Abdominal Tract: UGI bleed Scenarios: ER with hematemesis Blood in NGT +/- h/o EtOH * The patient will

likely be either borderline HD stable or about to become unstable. If HD stable-OK to proceed with gathering a lot of history and PE data but the scenario can change quickly.
if clearly in hemorrhagic shock-treat like a bad trauma-what are the vitals, is the airway secure? intubate if not and transfer to ICU (aspirating blood is bad), drop an NGT and place large bore IVs for access, send labs including coags and T&C, OK to start transfusing universal match blood as needed. CXR and EKG. Gather minimal history needed and go for an intervention early with no prolonged imaging workup. No observing, no angio and no absolutely no nuclear scan for these folks! Focus on stopping the bleeding. EGD to locate source then intervention. If no time for EGD/equipment not available can take to OR do a gastrotomy, extend into duodenum and look around but best to try EGD first. Transfer to ICU to observe/resuscitate/monitor (Foley and A-line) or OR for intervention. Patients with an active bleed of unknown source- even if HD stable- do not go to the floor or home! Dont forget to reverse any coagulopathies for those on anticoagulants-FFP/Vitamin K. If the patient has had a recent surgical procedure (gastric bypass-think bleed from gastric anastomosis or marginal ulcer bleed, Whipple-think GDA stump bleed, any bypass connecting the biliary tree to the intestines-think bleeding due to procedure), any procedures that were ineffective- ex. Ligating duodenal ulcer that re-bleeds (reoperate and ligate GDA) you can target the treatment.

DDx: bleeding peptic ulcer Benign or malignant Zollinger-Ellison syndrome-is ulcer distal to D1 (only normal in 10% of cases not associated with ZE) Chronic steroid use, cocaine use gastritis Bleeding duodenal ulcer Mallory weiss tear variceal bleed marginal ulcer after partial gastrectomy (typically on jejunal side) Aortoenteric fistula after AAA repair Background

The most common medical causes are peptic ulcer disease and variceal bleeding. Peptic ulcer disease: Disease is caused by mucosal erosion that is painful due to the acidity of the environment in the stomach and proximal duodenum. H. pylori has been associated with > 70% of cases. Treated mostly medically with PPIs and H.pylori treatment but can lead to complications that need surgical intervention. These are: perforation (10% mortality), bleeding (2.5% mortality) and structuring of the duodenum from inflammation leading to gastric outlet obstruction. Testing for H. Pylori: Serological antibody testing Urea breath test Urease test on antral biopsy specimens (stop all PPIs, bismuth meds x 4 weeks before the biopsy) Rx: PPI: PO doses (for outpatient): IV dose (for sick inpatient or one not tolerating PO): H. Pylori treatment: Bonus points: How do you know it is eradicated? Urea breath test or repeat endoscopy Off PPI x 1 week and 1 month after completion of antibiotic course Must r/o cancer in ulcers found in the stomach (5% incidence of cancer, 30% if > 3 cm) whereas duodenal ulcers tend to be benign. * See section on gastric ulcers for management of the intractable ulcer/resistant to H. pylori and PPI txt that is inevitably a gastric cancer-different management. Found in Surgical Oncology section. There are 5 classes of peptic ulcers based on location and cause:
I II Location Lesser curve, before incisura (Most common) One in stomach before Cause Need for vagotomy No Yes* Operation Distal gastrectomy with Billroth I reconstruction Antrectomy, truncal

acid

III IV

Distal gastrectomy with Billroth I or II reconstruction or near-total gastrectomy with R-Y gastreojejunostomy V Anywhere in stomach NSAID No Heals after NSAID stopped, if operating required-depends on closeness to GEJ * 10% risk of post-vagotomy complications with truncal vagotomy. In compliant patients give life-long PPI to avoid risk (cheap and effective). For non-compliant patients or those with failed medical management->vagotomy.

incisura and another in duodenum Prepyloric Near GEJ along lesser curve

vagotomy (or lifetime PPI use) acid Yes* No

Ulcers > 3cm: higher risk of malignancy

Varices, esophageal: Medical treatment is the standard (b-block, endoscopic banding). TIPS if recurrent bleeding episodes. No surgical intervention indicated in the acute setting. OLT or shunt (side-side portocaval shunt) for prevention of recurrent bleed. Mallory Weiss: Caused by a tear (usually single) in the mucosa of the esophagus (distal) due to vomiting. The most common location is below GEJ before the lesser curve of the stomach. Only a minority need surgical intervention given that they can heal spontaneously and are amenable to endoscopic intervention (cautery, epinephrine injection, clips or banding) if not. Surgery is reserved for cases of re-bleeding or when the bleeding is massive enough to prevent endoscopic treatment. Gastritis: Treatment is medical: IV PPI, resusitate, transfuse as needed. Can control focal bleeding points endoscopically with cautery. If all else fails: OR for gastrotomy and suture ligation of main bleeders. The extreme casesdevascularization of the stomach (all essels except for the short gastrics are ligated) Goals:

Transfuse, resuscitate and intubate to protect the airway (if needed) Quickly identify and control the source-start with endoscopy Treat factors that may lead to recurrence (portal hypertension, H. pylori, medications that increase GI bleeding risk-NSAID use) Gastric ulcer with visible vessel or pulsatile bleeding during endoscopy is at a higher risk to re-bleed. If visible clot or non-pulsitile bleed-lower risk but still possible. Initial Management