Medical Care:
Stabilize the patient with intravenous fluids (usually normal saline, except in patients with severe liver disease, ascites, or heart failure) and transfuse to maintain a hemoglobin level of 8-10 g. Promptly correct any abnormalities in coagulation. Baradarian et al (2004) demonstrated that early, aggressive resuscitation can reduce mortality in acute UGIB.
The use of H2-receptor antagonists has not been shown to be effective in altering the course of UGIB.
The efficacy of oral proton pump inhibitors (PPIs) remains controversial (one study with small numbers). Intravenous PPIs may improve the stability of the clot if the gastric pH can be kept above 6.2 (reducing fibrinolysis). This requires high-dose intravenous therapy: an intravenous bolus followed by continuous infusion for 48-72 hours. The primary problem is a perforated arterial (high pressure) vessel with a potential to rebleed; therefore, pharmacologic therapy should be used only after endoscopic therapy. This therapy has been shown to be cost-effective by Barkun et al (2004).
The goal of medical therapy is to correct shock and coagulation abnormalities and to stabilize the patient so that further evaluation and treatment can proceed.
Surgical Care:
Specific characteristics at endoscopy can predict rebleeding.
Rebleeding occurs in 55% of patients who have active bleeding (pulsatile, oozing), in 43% who have a nonbleeding visible vessel, in 22% who have an ulcer with an adherent clot, and in 0-5% who have an ulcer with a clean base.
At endoscopy, the prevalence rate for a clean base is 42%, for a flat spot is 20%, for an adherent clot is 17%, for a visible vessel is 17%, and for active bleeding is 18%.
Freeman et al have described a pale visible vessel that appears to have a very high risk for rebleeding. This must be differentiated from the presence of a clean ulcer base. Good visualization is important. The uncleared fundal pool may obscure an ulcer, mucosal tear, gastric varices, portal gastropathy, or tumor (eg, leiomyoma, adenocarcinoma, lymphoma). Endoscopic therapy is recommended for ulcers at increased risk for rebleeding.
Contraindications to upper endoscopy include an uncooperative or obtunded patient, severe cardiac decompensation, acute myocardial infarction (unless active, life-threatening hemorrhage is present), and perforated viscus (eg, esophagus, stomach, intestine).
Contraindications to emergency surgery include impaired cardiopulmonary status and bleeding diathesis.
Esophagogastroduodenoscopy may be more difficult or impossible if the patient has had previous oropharyngeal surgery or radiation therapy to the oropharynx.
The presence of a Zenker diverticulum can make intubation of the esophagus more difficult.
Patients with Down syndrome are more sensitive to conscious sedation and should receive much less sedation, or they should be monitored by an anesthesiologist and/or intubated prophylactically prior to the procedure.
Hypotension may be exacerbated by sedation; therefore, patients who are unstable should be given less sedation.
Patients with massive bleeding should be considered for intubation to reduce the increased risk of aspiration. Such patients should be treated in an intensive care setting.
Ideally, the patient should be stabilized prior to endoscopy and abnormalities in coagulation should be corrected. When this is not possible, the judgment of an experienced endoscopist is vital.
The patient should undergo upper endoscopy prior to any operative intervention in order to diagnose and localize the bleeding site. Most patients (85-90%) respond to endoscopic therapy.
During the endoscopy, the patient is monitored according to analgesia and sedation guidelines formulated by the American Society of Anesthesiology. The characteristics of the bleeding lesion are noted, and appropriate therapy is applied when necessary for high-risk lesions or active bleeding.
The techniques used are heater probe coaptive coagulation, bipolar probe coaptive coagulation, sclerosant or epinephrine injection, laser therapy, and hemostatic clip placement.
A combination of therapies has become more common. Injection therapy is applied first to better clarify the bleeding site, especially in the actively bleeding patient; then, heater probe or bipolar (gold) probe coagulation is applied. Injection therapy can also be performed prior to endoscopic placement of hemoclips. Injection therapy is useful prior to laser therapy to reduce the heat sink effect of rapidly flowing blood prior to laser coagulation.
Reports have been published on the use of argon plasma coagulation for ulcer hemorrhage; however, there are significant theoretical and experimental considerations from animal models about the use of a noncontact monopolar cautery in this situation. In the animal model, obliterative closure is effective only for vessels less than 1 mm in diameter and causes deeper tissue damage.
The heater probe consists of a resistor electrode enveloped by a titanium capsule and covered by Teflon to reduce sticking to the mucosa. The probe temperature rises to 250Β°C (482Β°F).
The bipolar probe consists of alternating bands of electrodes producing an electrical field that heats the mucosa and the vessel. The electrodes are coated with gold to reduce adhesiveness. The probes are stiff to allow adequate pressure to the vessel to appose the walls and thus produce coaptive coagulation when the energy is transmitted (heat energy by the heater probe, electrical-field energy by the bipolar probe). Careful technique is required to heat-seal the perforated vessel.
Alternatively, epinephrine (1:10,000, 1:20,000) can be injected in 0.5-mL aliquots around the base of the vessel. This causes coagulation by compression, with perhaps some additive effect of activation of platelet factor 3 or vasoconstriction. Other solutions that have been used for injection are ethanol (more necrosis), hypertonic saline, sterile water, and cyanoacrylate (not available in the United States). Epinephrine injection is often used to reduce the volume of bleeding so that the lesion can be better localized and then treated with a coaptive technique (ie, heater probe, gold probe). Such combination therapy has become more frequent and has evolved into the standard technique.
