rebleeding and shorter time of remaining when endoscopy is did within 24 hours of admission.

Early endoscopy : to perform endoscopy so early in the first 24 hours of an acuteייייייי upper gastrointestinal tract bleedingיייייייי and it found to be related with decreasing in the length period of hospitalization , rate of recurrent and rebleeding, and needing of emergent surgical intervention.

According to the 2011 consensus on nonvariceal upper gastrointestinal bleeding, endoscopy in early time performed (at 24 hours of presentation) is matched for mostly patients with ייייupper gastrointestinal bleeding יייי. In a review that involve more than 31,000 o cases, the mortality rates were more than tow times more as high for patients who didnt performed an early endoscopic than for those who did performed the procedure early on ייייייי11.0% vs 5.3%ייייייי

Endoscopic techniques

יייייendoscopic techniques to achieving hemostasisיייי?יי

To inject sclerosants or epinephrine

Ligation banding

coagulation such as heater probe

pressure tamponade steady probe

coagulator such as argon type of plasma

photocoagulation lazer type

band ligation such as rubber

implementation biologic glue including hemostatic materials

implementation of hemoclips or endoclips

implementation of expiremental nanopowder

to treat doctors must using a both of endoscopic therapies to combinate now become more common. For example, injection therapy can be enforcement firstly to better clarify the bleeding site, especially in the active bleeding patient, followed by the implementation of bipolar ייייgold type יייי or heater probe coagulation. Injection treatment can also be fulfillment beore to endoscopic setting of hemoclips.

With regarded to the 2009 SIGN guideline, integration of endoscopy with an injection of at least 13 mL of 1:10,000 adrenaline, coupled with either a thermal or mechanical therapy , are more valid than single manner.

The 2011 international consensus guidelines on יייי upper gastrointestinal bleedingיייי admonish the use of endoscopic clips or thermal therapy for high-risk lesions. As another pattern , injection therapy is beneficial before to laser therapy to decrease the heat sink effect of rapidly flowing blood before to laser coagulation.

Coagulationיheater יprobe ;

Thatיconsistsיofיaיelectrodeיenvelopedיbyיaיtitaniumיcapsuleיandיcovereage by Teflon (to decrease sticking to the mucosa by the probe). The temperature increase to 250°C (482°F).

Bipolar electrocoagulation

The bipolar probe consists of alternating bands of electrodes producing an electrical field that heats the mucosa and the vessel. The electrodes are coated with gold to reduce adhesiveness. The probes are stiff in order to allow adequate pressure to the vessel to appose the walls and thus produce coaptive coagulation when the electrical-field energy is transmitted. Careful technique is required to heat-seal the perforated vessel.

Injection therapy

Injection therapy involves the use of several different solutions injected into and around the bleeding lesion. The different solutions available for injection are epinephrine, sclerosants, and clot-producing materials, such as fibrin glue.

The epinephrine used for injection is diluted (1:10,000) and injected as 0.5- to 1-mL aliquots. Debate continues over whether the hemostatic effect of epinephrine is due to induced vessel vasoconstriction and subsequent platelet aggregation or to the tamponade effect produced by injecting the volume of drug into the tissue surrounding the bleeding lesion.

Epinephrine injection is often used to reduce the volume of bleeding so that the lesion can be better localized and then treated with a coaptive techniqueיייי, heater probe, gold probe).

Combining epinephrine injections with human thrombin (six hundred tell one thaousand IU) decreased the risk of occurring the bleeding.

administration of epinephrine in injection treatment is absorbed into the all systemic circulation, this don’t appear to have any adverse effects on hemodynamic situation.

To ingect volume of sterile isotonic sodium chloride solution and providing a tamponade effect also can leads to hemostasis, although not as effectively as does epinephrine

The solutions sclerosant used today include sodium tetradecy sulate lייי polidocanol and ethanol.

The sclerosants create hemostasis by inducing thrombosis, tissue necrosis, and inflammation at the site of injection. When large volumes are injected, the area of tissue necrosis can produce an increased risk of local complications, such as perforation. Combining the various agents into a single injection has not been shown to be more beneficial than single-agent therapy alone.

The use of fibrin glue in injection therapy has been shown to be successful, with results similar to those of epinephrine injections.

THERAPY BY THE LIZER

Phototherapy Lizer uses an Nd:YAG laser to create hemostasis by generating heat and direct vessel coagulation. This is a noncontact thermal method. It is not as effective as coaptive coagulation, because it lacks the use of compression to create a tamponade effect.ייייייי An additional deterrent to its use is expense.

