Stomach and Duodenum—Upper GI Bleeding
Concept
Important to pay attention to the broad DDx here as well as close attention to the ABCs as the patient with massive hematemesis may exanguinate while you are still perform- ing a history with questions related to alcohol use, vomit- ing, and liver disease.
Way Question May be Asked?
“51 y/o male presents to ED with vomiting blood twice at home. BP is 80/50. What do you want to do?” May have patient that presents with more chronic blood loss with black, tarry stools. Presentation will guide how quickly you move into treatment options.
How to Answer?
Brief H+P While Resuscitating the Patient
History of PUD Associated pain Age
ASA, NSAID, steroid/alcohol use
Recent retching/vomiting (Mallory-Weiss Tear) Liver disease
Trauma
History of UGI surgery (marginal ulcer) History of AAA repair (aortoenteric fistula)
Physical Exam
Stigmata of liver disease
Evidence of prior surgery (always note any surgical scars)
Melena (never leave out rectal exam)
Algorithm
ABCs
Resuscitation (IVF, full labs including PT/PTT, T+C, NGT)
Gastric irrigation through NGT
+/− endotracheal intubation depending on severity of bleed
Endoscopy (localization and possibly therapeutic) +/− angiography
Endoscopic Methods to Control Bleeding
Heater probe Electrocautery Epinephrine injection
Band ligation/sclerotherapy (esophageal varices) (appearance important here as overlying clot/visible
vessel have higher chance of rebreeding than clean ulcer base)
Angiography
Can treat certain bleeds with intra-arterial gelfoam, metal coil springs, vasopressin
Useful for gastric/duodenal ulcers If bleeding controlled, don’t forget:
Antacids, H2blockers, treatment of H. pylori
Surgical Treatment
Reserved for pts with continued or recurrent bleeding (6 U pRBCs), complicated ulcer disease, massive UGIB, non-healing ulcers
For gastric adenoCA: resect with 5 cm margin, if within 5 cm of GEJ= total gastrectomy
For stress gastritis: total gastrectomy, or gastric devas- cularization if unstable (quicker)
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For gastric ulcer:
→stable pt antrectomy to include ulcer or suture ligation/biopsy/+ antrectomy
→ unstable, wedge resection or suture ligation/biopsy/vagotomy/pyloroplasty For duodenal ulcer:
→ high risk/unstable, vagotomy/pyloroplasty/- oversew ulcer (U stitch)
→ stable pt, no hx PUD, small ulcer, oversew and parietal cell vagotomy
→ giant ulcer/stable/hx PUD→ antrectomy +vagotomy
For bleeding from anastomotic line from recent surgery:
→ EGD, if/when fails, re-explore and ligate bleeder For Mallory–Weiss:
→ gastrotomy, suture ligation of mucosal tears (if tears in esophagus, left thoracotomy/esophago- tomy, suture ligate bleeders
For Aorto-enteric fistula:
→control bleeding, then extra anatomic bypass For varices
→TIPS or emergency portacaval shunt
Common Curveballs
Angiogram won’t localize lesion, and/or embolization won’t work
Endoscopy won’t localize lesion Pt will have had prior ulcer surgery Pt will have had prior AAA repair All coags will be abnormal NGT won’t get bilious return
Bleeding will be from duodenum despite non-bloody, bilious NGT aspirate
Bleeding will recur after endoscopic treatment Large ulcer will be malignant
May need to make gastrotomy/duodenotomy to localize bleeding
May be from nasopharynx or hemoptysis from lungs GI doc won’t be available to perform EGD
Any nonoperative therapy will fail
“U-stitch” won’t work→ligate gastroduodenal
Strikeouts
Not placing NGT Taking too long in H+P
Not resuscitating pt prior to surgery Not taking pt to surgery when appropriate Not treating for H. pylori
Not biopsying an ulcer seen at EGD
Placing Sengstaken/Blakemore tube for Mallory-Weiss tear
Performing distal splenorenal shunt emergently for bleeding varices
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