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