To perform laser coagulation, the area near the vessel is first injected with epinephrine to reduce blood flow (reducing the heat-sink effect); then, the laser is applied around the vessel, producing a wall of edema. Caution must be observed to avoid drilling into the vessel with the laser, causing increased bleeding.

endoclips and hemostatic clips

in the United States the hemostatic clips are so available.

Modification of the delivery system has made clip placement much easier than it was in the original model. With careful placement of the clip, closing the defect in the vessel is possible. Usually, multiple clips are applied. They vary in the size and the strength of the clip. Four models of hemoclips are available: QuickClip2, which is rotatable; Resolution Clip, which can be reopened after closure; TriClip, which has 3 prongs; and InScope, which is a multiclip applier with 4 endoclips. The Resolution Clip seems to be the current clip of choice by experienced endoscopists.

Considering the available data, the efficacy of hemoclips is similar to that of thermal coagulation methods.

One report, concerning 113 patients with major stigmata of ulcer hemorrhage, found no difference between the use of hemoclips and photocoagulation with regard to hemostasis, 30-day mortality, and the need for emergency surgery.[ Patients randomized to the endoclip group had significantly lower rebleeding rates (2% vs 21%). However, only 60% of active bleeders were successfully treated with the heater probe, a rate much lower than in previous reports.

A study of 80 patients found a higher rate of control of initial bleeding with the heater probe compared with the Olympus endoclip (100% vs 85%).[Rebleeding rates were not significantly different.

No significant differences in procedure duration, initial hemostasis, or rebleeding rates were found in a study of 47 patients comparing combination therapy with epinephrine injection plus monopolar electrocoagulation versus hemoclips.

There are some clinical settings in which endoclips may be preferred over other hemostatic methods. These include the treatment of ulcers in patients who are coagulopathic or who require ongoing anticoagulation; in such patients, electrocoagulation will increase the size, depth, and healing time of treated lesions. Endoclips may also be preferable in the retreatment of lesions that rebleed after initial thermal hemostasis.

Ulcers on the lesser curvature, the posterior duodenum, or the cardia increase the difficulty of clip deployment and clip failure rates.

Larger endoclips have advantages over smaller hemoclips for the hemostasis of chronic ulcers and the closure of larger lesions.

Argon plasma coagulation

Argon plasma coagulation is a technique in which a stream of electrons flows along a stream of argon gas. The coagulation is similar to monopolar cautery, with the current flow going from a point of high current density (the point of contact of the gas with the mucosa) to an area of low current density (the conductive pad on the patient's body). The current flows through the body in an erratic path to the pad.

This monopolar cautery technique is similar to the laser technique in that energy is delivered to the vessel for coagulation with apposition of the vessel walls. This technique was found to not be effective for visible vessels larger than 1 mm. No animal models have been used for ulcer hemorrhage to validate this technique.

Nanopowder

Nanopowder has been found to be effective in a small study using a porcine model of arterial bleeding.[52] Further trails are awaited.

Endoscopic treatment decisions

The choice of treatment modality is influenced by the size of the vessel. Animal studies have demonstrated that the heater probe and bipolar probe are effective for vessels as large as 2 mm in diameter.

Other techniques (eg, clips, band ligation) or a combination of techniques are needed for larger vessels or vessels that are not approachable by the heater probe or bipolar probe. (Surgical intervention should be considered when dealing with vessels larger than 2 mm in diameter, discounting an enlargement due to the development of pseudoaneurysm.)

The 2008 SIGN guidelines recommend variceal band ligation in patients with confirmed esophageal variceal hemorrhage. It can be combined with a beta blocker as secondary prevention for esophageal variceal hemorrhage. For patients in whom band ligation is not suitable, a combination of nonselective beta blocker and nitrate is recommended as secondary prevention.

Ulcers with an overlying clot

In the patient who has an ulcer with an overlying clot, attempting to remove the clot by target washing is critical. Endoscopic removal of the clot by washing or cold snare has been demonstrated to be effective in reducing the recurrence of bleeding.[57](Cutting away the adherent clot is somewhat controversial but is recommended based on study results from experienced centers.)

The findings under the clot (eg, bleeding vessel, visible vessel, clean base, examples of which are seen in the images below) help to determine the therapy needed and improve efficacy by allowing treatment to be applied directly to the vessel. (See the table below.)

