Case Files Surgery, (LANGE Case Files) 4th Ed.

SECTION II. Clinical Cases

CASE 9

A 38-year-old man presents at the emergency department with tarry stools and a feeling of light-headedness. The patient indicates that over the past 24 hours he has had several bowel movements containing tarry-colored stools and for the past 12 hours has felt light-headed. His past medical and surgical history is unremarkable. The patient complains of frequent headaches caused by work-related stress for which he has been self-medicating with six to eight tablets of ibuprofen a day for the past 2 weeks. He consumes two to three martinis per day and denies tobacco or illicit drug use. On examination, his temperature is 37.0°C (98.6°F), pulse rate 105 beats/min (supine), blood pressure 104/80 mm Hg, and respiratory rate 22 breaths/min. His vital signs upright are pulse 120 beats/min and blood pressure 90/76 mm Hg. He is awake, cooperative, and pale. The cardiopulmonary examinations are unremarkable. His abdomen is mildly distended and mildly tender in the epigastrium. The rectal examination reveals melanotic stools but no masses in the vault.

Images What is your next step?

Images What is the best initial treatment?

ANSWERS TO CASE 9: Upper Gastrointestinal Tract Hemorrhage

Summary: A 38-year-old man presents with signs and symptoms of acute upper gastrointestinal (GI) tract hemorrhage. The patient’s presentation suggests that he may have had significant blood loss leading to class III hemorrhagic shock.

• Next step: The first step in the treatment of patients with upper GI hemorrhage is intravenous fluid resuscitation. The etiology and severity of the bleeding dictate the intensity of therapy and predict the risk of further bleeding and/or death.

• Best initial treatment: Prompt attention to the patient’s airway, breathing, and circulation (ABCs) is mandatory for patients with acute upper GI hemorrhage. After attention to the ABCs, the patient is prepared for endoscopy to identify the etiology or source of the bleeding and possible endoscopic therapy to control hemorrhage.

ANALYSIS

Objectives

1. Be able to outline resuscitation and treatment strategies for patients presenting with acute upper GI tract hemorrhage and hemorrhagic shock.

2. Learn the common causes of upper GI tract hemorrhage and their therapies.

3. Know the adverse prognostic factors associated with continued bleeding and increased mortality.

Considerations

The treatment of patients with suspected upper GI tract hemorrhage begins with an initial assessment to determine if the bleeding is acute or occult. Acute bleeding is recognized by a history of hematemesis, coffee-ground emesis, melena, or bleeding per rectum, whereas patients with occult bleeding may present with signs and symptoms associated with anemia and no clear history of blood loss. A critical part of the initial evaluation is assessment of the patient’s physiologic status to gauge the severity of blood loss. The sequence in the management of acute upper GI tract hemorrhage consists of (1) resuscitation, (2) diagnosis, and (3) treatment, in that order. In this patient’s case, his symptoms and physiologic parameters suggest severe, acute blood loss (class III hemorrhagic shock with up to 35% total blood volume loss) and should prompt immediate resuscitation with close monitoring of patient response (urine output, clinical appearance, blood pressure, heart rate, serial hemoglobin and hematocrit values, and consideration of central venous pressure [CVP] monitoring). A nasogastric tube should be inserted following resuscitation to determine whether bleeding is active. The stomach should be irrigated with room-temperature water or saline until gastric aspirates are clear. For patients with massive upper GI tract bleeding, agitation, or impaired respiratory status, endotracheal intubation is recommended prior to endoscopy. Laboratory studies to be obtained include a complete blood count (CBC), liver function studies, prothrombin time (PT), and partial thromboplastin time (PTT). A type and cross-match should be ordered. Platelets or fresh-frozen plasma should be administered when thrombocytopenia or coagulopathy is identified, respectively. Early endoscopy identifies the bleeding source in patients with active ongoing bleeding and may achieve early control of bleeding. Given the history of nonsteroidal anti-inflammatory drug (NSAID) use, it would be appropriate to begin empirical therapy for a presumed gastric ulcer and gastric erosions with a proton pump inhibitor (PPI) prior to endoscopic confirmation.

APPROACH TO: Upper GI Bleeding

DEFINITIONS

MALLORY-WEISS TEAR: A proximal gastric mucosa tear following vigorous coughing, retching, or vomiting. The bleeding is generally self-limiting, mild, and amenable to supportive care and endoscopic management.

DIEULAFOY EROSION: Infrequently encountered, this problem describes bleeding from an aberrant submucosal artery located in the stomach. This bleeding is frequently significant and requires prompt diagnosis by endoscopy, followed by endoscopic or operative therapy.

ARTERIOVENOUS (AV) MALFORMATION: A small mucosal lesion located along the GI tract. Bleeding is usually abrupt, but the rate of bleeding is usually slow and self-limiting.

ESOPHAGITIS: Mucosal erosions frequently resulting from gastroesophageal (GE) reflux, infections, or medications. Patients most frequently present with occult bleeding, and treatment consists of correction or avoidance of the underlying causes.