Laser therapy is rarely used. To perform laser coagulation, the area near the vessel is first injected with epinephrine to reduce blood flow (reducing the heat-sink effect); then, the laser is applied around the vessel (producing a wall of edema). Caution must be observed to avoid drilling into the vessel with the laser, causing increased bleeding.
Hemostatic clips have recently become available in the United States. Modification of the delivery system has made clip placement much easier than with the original model. With careful placement of the clip, closing the defect in the vessel is possible. Usually, multiple clips are applied. The clipping devices are single-use devices with a single clip deployed with each instrument. They vary in the size and strength of the clip. A multiple clip device is planned to be introduced in early 2006.
Argon plasma coagulation is a technique in which a stream of electrons flows along a stream of argon gas. The coagulation is similar to monopolar cautery with the current flow going from a point of high current density, the point of contact of the gas with the mucosa, to an area of low current density, the conductive pad on the patient's body. The current flows through the body in an erratic path to the pad. This monopolar cautery technique is similar to the laser technique in that energy is delivered to the vessel for coagulation with apposition of the vessel walls. This technique was not effective for visible vessels larger than 1 mm. No animal models have been used for ulcer hemorrhage to validate this technique.
The choice of treatment modality is influenced by the size of the vessel. Animal studies have demonstrated that the heater probe and bipolar probe are effective for vessels as large as 2 mm in diameter. Other techniques (eg, clips, band ligation) or a combination of techniques is needed for larger vessels or vessels not approachable by the heater probe or bipolar probe. Surgical intervention should be considered when dealing with vessels larger than 2 mm in diameter (discounting the enlargement due to the development of pseudoaneurysm). Angiographic embolization is an option in the patient at high risk for surgical intervention.
In the patient who has an ulcer with an overlying clot, attempting to remove the clot by target washing is critical. Endoscopic removal of the clot by washing or cold snare has been demonstrated to be effective in reducing the recurrence of bleeding (Bini EJ et al, 2003).
The findings under the clot (eg, bleeding vessel, visible vessel, flat spot, clean base) help determine the therapy needed and improve efficacy by allowing treatment to be applied directly to the vessel.
If the clot cannot be removed by washing, then cutting away the clot using a cold snare can be considered by experienced endoscopists.
Vigorous washing of the clot formed after therapy is useful to determine the adequacy of coagulation. A combination of injection with heater probe or bipolar coaptive coagulation is often used and has been shown to be more effective in patients with active bleeding.
In an effort to improve the teaching of these techniques, an in vitro pig stomach model has been developed by Hochberger. This model has been used with first-year fellows in gastroenterology in New York and Germany (Hochberger J, 2004).
The patient is monitored under the protocol for conscious sedation, also called analgesia and sedation (ie, per American Society of Anesthesiologists and American Society for Gastrointestinal Endoscopy guidelines).
Rebleeding occurs in 10-30% of endoscopically treated patients. A second attempt at endoscopic control is warranted. Some authorities have concerns about the perils of a second esophagogastroduodenoscopy, which may result in delayed surgery, perforation, and increased morbidity and mortality rates. This approach has been validated in a large, randomized controlled trial that showed decreased morbidity and mortality rates.
Using a combination of techniques is prudent when re-treating the ulcer site because the first therapy produced necrosis and weakening of the intestinal wall. Ulcers on the anterior surface of the stomach and duodenum are at increased risk for perforation. Using injection as the first step increases the thickness of the submucosal layer, thus providing an extra margin of safety.
Even operative techniques can have a significant rebleeding rate with significant mortality, as noted in the study of Poxon et al in which the rebleeding rate was 10% (80% mortality for rebleeders) in patients who underwent a conservative surgical technique in which the ulcer base was undersewn. This more conservative approach was compared with the standard surgical technique (ie, vagotomy and pyloroplasty or partial gastrectomy). The comparison of the conservative approach with a standard gastrectomy resulted in similar mortality rates, ie, 26% versus 19%, respectively, with no rebleeding after partial gastrectomy.
Blind total gastrectomy has been studied by Primrose et al as a last resort when the UGIB site cannot be determined in a patient who continues to bleed.
Bouillot et al report the use of a combined endoscopic and laparoscopic approach in a patient with a bleeding Dieulafoy lesion unresponsive to endoscopic therapy. Intraoperative endoscopy located the small bleeding lesion, which was removed by a limited resection.
Postoperatively, the patient is monitored for recovery from conscious sedation after endoscopy and from general anesthesia after abdominal surgery. Monitor the patient's mental status, vital signs, chest, cardiac, and abdominal findings to ascertain that the patient's clinical status has stabilized and that no complications (eg, aspiration, perforation, recurrent bleeding, myocardial infarction due to hypotension) have occurred. Monitor the hemoglobin level.
DRUG TREATMENT :
1. PROTON PUMP INHIBITORS :
- PANTOPRAZOLE
- ESOMEPRAZOLE
- RABEPRAZOLE
- OMEPRAZOLE