Ulcer with active bleeding.

Ulcer with a clean base.

Diagram of an ulcer with a clean base.

Ulcer with an overlying clot.

Ulcer with a visible vessel.

If the cloting not possible to removed by washing, then the clot cutting away using a cold snare can be considered by experienced endoscopists.

Washing vegrious of the clot formed after therapy is so useful in determining the adequacy of coagulation pathology . A combination of injection with heater probe or bipolar coaptive coagulation is often used and has been shown to be more effective in patients with active bleeding.

The patient is monitored under the protocol for conscious sedation, also called analgesia and sedation(, per the American Society of Anesthesiologists and the American Society for Gastrointestinal Endoscopy guidelines).

Active bleeding and rebleeding

Attempting to control active bleeding using the recommended techniques with the appropriate equipment or instituting appropriate therapy for a high-risk lesion is important. The large-channel therapeutic endoscope should be used so that the 10-French thermal probe can be employed for adequate coaptation.

Endoscopists should use the technique with which they have the most familiarity. The endoscopy should not be started unless the endoscopist is equipped for any potential lesions (, ulcer, varix, angioectasia, tear, tumor). The patient should be monitored for recurrent bleeding and treated a second time if appropriate. A surgical consultation should be considered for all patients with gastrointestinal hemorrhage.

The 2008 SIGN guidelines urge the consideration of transjugular intrahepatic portosystemic stent shunts (TIPS) to prevent esophageal variceal rebleeding for patients in whom endoscopy is contraindicated or has failed, and/or who are intolerant to pharmacological therapy,

Recurrent bleeding occurs in 11-33% of endoscopically treated patients. Aיי 2 יי attempt at endoscopic control is warranted. Some have concerns about the perils of a second esophagogastroduodenoscopy, which may result in delaying surgery, perforation, and increased morbidity and mortality rates. However, this approach has been validated in a large, randomized, controlled trial that showed decreased morbidity and mortality rates.

Specific characteristics at endoscopy can predict rebleeding. Rebleeding occurs in 55% of patients who have active bleeding (pulsatile, oozing), in 43% who have a nonbleeding visible vessel, in 23% who have an ulcer with an adherent clot, and in 0-5% who have an ulcer with a clean base.

At endoscopy, the prevalence rate for a clean base is 42%, for a flat spot is 20%, for an adherent clot is 17%, for a visible vessel is 17%, and for active bleeding is 19%.

Freeman et al have described a pale, visible vessel that appears to have a very high risk for recurrent this differentiated from the presence of abase cleaning ulcer .

visualization is so important. The unclearing fundal pool may obscure an ulcer, mucosal tear, gastric varices, portal gastropathy, or tumor (for examplesייי lymphomaיייי adenocarcinoma leiomyoma,). Endoscopic therapy is recommendation for ulcers at increased risk for recurrent bleeding .

In 2008 SIGN guidelines, TIPS should be considered to prevent gastric variceal rebleeding.

Using a combination of techniques is prudent when re-treating the ulcer site because the first therapy produced necrosis and weakening of the intestinal wall. Ulcers on the anterior surface of the stomach and duodenum are at increased risk for perforation. Using injection as the first step increases the thickness of the submucosal layer, thus providing an extra margin of safety.

Even operative techniques can have a significant rebleeding rate with significant mortality, as noted in the study of Poxon et al. In this investigation, the rebleeding rate was 10% (80% mortality for rebleeders) in patients who underwent a conservative surgical technique in which the ulcer base was undersewn.[59] This more conservative approach was compared with the standard surgical technique (ie, vagotomy and pyloroplasty or partial gastrectomy). The comparison of the conservative approach with a standard gastrectomy resulted in similar mortality rates, ie, 26% versus 19%, respectively, with no rebleeding after partial gastrectomy.

Postendoscopic monitoring

Postoperatively, the patient is monitored for recovery from conscious sedation after endoscopy and from general anesthesia after abdominal surgery. Monitor the patient's mental status, vital signs, chest, cardiac, and abdominal findings to ascertain that the patient's clinical status has stabilized and that no complications (eg, aspiration, perforation, recurrent bleeding, myocardial infarction due to hypotension) have occurred. Monitor the hemoglobin level.

Bleeding Peptic Ulcer Treatment

Upper GI endoscopy is the most effective diagnostic tool for PUD and has become the method of choice for controlling active ulcer hemorrhage. Failure of endoscopy to maintain hemostasis is one of the indications to initiate surgical intervention, especially in high-risk patients.