ESOPHAGEAL VARICEAL BLEEDING: Engorged veins of the GE region, which may ulcerate and lead to massive hemorrhage; related to portal hypertension and cirrhosis.

SHOCK: Insufficient physiologic mechanism to adequately supply substrate to tissue. The American Trauma Life Support (ATLS) system grades shock from stages I to IV.

Stage I: Less than 750-mL blood loss, well compensated

Stage II: 750- to 1500-mL blood loss, slight tachycardia, normal blood pressure

Stage III: 1500- to 2000-mL blood loss, moderate tachycardia, hypotension

Stage IV: Less than 2000-mL blood loss, marked tachycardia, prominent hypotension

CLINICAL APPROACH

Upper GI bleeding describes bleeding from a location proximal to the ligament of Treitz and accounts for 80% of all significant GI bleeding. The sources of upper GI tract bleeding can be broadly categorized as variceal (20%) versus nonvariceal (80%). Common nonvariceal bleeding sources include duodenal ulcers (25%), gastric erosions (20%), gastric ulcers (20%), and Mallory-Weiss tears (15%). Up to 30% of patients have multiple etiologies of bleeding identified during endoscopy. In addition, all studies indicate that a proportion of cases have no endoscopically discernible cause, and these cases are associated with an excellent outcome. Rare causes of upper GI tract bleeding include neoplasms (both benign and malignant), AV malformations, and Dieulafoy erosions. Bleeding tends to be self-limited in approximately 80% of all patients with acute upper GI tract bleeding. Continuing or recurrent bleeding occurs in 20% of patients and is the major contributor to mortality. The overall mortality associated with upper GI tract bleeding is 8% to 10% and has not changed over the last several decades. There are striking differences in the rates of rebleeding and mortality depending on the diagnosis at endoscopy (Table 9–1). Patient mortality with acute upper GI tract bleeding increases with rebleeding, increased age, patients’ comorbid conditions, and in patients who develop bleeding in the hospital. A number of clinical predictors and endoscopic stigmata are associated with the increased risk of recurrent bleeding (Table 9–2). The use of NSAIDs contributes to the development of NSAID-induced gastric ulcers. All NSAIDs produce mucosal damage. The risk of developing an ulcer is dose related. Roughly 2% to 4% of NSAID users have GI tract complications each year. Approximately 10% of patients taking NSAIDs daily develop an acute ulcer.

Table 9–1 • RISK OF REBLEEDING BASED ON SOURCE

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Table 9–2 • FACTORS ASSOCIATED WITH INCREASED REBLEEDING AND MORTALITY

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Upper GI tract endoscopy establishes a diagnosis in more than 90% of cases and assesses the current activity of bleeding. It aids in directing therapy and predicts the risk of rebleeding. Furthermore, it allows for endoscopic therapy. Endoscopic hemostasis can be achieved through a variety of ways, including thermotherapy with a heater probe, multipolar or bipolar electrocoagulation, and ethanol or epinephrine injections. As shown in Figure 9–1, endoscopy can demonstrate bleeding, esophageal varices, gastroduodenal bleeding, or no bleeding. For nonvariceal bleeding, endoscopic hemostasis is usually achieved with the use of epinephrine injections followed by thermal therapy. Permanent hemostasis occurs in roughly 80% to 90% of patients. Once bleeding is controlled, long-term medical therapy with antisecretory agents such as histamine-2 blockers or PPIs is used to treat the underlying disease. Testing for Helicobacter pylori should be performed, and, if this organism is present, treatment should be initiated. Any NSAID use should be discontinued. If this is not possible, a prostaglandin analogue (such as misoprostol) should be used or, alternatively, one of the selective COX-2 inhibitors could be used to replace nonselective COX inhibitors. When considering the use of COX-2 inhibitors, it is important to weigh the potential benefits of this treatment modality versus the possible cardiovascular side effects of this treatment regimen.

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Figure 9–1. Algorithm for the treatment of patients with hematochezia or melena without hematemesis. ABCs, airway, breathing, circulation; ASA, aminosalicylate; CBC, complete blood count; GI, gastrointestinal; HTN, hypertension; NGT, nasogastric tube; NSAID, nonsteroidal anti-inflammatory drug; PT, prothrombin time; PTT, partial thromboplastin time.

Published clinical trials showed that nonvariceal upper GI bleeders with high-risk endoscopic findings (high-risk locations, visible vessel, clot over visible vessel) benefit from initial high-dose intravenous PPI treatment. This should be given as an equivalent of 80 mg omeprazole intravenous bolus, followed by an 8-mg/h infusion for 72 hours. Patients with low-risk endoscopic findings (clean ulcer base) could be managed with high-dose oral PPI. The effectiveness of endoscopic treatment has been assessed, and findings suggest that combination endoscopic modalities (coagulation, clips, and injections) appear to be more effective than endoscopic injections alone.

