Editing Upper GI bleed (section)

== '''Bleeding ulcers''' ==

=== '''Classification:''' ===

**

{| class="wikitable"
|Forrest classification
|Stigmata
|Risk of re-bleeding on medical management
|-
|I a
|Brisk bleeding/spurting
|90%
|-
|I b
|Oozing
|10-20%
|-
|II a
|Non-bleeding visible vessel
|50%
|-
|II b
|Adherent clot
|25-30%
|-
|II c
|Flat pigmentation spot
|5-10%
|-
|III
|Clean-based ulcer
|3-5%
|}

*** Iic ulcer
** Intervene on category I, II a and II b ulcers
** Other high-risk factors - ulcers >2cm, posterior duodenal wall ulcer, lesser gastric curve ulcer

=== '''First-line: endoscopic intervention''' ===

** Wash off adherent clot if present
** inject with ~10mL total of 1:10,000 adrenaline spread between all four quadrants, AND another modality
** Either thermal (gold) probe, haemoclip (IIa ulcers), APC or sclerosant (alcohol) injection
*** Push gold probe into base of ulcer and fire - bleeding is most often caused by an artery in the base, and you can collapse the walls then fire the probe. Fire it a few times.
** Important thing is to use dual modality

=== '''Second-line: embolization''' ===

** If no resolution possible on endoscopy, proceed to transcatheter arterial embolization (TAE) - seems to have equal outcomes with surgery and lower complication rates
** Better for duodenal rather than gastric bleeds
** Especially useful with haemorrhage into biliary tree or pancreatic duct
** Most common bleeding vessel is GDA, left gastric, right gastric, splenic arteries
** Higher rates of re-bleeding from TAE than surgery, but good in high operative risk patients
** Efficacy for UGIB 44-100%
** Previously vasopressin infusion may have been used, but not deployed any more

=== '''Third-line: surgery (needed in 5-10%)''' ===

** Indications:
*** Failed endoscopy x2
*** Haemodynamically unstable despite vigorous resus (>3 units)
**** Previously, >= 6 units in index 24 hrs was indication for surgery
*** Recurrent haemorrhage after haemostasis with endoscopy (reasonable to try twice with endoscopy)
*** Ongoing transfusion requirement >3 units per day
*** Unable to transfuse (rare blood type, refusal of transfusion)
** Technique
*** Upper midline laparotomy (bleeding duodenal ulcers can technically be treated laparoscopically, but difficult)
*** Examine for external signs of ulcer - will often be able to see serosal inflammatory changes at the site of a chronic ulcer
*** If any doubt as to location, use intra-operative gastroscopy
** Duodenal ulcers: intervention will usually be to oversew or ligate bleeding vessel, which is the '''GDA''' at the base of a posterior ulcer

*** May need a Kocher maneuvre to mobilise the duodenum and get manual control
*** Longitudinal duodenotomy/pyloroduodenotomy from pylorus through to anterior wall of D1/D2
*** Remove blood, isolate bleeding
*** Apply pressure and time for anaesthetics to catch up
*** Underrun bleeding vessel with 3-point U-stitch technique of 2/0 Vicryl
**** Careful of CBD - can insert a probe through the ampulla if necessary - although Mosche says he has never heard of it being sutured over
**** Classically need to suture ligate GDA superiorly and inferiorly (12 and 6 o'clock), with another suture at 3 o'clock for transverse pancreatic branch
*** Close the duodenotomy transversely (like a stricturoplasty)
*** Consider vagotomy or other acid-reducing operation, but this is generally unnecessary nowadays

** Gastric ulcers

*** Use the simplest possible operation that will stop the bleeding
*** First gastrotomy and underrun the bleeding ulcer (30% rebleeding risk)
*** Wedge resection may be a good option for greater curvature ulcers, but this gives a 10% rebleeding risk, so distal gastrectomy is favoured
*** Bleeding proximal ulcers near GOJ are quite difficult to manage - proximal or near-total gastrectomy has very high mortality in setting of haemorrhage. Perhaps a distal gastrectomy with a tongue of proximal stomach, or a wedge resection/buttressed oversewing of the ulcer?

=== '''Rebleeding''' ===

** Repeat endoscopy if technically possible. Surgery is better for haemostasis but more complications

=== '''Medical management''' ===

** ICU?
** IIb and above ulcers should stay on IV PPI for 72 hours then can be discharged (can be BD high-dose - no benefit to infusion in most cases)

*** There doesn't appear to be much difference between IV and PO PPI even while still in hospital, but guidelines still recommend staying on IV

** Pause aspirin, clopidogrel, NSAIDs and SSRIs for 24 hours with ulcer bleeding
*** Aspirin can be resumed after 24 hours - rationalise ongoing need (stop it if it was primary prevention, restart for secondary prevention 1-7 days after bleeding cessation in most cases)
*** Clopidogrel can be resumed after three days in patients with stents
*** SSRIs five days
*** COX-2 selective inhibitors combined with PPIs have a low rebleeding risk, so that is an acceptable combination if anti-inflammatories must continue.
** Don't give tranexamic acid
** Clear fluids first 24 hours then normal diet. IIc and below can go straight to normal diet.
** Discharge - IIc and below can go 24 hours after endoscopy. Anyone that needs treatment for a bleeding ulcer should stay for 72 hours.
** All patients must have H. pylori status established and eradicated if present. Once it has been confirmed eradicated, there is no need for long-term PPI as it doesn't decrease the re-bleed risk of 1.3%.

[[Category:UGIS]]
[[Category:Intern education]]