In a randomized, prospective trial that included 92 patients with recurrent peptic ulcer bleeding after initial endoscopic therapy for hemostasis, patients who underwent a second endoscopic attempt to control bleeding were found to have decreased transfusion requirements, 30-day mortality rates, and duration of ICU stay in comparison with the surgical group.[60]

With the exception of a patient in shock who has a life-threatening recurrent hemorrhage, this study supports attempting another trial of endoscopy to control a bleeding ulcer.

Regardless of the endoscopic therapy, however, 10-12% of patients with acute ulcerous hemorrhage require an operation as the definitive procedure to control the bleeding ulcer. In most circumstances, the operation is performed emergently, and the associated mortality rate is as high as 15-25%.

Medical therapy used in conjunction with endoscopy involves PPI administration. PPIs decrease rebleeding rates in patients with bleeding ulcers associated with an overlying clot or visible, nonbleeding vessel in the base of the ulcer.[61, 62] Consider transcatheter angiographic embolization in patients who are poor surgical candidates. Because of the extensive collateral circulation of the upper GI tract, ischemic complications are rare.

Surgical treatment

If 2 attempts at endoscopic control of the bleeding vessel are unsuccessful, avoid further attempts (ie, because of increased rebleeding and mortality rates) and pursue surgical intervention. The indications for surgery in patients with bleeding peptic ulcers are as follows:

Severe, life-threatening hemorrhage not responsive to resuscitative efforts

Failure of medical therapy and endoscopic hemostasis with persistent recurrent bleeding

A coexisting reason for surgery, such as perforation, obstruction, or malignancy

Prolonged bleeding, with loss of 50% or more of the patient's blood volume

A second hospitalization for peptic ulcer hemorrhage

The operative treatment options for a bleeding duodenal ulcer historically include vagotomy, gastric resection, and drainage procedures. Each specific operative option is associated with its own incidence of ulcer recurrence, postgastrectomy syndrome, and mortality (as seen in the table below). When making an intraoperative judgment on how to best manage the bleeding ulcer, it is extremely important for the surgeon to be aware of these differences.[15]

Table 6. Recurrent Ulcer and Postgastrectomy Syndromes After Operations for Duodenal Ulcer (Open Table in a new window)

The 3 most common operations performed for a bleeding duodenal ulcer are as follows[9] :

Truncal vagotomy and pyloroplasty with suture ligation of the bleeding ulcer

Truncal vagotomy and antrectomy with resection or suture ligation of the bleeding ulcer

Proximal (highly selective) gastric vagotomy with duodenostomy and suture ligation of the bleeding ulcer

The purpose of the vagotomy is to divide the nerves to the acid-producing body and fundus of the stomach. This inhibits the acid production that occurs during the cephalic phase of gastric secretion. Although acid secretion is controlled, gastric motility and gastric emptying is affected, as indicated in the following table.[15]

Table 7. Effects of Operations for PUD on Gastric Emptying and Motility (Open Table in a new window)

Proximal vagotomy abolishes gastric receptive relaxation and impairs storage in the proximal stomach. As a result, a more rapid gastric emptying of liquids occurs. A drainage procedure is not required, because the innervation of the antrum and pylorus is still intact. Because of this, the gastric emptying of solid food is not altered. The antropyloric mechanism still functions normally and continues to prevent duodenogastric reflux.

In addition to having the same effects as a highly selective vagotomy in the proximal stomach, a truncal vagotomy also has marked effects on distal gastric motor function. It weakens distal gastric peristalsis, thus requiring the creation of a pyloroplasty to decrease the resistance to outflow from the stomach.

Truncal vagotomy and suture ligation of a bleeding ulcer is a frequently used operation for treating upper gastrointestinal bleeding (UGIB) in elderly patients with life-threatening hemorrhage and shock. The procedure can be performed rapidly, minimizing the time spent in the operating room under general anesthesia.

The principles of suture ligation of a duodenal bleeding ulcer that involves the gastroduodenal artery require use of the 3-point ligation technique.

The gastroduodenal artery is ligated proximally and distally to the arterial bleeding site. The third suture is a horizontal mattress placed to control hemorrhage from the transverse pancreatic branch of the gastroduodenal artery. Failure to place this third stitch may result in recurrent bleeding that requires another emergent laparotomy of the abdomen. Vagotomy with antrectomy is reserved for patients whose conditions have failed to respond to more conservative attempts at surgical intervention and for those with aggressive and recurrent duodenal ulcer diathesis, such as gastric outlet obstruction.

