First Year Fellows Endoscopy Course (July 31 - August 1)

7_Upper GI Bleeding
Pdf Summary
Upper gastrointestinal (GI) bleeding is a significant medical problem, with over 250,000 hospital admissions per year in the United States. It has a mortality rate of 2-10%, which increases if the patient was hospitalized for another reason before the bleeding occurred. Most cases of upper GI bleeding stop spontaneously, but endoscopic therapy is the main treatment for active bleeding. <br /><br />Initial assessment involves gathering the patient's history, assessing signs of bleeding, and estimating the bleeding volume. The most common causes of upper GI bleeding are peptic ulcers, esophageal varices, arteriovenous malformations, Mallory-Weiss tear, tumors, and Dieulafoy lesion. <br /><br />Warfarin reversal is indicated for patients on anticoagulant therapy with upper GI bleeding, using prothrombin complex concentrate and vitamin K. Risk stratification is important to determine the need for intervention and death. The Glasgow Blatchford score is a predictive tool that can help guide management decisions. <br /><br />Acid suppression with proton pump inhibitors (PPIs) is recommended before and after endoscopy for upper GI bleeding. Continuous PPI infusion is used for high-risk lesions for 72 hours, while low-risk lesions can be managed with oral PPIs. <br /><br />Endpointoscopy within 24 hours of presentation is recommended for most patients with acute upper GI bleeding. Urgent endoscopy within 12 hours is recommended for variceal bleeding, but studies have not shown a decrease in rebleeding, surgery, or mortality. <br /><br />Prophylactic endotracheal intubation should be considered in cases of massive hematemesis or altered mental status to protect the airway, but caution must be taken to avoid aspiration pneumonia or cardiac adverse events. <br /><br />During endoscopy, techniques such as evacuation of the stomach, the use of therapeutic large channel scopes, power irrigation, external suction devices, and changing patient positions can improve visualization. Hemostatic techniques include injection, thermal coagulation, mechanical methods such as hemoclips or over-the-scope clips, and combination therapy. <br /><br />Patients on aspirin who experience an upper GI bleed can restart aspirin 1-7 days after bleeding stops for secondary prevention. For patients on warfarin, it is recommended to resume anticoagulation within 4-7 days after therapeutic endoscopy. <br /><br />For suspected variceal bleeding, octreotide and IV antibiotics are recommended. Monitoring and repeat endoscopy may be necessary for rebleeding cases. <br /><br />In conclusion, the initial assessment, risk stratification, medication management, optimizing endoscopic visualization, and applying effective endoscopic therapy are essential in managing upper GI bleeding.
Keywords
Upper gastrointestinal bleeding
hospital admissions
endoscopic therapy
causes of upper GI bleeding
Warfarin reversal
Glasgow Blatchford score
proton pump inhibitors
urgent endoscopy
hemostatic techniques
variceal bleeding