Lower gastrointestinal bleeding, 578.9
Upper gastrointestinal bleeding, 578.9
ESOPHAGEAL VARICES
I. Definition
A. Dilated submucosal veins that may develop in patients with underlying portal hypertension that can result in severe GI bleeding
B. Varices can rupture at any moment and become a medical emergency.
C. Three of ten patients will die from the initial hemorrhage.
D. Overall mortality reaches nearly 60% because rebleeding claims the lives of another three of ten.
II. Etiology
A. Cirrhosis—most common
B. Portal venous pressure of at least 12 mmHg is needed for varices to bleed (normal pressure, 2 to 6 mmHg).
C. Bleeding from esophageal varices usually occurs in the distal 5 cm of the esophagus and in the upper portion of the stomach.
D. Aspirin, used alone or in combination with other NSAIDs, has been associated with a first variceal bleeding episode in patients with cirrhosis.
III. Clinical manifestations
A. Hematemesis
B. Melena
C. Hematochezia (indicates massive bleed; more than 1000 ml)
D. Abdominal discomfort
E. Signs and symptoms of hypovolemia or shock
IV. Diagnostics/laboratory findings
A. CBC
1. Hemoglobin/hematocrit—normal, then decreased because of hemoconcentration/volume resuscitation
3. Platelet count—increased, then decreased because of attempts to restore homeostasis; finally, reflects true blood loss
B. Electrolyte panel
1. K+—decreases as a result of emesis, then increases
2. Na++—decreases, then increases as a result of hemoconcentration/fluid resuscitation
3. Ca++—normal or decreased
4. Hyperglycemia—stress response
5. BUN/Creatinine ratio—elevated because of poor perfusion to the liver and kidneys
6. Lactate levels—elevated (lactic acidosis related to anaerobic metabolism)
7. Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ratio and bilirubin level are usually abnormal in patients with underlying chronic liver disease.
8. Albumin—low
9. Prolonged prothrombin time (PT) and partial thromboplastin time (PTT)
10. Arterial blood gases—respiratory alkalosis/metabolic acidosis
C. Endoscopy—after stabilization, to identify the source of the bleed
D. Barium studies—can be performed to define the presence of peptic ulcers, bleeding sites, tumors, and inflammation
V. Management
A. Emergency resuscitation
1. Insert two large-bore (16-gauge) IV lines, and establish central venous pressure (CVP) line access.
2. Laboratory studies: blood type and crossmatch, PT/PTT, CBC, electrolyte panel, renal and liver function tests
3. Infuse crystalloids (lactated Ringer’s or normal saline) for treatment of hypotension until blood products can be administered. (Note: Overzealous hydration increases portal pressure and can exacerbate or cause rebleeding of varices.)
a. Maintain
i. Systolic blood pressure higher than 110 mmHg
ii. CVP 10 mmHg or less
iii. Pulmonary capillary wedge pressure 8 mmHg or less (if pulmonary artery catheter is in place)
b. Administer fresh frozen plasma for coagulopathies.
4. Administer oxygen at 5 to 10 L/minute.
5. Insert a Foley catheter.
6. NPO—Insert nasogastric tube.
7. Consult a surgeon and a gastroenterologist.
B. Sixty to eighty percent of patients stop bleeding spontaneously; however, without therapy, more than half rebleed within 1 week.
D. Vasopressin—vasoconstrictor that decreases portal pressures by reducing splanchnic flow (successful in only 50% of cases)
1. Dose: 0.2-0.4 unit/minute to a maximum of 0.8 unit/minute
2. Taper down over 24 hours after the bleeding is controlled.
a. Use only in a peripheral line, not in a central line, because severe coronary spasms may result.
3. Monitor for vasopressin-induced adverse effects.
a. Chest pain
b. Sweating
c. Paleness
E. Octreotide (Sandostatin), 25-100 mcg/hour, works similarly to vasopressin but without the adverse effects.
F. Vitamin K—10 mg IM for cirrhotics with coagulopathies
G. Lactulose—30 ml twice daily for patients with severe liver disease, to prevent encephalopathy (causes induction of two to three stools/day)
H. Balloon tamponade may be necessary to control bleeding.
1. Sengstaken-Blakemore (SB) tube (three ports), or
2. Minnesota tube (four ports)
a. Normal inflation pressure is 20 to 45 mmHg.
b. Inflation pressures must be continually monitored.
c. Balloons should be deflated every 8 to 12 hours.
3. The esophageal balloon must be deflated before the gastric tube is removed to prevent tube displacement upward and occlusion of the airway.
a. Keep scissors at the bedside.
b. Possible complications:
i. Gastric balloon rupture—occlusion of airway
ii. Esophageal rupture—characterized by severe back pain
iii. Ulcerations of the esophageal or gastric mucosa
VI. Prevention of rebleeding
A. Routine follow-up with endoscopy
B. Beta blockers
1. Propranolol or labetalol, 20 mg twice daily, increased gradually until heart rate falls by 25% or reaches 55 beats per minute.
2. Average dose: 60 mg twice daily
3. Used frequently in combination with sclerotherapy
C. Transjugular intrahepatic portosystemic stent (TIPS)—for patients with recurrent bleeds despite the therapies listed previously
D. Portosystemic shunt—usually reserved for patients for whom beta blockers have failed or for those who are noncompliant. (TIPS is used more commonly than portosystemic shunt.)
E. Liver transplantation
VII. Prevention of first episode of variceal bleeding
A. A high mortality rate is associated with variceal hemorrhage.
C. Sclerotherapy in patients who have never had a bleed results in greater likelihood of mortality than in those treated with a placebo or with beta blockers and is not recommended.
D. Banding prophylactically has been noted to decrease the incidence of first-time bleeding; however, it is not widely practiced.
UPPER GASTROINTESTINAL BLEEDING
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