When performing a highly selective vagotomy, the duodenostomy or the pyloroduodenostomy is closed anatomically, preserving the normal pyloric sphincter muscle. Most commonly, this operation is reserved for young, stable, low-risk patients. Although long-term follow-up care is still necessary, the recurrent ulcer rate is less than 10% at a mean follow-up of 3.5 years.

Much of what is now known about the operations performed for bleeding duodenal ulcers came from the era before the etiologic role for H pylori and NSAIDs in the development of peptic ulcers was understood. Reducing gastric acidity has been proven to be beneficial, with lower rebleeding rates when using high-dose omeprazole.[5] Although PPIs seem to have an advantage, they have no affect on mortality.

The diagnosis of H pylori infection is important in the management of patients with a complicated bleeding peptic ulcer. If a patient with a bleeding ulcer requires surgery, then knowledge of the patient's H pylori status becomes pertinent, because it may help to guide the decision to choose a particular surgical procedure, eg, simply oversewing the ulcer as opposed to performing an antiulcer operation. Many studies support the decision to manage the bleeding ulcer in conjunction with eradication of H pylori.

The 2008 SIGN guideline recommends testing for H pylori in patients with peptic ulcer bleeding and a 1-week course of therapy prescribed for those who test positive. Three weeks of continuous treatment should be given. In those who use NSAIDs, maintenance antisecretory therapy should not persist after successful healing of the ulcer and H pylori eradication.[34]

Bleeding Gastric Ulcer Treatment

The surgical management of bleeding gastric ulcers is slightly different from that of duodenal ulcers, but the concepts are identical. The 3 most common complications of a gastric ulcer that mandate emergent surgical intervention are hemorrhage, perforation, and obstruction. The goals of surgery are to correct the underlying emergent problem, prevent recurrent bleeding or ulceration, and exclude malignancy.

A bleeding gastric ulcer is most commonly managed by a distal gastrectomy that includes the ulcer, with a gastroduodenostomy or a gastrojejunostomy reconstruction.

The common operations for the management of a bleeding gastric ulcer include (1) truncal vagotomy and pyloroplasty with a wedge resection of the ulcer, (2) antrectomy with wedge excision of the proximal ulcer, (3) distal gastrectomy to include the ulcer, with or without truncal vagotomy, and (4) wedge resection of the ulcer only.

Types of gastric ulcers

The choice of operation for a bleeding gastric ulcer depends on the location of the ulcer and the hemodynamic stability of the patient to withstand an operation. Five types of gastric ulcers occur, based on their location and acid-secretory status.

First type–gastric ulcers are located on the lesser curvature of the stomach, at or near the incisura angularis. These ulcers are not associated with a hypersecretory acid state.

Second type–- ulcers represent a combination of 2 ulcers that are associated with a hypersecretory acid state. The ulcer locations occur in the body of the stomach in the region of the incisura. The second ulcer occurs in the duodenum.

Third type–- ulcers are prepyloric ulcers. They are associated with high acid output and are usually within 3 cm of the pylorus.

Fourth type–-ulcers are located high on the lesser curvature of the stomach and (as with type 1 ulcers) are not associated with high acid output.

Type 5 ulcers are related to the ingestion of NSAIDs or aspirin. These ulcers can occur anywhere in the stomach.

Surgical management according to ulcer type

A vagotomy is added to manage type 2 or type 3 gastric ulcers.

Patients who are hemodynamically stable but have intermittent bleeding requiring blood transfusions should undergo a truncal vagotomy and distal gastric resection to include the ulcer for type 1, 2, and 3 ulcers.

In patients who present with life-threatening hemorrhage and a type 1, 2, or 3 ulcer, biopsy and oversew or excision of the ulcer in combination with a truncal vagotomy and a drainage procedure should be considered.

Patients with type 4 ulcers usually present with hemorrhage. The left gastric artery should be ligated, and a biopsy should be performed on the ulcer. Then, the ulcer should be oversewn through a high gastrotomy.

Rebleeding rates for the procedures that keep the ulcer in situ range from 20-40%.[15]

Gastric bleeding in the immediate postoperative period from recurrent PUD is initially best managed by endoscopic or angiographic means. If reoperation is required, gastric resection is usually indicated, because a repeat vagotomy is not reliable. A more definitive solution is warranted.

