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GI Bleeding (APPROACH (EVALUATION AND MANAGEMENT OF LGIB, EVALUATION AND…

- - - - poorer outcomes than other sources of UGIB.
      - Combination endoscopic + medical therapy: superior to either therapy alone in decr rebleeding
      - in cirrhotics w/ UGIB: Urgent endoscopy within 12 h , and if esophageal varices present, endoscopic ligation + an IV vasoactive medication (e.g., octreotide) given for 2–5 days.
      - in well-compensated cirrhosis: Decompressive surgery (e.g., distal splenorenal shunt) instead of TIPS
      - Portal HTN also responsible for bleeding from gastric varices, varices in small and large intestine, and portal hypertensive gastropathy and enterocolopathy. Bleeding gastric varices due to cirrhosis: endoscopic injection of tissue adhesive (e.g., n-butyl cyanoacrylate), if available; if not, TIPS performed.
      - In advanced liver disease (e.g., Child-Pugh class C w/ score 10–13): transjugular intrahepatic portosystemic shunt (TIPS) within first 1–2 days of hospitalization, over long term: nonselective BBs + endoscopic ligation together
      - In persistent / recurrent bleeding despite endoscopic + medical therapy: TIPS recommended.
      - [internet: Varices: dilated blood vessels in esophagus or stomach caused by portal HTN, cause no symptoms unless they rupture and bleed]
    - - :endoscopically visualized subepithelial hemorrhages and erosions.
      - mucosal lesions--> absence of arteries/veins in mucosa--> don't cause major bleeding
      - Erosions most importantly develop in NSAID use, alcohol intake, and stress.
        
        1/2 of pxs w/ chronic NSAID ingestion: erosions
        
        up to 20% of actively drinking alcoholics w/ symptoms of UGIB: subepithelial hemorrhages or erosions
        
        Stress-related gastric mucosal injury
        
        only in extremely sick patients (ex experienced serious trauma, major surgery, burns covering >1/3 of body surface area, major intracranial disease, or severe medical illness (i.e., ventilator dependence, coagulopathy));
        
        Severe bleeding should not develop unless ulceration. mortality rate quite high bc of serious underlying illnesses.
        
        incidence of bleeding decr dramatically in recent yrs (better care of critically ill)
        
        Pharmacologic prophylaxis may be considered in high-risk pxs mentioned: PPIs more effective than H2 R antagonists
    - - classic hx: vomiting, retching, or coughing preceding hematemesis, esp in alcoholic
      - Bleeding (tears u. on gastric side of GE junction) stops spontaneously in 80–90% of pxs and recurs in only 0–10%
      - therapy: for actively bleeding Mallory-Weiss tears: Endoscopic (Angiographic w/ embolization + operative therapy w/ oversewing of tear rarely required)
    - - Characteristics of an ulcer at endoscopy: important prognostic information:
        
        1/3 of pxs w/ active bleeding or a nonbleeding visible vessel: have further bleeding that requires urgent surgery if treated conservatively; Pxs w/o clean-based ulcers: remain in hospital for 3 days (bc most episodes of recurrent bleeding occur within 3 days); in high-risk ulcers (active bleeding, nonbleeding visible vessel, adherent clot): endoscopic therapy (w/ bipolar electrocoagulation, heater probe, injection therapy (e.g., absolute alcohol, 1:10,000 epinephrine), and/or clips) + subsequent high-dose, constant-infusion IV PPI (sustains intragastric pH >6 + enhances clot stability)
        
        Pxs w/ clean-based ulcers: rates of recurrent bleeding approaching zero; may be discharged home after endoscopy; lower-risk findings (flat pigmented spot or clean base): do not require endoscopic therapy + recieve standard doses of oral PPI.
      - 1/3 of bleeding ulcers will rebleed within next 1–2 yrs if no preventive strategies employed. Prevention focuses on: H. pylori, NSAIDs, and acid.
        
        NSAIDs should be discontinued. If they must be given, a COX-2 inhibitor + a PPI should be used together; established cardiovascular disease who develop bleeding ulcers while taking low-dose aspirin should restart aspirin as soon as possible after bleeding episode (1–7 days)
        
        unrelated to H. pylori or NSAIDs: remain on PPI therapy indefinitely.
        
        Eradication of H. pylori