If bleeding continues or recurs, surgery or angiographic embolization may be necessary. Surgery is indicated for complicated peptic ulcer disease with massive, persistent, or recurrent upper GI tract hemorrhage or in association with nonhealing or giant ulcers (>3 cm). For a bleeding gastric ulcer where there is a concern for possible malignancy, either gastrectomy or excision of the ulcer is indicated. For other types of ulcers, the vessel may require ligation followed by a vagotomy procedure and pyloroplasty. The utility of surgery versus angiographic treatments has not been evaluated by randomized controlled trials; therefore, it is unclear when one form of treatment is better than another. When considering the most appropriate approaches for patients, one must consider local resources, expertise, and the availability of these resources. Angiographic approach can diagnose and treat bleeding in roughly 70% of patients; arterial embolization with gel foam, metal coil springs, or a clot can be used to control bleeding. In addition, arterial vasopressin can cause bleeding to stop in some patients with peptic ulcer disease.

COMPREHENSION QUESTIONS

9.1 A 55-year-old man has undergone upper endoscopy. He is told by his gastroenterologist that although this disorder may cause anemia, it is unlikely to cause acute GI hemorrhage. Which of the following is the most likely diagnosis?

A. Gastric ulcer

B. Duodenal ulcer

C. Gastric erosions

D. Esophageal varices

E. Gastric cancer

9.2 A 32-year-old man comes to the emergency department with a history of vomiting “large amounts of bright red blood.” Which of the following is the most appropriate first step in the treatment of this patient?

A. Obtaining a history and performing a physical examination

B. Determining hemoglobin and hematocrit levels

C. Fluid resuscitation

D. Inserting a nasogastric tube

E. Performing urgent endoscopy

9.3 A 65-year-old man is brought into the emergency department with acute upper GI hemorrhage. A nasogastric tube is placed with bright red fluid aspirated. After 30 minutes of saline flushes, the aspirate is clear. Which of the following is the most accurate statement regarding this patient’s condition?

A. He has approximately 20% chance of rebleed.

B. The mortality for his condition is much lower today than 20 years ago.

C. His age is a poor prognostic factor for rebleeding.

D. Mesenteric ischemia is a likely cause of his condition.

9.4 A 52-year-old man with alcoholism and known cirrhosis comes into the emergency department with acute hematemesis. Bleeding esophageal varices are found during upper GI endoscopy. Which of the following is most likely to be effective treatment for this patient?

A. Balloon tamponade of the esophagus

B. PPI

C. Triple antibiotic therapy

D. Misoprostol oral therapy

E. Endoscopic sclerotherapy

ANSWERS

9.1 E. Gastric cancer is relatively asymptomatic until late in its course. Weight loss and anorexia are the most common symptoms with this condition. Hematemesis is unusual, but anemia from chronic occult blood loss is common.

9.2 C. Fluid resuscitation is the first priority to maintain sufficient intravascular volume to perfuse vital organs. Assessment of volume status is best accomplished clinically; acutely the hemoglobin and hematocrit levels do not fall and do not reflect volume depletion.

9.3 A. Approximately 20% of patients with acute upper GI hemorrhage have continued or rebleeding episodes. The mortality has remained the same (approximately 8%-10%) over the past 20 years.

9.4 E. Endoscopic injection of sclerosing agents directly into the varix is effective in controlling acute hemorrhage caused by variceal bleeding in approximately 90% of cases. Balloon tamponade is a therapy used infrequently for acute esophageal variceal bleeding because of its limited effectiveness in achieving sustained control of bleeding. Other therapies include vasopressin or octreotide to decrease portal pressure.

CLINICAL PEARLS

Images Early endoscopy is useful in identifying the bleeding sources, and in patients with active ongoing bleeding it may help in achieving early control of bleeding.

Images Approximately 10% of patients who take daily NSAIDs develop an acute ulcer.

Images Surgery is indicated for complicated peptic ulcer disease with massive, persistent, or recurrent upper GI tract hemorrhage or in association with nonhealing or giant ulcers (>3 cm).

Images Acute GI tract hemorrhage should be treated with aggressive fluid resuscitation, close monitoring of patient response, nasogastric tube insertion following resuscitation to determine whether bleeding is active, and gastric irrigation with room-temperature water or saline until gastric aspirates are clear.

Images The most common cause of upper GI tract hemorrhage in a patient with cirrhosis and portal hypertension is variceal bleeding, which carries a high rate of mortality and risk of rebleeding.

Images The most common cause of pediatric significant upper GI tract hemorrhage is variceal bleeding from extrahepatic portal venous obstruction.

REFERENCES

Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. 2010;152:101-113.

Cappell MS, Friedel D. Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy. Med Clin North Am. 2008;92:491-509.

Chiu PWY, Ng EKW. Predicting poor outcome from acute upper gastrointestinal hemorrhage. Gastroenterol Clin North Am. 2009;38:215-230.

Kovacs TOG. Management of upper gastrointestinal bleeding. Curr Gastroenterol Rep. 2008;10:535-542.