According to the 2008 SIGN guidelines, patients with confirmed gastric variceal hemorrhage require endoscopic therapy, preferably with cyanoacrylate injection.[34]

Stress Gastritis Treatment

Knowledge of the predisposing conditions for stress ulceration allows the clinician to identify patients at risk for developing gastritis and GI bleeding. Treatment in this group of high-risk patients should focus on prevention. This is best accomplished by treating the underlying causes of ulceration.

Aggressive support of hemodynamic parameters ensures adequate mucosal blood flow. In addition, several strategies have evolved to treat gastric luminal acidity. Histamine receptor antagonists (HRAs) have proven to be the most effective at controlling stomach pH. Proton pump inhibitors (PPIs) are superior to the HRAs at suppressing acid; however, their role in stress ulceration prophylaxis is still being studied.[16]

Stress-related bleeding usually occurs 7-10 days after the initial insult but may manifest sooner. Initially, endoscopy is the most important diagnostic tool. The acute superficial erosions are multiple, begin in the fundus, and progress toward the antrum. Ninety percent of patients stop bleeding with conservative medical therapy that includes NGT lavage and gastric acid–controlling medications to maintain the gastric luminal pH above 5.0.[17]

Endoscopic hemostasis is attempted using electrocoagulation, laser, or injection therapy. Selective angiographic catheterization of the left gastric artery may be attempted with selective infusion of vasopressin (48-72 h) or embolization using Gelfoam, coils, or autologous clot to embolize the left gastric artery. Regardless of the angiographic technique used, it is often unsuccessful because of the rich and extensive submucosal plexus and collateral circulation within the stomach.

Surgical treatment

Surgical intervention becomes necessary if nonoperative therapy fails and blood loss continues. The goals of operative treatment are to control bleeding and to reduce recurrent bleeding and mortality. These patients are at extremely high risk, and the most expeditious procedure is the best option.

Simply oversewing an actively bleeding erosion is sometimes effective enough to control the bleeding. In the setting of life-threatening hemorrhage not amenable to endoscopic control, gastric resection with or without vagotomy with reconstruction may be necessary.

The type of gastric resection depends on the location of the gastric erosions, ie, whether they are proximal or distal. The options are antrectomy and subtotal, near total, or total gastrectomy. Operative mortality rates range from 4-17%.[63] The choice of the initial operation must be made with an understanding of the patient's condition, the amount and location of gastric disease, and an accurate assessment of one's technical ability to rapidly and safely perform a gastric resection. The trend has been to perform less surgery in general and to minialize the type of surgical procedure performed.[64]

Managing the underlying insult causing the gastric stress ulcerations is also important. This involves supportive measures to maintain acceptable hemodynamic parameters, to provide adequate nutritional support in the critically ill patient, and to treat sepsis (if present).

Mallory-Weiss Syndrome Treatment

Distinguishing Mallory-Weiss syndrome from Boerhaave syndrome is critical. Although both entities share a common pathogenesis, their management is completely different.

Boerhaave syndrome represents a full-thickness transmural laceration with perforation of the esophagus. A Gastrografin swallow helps to confirm the presence of the perforation in most cases, and prompt surgical intervention is necessary to prevent mediastinitis and sepsis.

On the other hand, surgical intervention in Mallory-Weiss syndrome is required to achieve hemostasis in only 10% of cases.[17] The bleeding from a Mallory-Weiss tear spontaneously ceases in 50-80% of patients by the time endoscopy is performed.[17]

For patients in whom bleeding is visualized at endoscopy, the endoscopic treatment options are electrocoagulation, heater-probe application, hemoclips, epinephrine injection, or sclerotherapy.

In a series published by Bataller et al, hemostasis was achieved in 100% of patients with Mallory-Weiss tears by using endoscopic sclerotherapy with epinephrine (1:10,000) and 1% polidocanol. Other nonoperative therapies are reserved for cases in which endoscopic attempts at creating hemostasis have failed.

Other available options are angiographic intra-arterial infusion of vasopressin and transcatheter embolization of branches of the left gastric artery using Gelfoam. Avoid the balloon tamponade technique using the Sengstaken-Blakemore tube in this particular circumstance, because this apparatus may extend the mucosal laceration into a transmural laceration with perforation.[17]

Surgical intervention is indicated in patients with continued bleeding after failed attempts at nonoperative therapies.

