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  • • History of—or risk factors for—peptic ulcer disease (PUD)

    Acute hemorrhage: Hematemesis or hematochezia perhaps with shock

    Chronic hemorrhage: Anemia with melena or trace amounts of blood in stool

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Epidemiology

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  • • Most common cause of massive upper GI hemorrhage

    • 20% of patients with PUD will have a bleeding episode, accounting for 40% of deaths from PUD

    • Chronic gastric and duodenal ulcers have about the same tendency to bleed, more severe bleeding with gastric ulcers

    • Bleeding duodenal ulcers are usually located on the posterior surface of the duodenal bulb and erode into the gastroduodenal artery

    • Rebleeding in the hospital has been attended by a death rate of about 30%

    • Gastric ulcer rebleed 3 times more commonly than duodenal ulcers

    • Most instances of rebleeding occur within 2 days from the time the first episode has stopped

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Symptoms and Signs

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  • • Epigastric pain

    • Abdominal tenderness

    Acute hemorrhage:

    • -Hematemesis or hematochezia

      -Hypotension or shock

    Chronic hemorrhage:

    • -Weakness

      -Anemia

      -Fecal occult blood

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Laboratory Findings

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  • Acute hemorrhage: Hct may not be reflective of blood lost

    Chronic hemorrhage: Anemia

    • Obtain blood for type and cross

    • Prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR) to evaluate for coagulopathy

    • Platelet count to evaluate for thrombocytopenia

    • Serial Hct to follow adequacy of transfusion and ongoing requirements

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Imaging Findings

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  • Upper GI endoscopy: Bleeding ulcer, visible vessel, ulcer with adherent clot

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  • • Diagnosis and treatment should be simultaneous

    • Upper GI endoscopy should be performed immediately in cases of acute hemorrhage for diagnosis and possible treatment

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Rule Out

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  • • Other causes of upper GI bleeding than PUD:

    • -Esophageal varices

      -Gastritis

      -Mallory-Weiss syndrome

      -Gastric cancer

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  • Acute hemorrhage:

    • -Admission to ICU

      -NG lavage

      -Laboratory tests (CBC, type and cross, PT, PTT, INR)

      -Upper GI endoscopy

    Chronic hemorrhage:

    • Laboratory tests (CBC, PT, PTT, INR)

    • Urgent endoscopy (upper and lower if source unclear)

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When to Admit

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  • • All patients with obvious GI bleeding should be admitted

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  • • Replace blood loss with crystalloid and blood products

    • NG lavage

    • Endoscopy for localization and possible treatment

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Surgery

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Indications

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  • • Massive hemorrhage with shock

    • Ongoing transfusion requirements

    • Recurrent hemorrhage

    • Excise ulcer (gastric) or oversew vessel (duodenal) and vagotomy

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Medications

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  • • H2 blockers, proton pump inhibitors (may reduce risk of rebleed)

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Treatment Monitoring

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  • • Twice-daily CBC

    • Treatment of PUD after bleeding episode

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Complications

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  • • Rebleeding: Repeat endoscopic therapy for first rebleeding episode if patient is stable

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Prognosis

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  • • 75% managed by ...

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