Bleeding from the gastroesophageal junction is visualized through an anterior gastrotomy. Once the tear is localized, the bleeding is controlled by oversewing the lesion.

The overall mortality rates for patients who require emergent surgery is 15-25%, in contrast to a mortality rate of 3% or less for patients whose bleeding stops by the time of the initial endoscopy.[17]

Treatment Complications

Complications of endoscopic therapy include aspiration pneumonia and perforation (1% for the first endoscopic therapy, 3% for the second). Bleeding can be caused by drilling into the vessel with the laser, by perforating the vessel with an injection, or by removing the clot with failure to coagulate the vessel.

Tseng et al investigated the cardiovascular effects of emergency endoscopy for UGIB in patients with stable coronary artery disease (CAD)[72] and found that the patients commonly experienced, primarily on a subclinical level, ventricular arrhythmias and myocardial ischemia. The authors' results were as follows:

Incidence of ventricular arrhythmias during endoscopy – 42% (patients with CAD) versus 16% (controls)

Frequency of ventricular arrhythmias during endoscopy – 1.19 events per minute (patients with CAD) versus 0.12 events per minute (controls)

Number of patients with ischemic ST changes – 9 patients with CAD versus 1 control

Complications from emergency abdominal surgery include ileus, sepsis, poor wound healing, and myocardial infarction.

Salvage surgery is associated with a high mortality rate, reflecting the comorbidities of patients who rebleed or continue to bleed.

Procedures

The Blakemore esophageal balloon used for stopping esophageal bleeds if other measures have failed

The benefits versus risks of placing a nasogastric tube in those with upper GI bleeding are not determined.[5]Endoscopy within 24 hours is recommended,[5] in addition to medical management.[29] A number of endoscopic treatments may be used, including: epinephrineinjection, band ligation, sclerotherapy, and fibrin glue depending on what is found.[3]Prokinetic agents such aserythromycin before endocopy can decrease the amount of blood in the stomach and thus improve the operators view.[5] They also decrease the amount of blood transfusions required.[30] Early endoscopy decreases hospital and the amount of blood transfusions needed.[5] A second endoscopy within a day is routinely recommended by some[14] but by others only in specific situations.[31] Proton pump inhibitors, if they have not been started earlier, are recommended in those in whom high risk signs for bleeding are found.[5] High and low dose PPIs appear equivalent at this point.[32] It is also recommended that people with high risk signs are kept in hospital for at least 72 hours.[5] Those at low risk of re-bleeding may begin eating typically 24 hours following endoscopy.[5] If other measures fail or are not available, esophageal balloon tamponade may be attempted.[3] While there is a success rate up to 90%, there are some potentially significant complications including aspiration and esophageal perforation.[3]

Colonoscopy is useful for the diagnosis and treatment of lower GI bleeding.[3] A number of techniques may be employed including: clipping, cauterizing, and sclerotherapy.[3] Preparation for colonoscopy takes a minimum of six hours which in those bleeding briskly may limit its applicability.[33] Surgery, while rarely used to treat upper GI bleeds, is still commonly used to manage lower GI bleeds by cutting out the part of the intestines that is causing the problem.[3] Angiographic embolization may be used for both upper and lower GI bleeds.[3] Transjugular intrahepatic portosystemic shunting (TIPS) may also be considered.[14]

8. Complications: of gastrointestinal bleeding

Anemia

Prolonged bleeding detectable in a microscopic study can lead to the loss of iron in the individual. This can cause anemia, reports the website CureResearch.com. Red blood cells contain a protein called hemoglobin. It is required to carry oxygen to the tissues of the body. A lack of hemoglobin and a lack of red blood cells can occur during constant GI bleeding, causing anemia. Symptoms of anemia include chest pain, dizziness, fatigue, weakness, headaches, shortness of breath and lack of mental clarity.

Hypovolemia

MedlineיPlusיreportsיthatיhypovelemiaיmayיoccurיasיaיcomplicationיofיGIיbleeding.יDue toי severeיlossיofיbloodיandי fluidיinיacuteיGIיbleeding, יtheיheartיfindsיitיdifficultיto pumpיenoughיbloodיtoיtheיbody,יwhichיisיreferred toיasיhypovelemia.יIt is aיlife-threateningיconditionיsince itיcanיcauseיtheיbody'sיorgansיtoיstopיworking.יSymptomsיof thisיconditionיincludeיcool,יclammyיskin;יconfusion;יagitation;יdecreasedיurineיoutput; weaknessי paleיskin;יquickיbreathing;יandיlossיofיconsciousness.

Shock

AnotherיcomplicationיofיGIיbleedingיisיshock,יstatesיCureיResearch.com. Acuteיand massiveיbleedingיfromיtheיgastrointestinalיtractיcanיleadיtoיaיlackיofיbloodיflowיtoיthe body.יThisיcanיdamageיtheיdifferentיorgansיofיtheיbody,יcausingיorganיfailure. MedlineיPlusיreportsיthatיshock יisיanיemergencyיconditionיandיifיitיisיnotיtreated immediately,יitיcanיworsenיquickly,יcausingיirreversibleיdamageיtoיtheיorgansיorיeven death.יSymptomsיofיshockיincludeיanיextremelי lowיbloodיpressure,יbluishיlipsיand fingernails,יchestיpain,יconfusion,יdizziness,יanxiety,יpaleיskin,יdecreasedיorיnoיurine output,יracingיbutיweak יpulseיrate,יshallowיbreathing,יandיunconsciousness.

Dehydration and Chest Pain

CureResearch.com explains that dehydration is another complication of gastrointestinal bleeding. The individual may also develop pain in the chest, especially if there is a heart condition present .

Prognosis of upper gastrointestinal tract:

peopleיandיeldrlyיpatientsיwithיchronicיmedicalיconditions יwithstandיacute UGIBי lessיwellיandיhaveיaיhigherיriskיofיdeath.יי Mortalityי isיaboutי7%יin patientsיadmittedיwithיanיUGIBי Itיisיasיhighיasי26%יinיpatientsיwhoיdevelop bleedingיwhilsי inיhospitalיhavingיbeenיadmittedיforיanotheי causeי Aיscorי of lessיthanי3יusingיtheיRockallיScoreיsystemיaboveי isיassociatedיwithיan excellentיprognosis,יwhereasיaיscorי of 8יorיabovי isיassociatedיwithיhigh mortality.

Factorsיwhichיaffectיtheיriskיofיdeathיinclude:

Age:יdeathsיunderיageי40יyearsיareיrare.י30% ofיpatientsיtheיageיofי90 yearsיwithי UGIBיdieיasיaיresultיofיtheיbleed.

Comorbidity: complicationsיareיmoreי likelyי withיcomorbidיdisease.

Shock: theיpresenceיofיsignsיofיshock יatיpresentationיconfersיaיworse prognosis.

Prognosis is alsoיworseיwithיliverיdisease,יbeingיanיinpatient,יcontinued bleedingיafterי presentation,יhaematemesis,י haematocheziaיandיelevated bloodיureaיי

Endoscopicיfindings:יmuchיworkיhasיbeenיdoneיonיclassifyingיand identifyingיendoscopicיfindingsיwhichיcorrelateיwithיhighיrisk -יforיexample:

Mallory-Weissיtearsיorיcleanיulcersיhaveיa lowיriskיof re-bleedingיand death.

Activeיbleedingיinיaיshockedיpatientיcarriesיan 80% riskיofיre-bleedingיor death.

Non-bleedingיbutיvisibleיvesselיhasיa 50%יriskיofיre-bleeding.

General conclusion

Giant strides continue to be made in the management and care of patients bleeding from their upper gastrointestinal tract. Nevertheless, recurrent bleedingיratesיareיstillיatיtimesיasיhighיasי20%,יwithיsignificantיmorbidity andיmortality.יAdoptingיnewיtechnologieיי(endoscopicיultrasound,יconfocal laserיendomicroscopyיandיendoscopicיsuturingיdevices)יmayיbeיhelpful butיwillיbeי insufficientיinיconqueringיthisיchallengingיproblemי Weיmust continueיtoיkeepיour mindsיopenיtoיnewיpossibilitiesיandיnewיapproaches.

Informationיwasיavailableיforי61י067 cases (81% publishedיsinceי1997 יof whomי5,001יdied.יTheיmortalityיrateיinיallיcasesיfellיsignificantly,יfrom 11.6%י(95%יconfidence יinterval,י11.0 to 12.2)יinיpre=1997יstudiesיtoי7.4% (7.2 to 7.6)יinיthoseיpublishedיsinceי1997.יInי5,526יpatientsיtakingיNSAID or aspirinיmortalityיincreased,יfromי14.7%י(13.6 to 15.8)יbeforeי1997יto 20.9%י(18.8 to 22.9)יsince 1997.

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