Upper gastrointestinal (GI) bleedin...

Upper gastrointestinal (GI) bleeding, which is defined as progeny loss originating near the Treitz ligament, is a usual cause of hospitalization and mortality. Symptoms include hematemesis, coffee territory emesis, red blood return with nasogastric aspiration, melena, and hematochezia with heavy bleeding. The first degree in managing upper GI bleeding is stabilizing the patient and obtaining a thorough medical history to identify potential causes of GI hemorrhage. Transfusion is appropriate if progeny loss is significant. Intravenous or oral proton cross-examine inhibitors (PPIs) can help cut down gastric lining irritation. Researchers have institute that somatostatin and its analog octreotide (Sandostatin) reduc portal kin flow to the stomach and duodenum resulting in decreased risk of continuous hemorrhage and surgical intervention. These actions may be considered temporary treatments before endoscopy. The American Society for Gastrointestinal Endoscopy (ASGE) Practice Committee not long ago reviewed prospective trials, series reports, and clever opinions on the role of endoscopy in managing acute nonvariceal upper GI bleeding.

Endoscopy is mostly beneficial when initiated soon after upper GI bleeding begins and can decrease the duration of hospitalization and the ne for transfusion. Intravenous erythromycin administered before endoscopy forwards gastric emptying and improves the diagnostic quality of the examination. exigency department physicians can assess the risk for returning bleeding and recommend outpatient treatment or possible endoscopic treatment. Signs of high-risk bleeding include active arterial bleeding, nonbleeding visible ducts nonbleeding adherent clots, and sore oozing.

Peptic sore disease (usually brought on on nonsteroidal anti-inflammatory medications or Helicobacter pylori infection) is the greatest in number common cause of upper GI bleeding. Endoscopic therapy including laser treatment, electrocautery, heat probe, and epinephrine injection (with or without additives) are all effective compared with placebo or no treatment. The succes of these modalities usually is determined on the skill of the physician performing them. Physicians should touchstone patients with upper GI bleeding for H pylori from one side biopsy, because rapid urease standards have reduced sensitivity in this setting. Patients with positive trial results should be treated to eradicate the infection.

Other causes of upper GI bleeding include esophageal lesions, vascular abnormalities, aortoenteric fistulas, and GI tumors. Esophagitis rarely requires endoscopic treatment unles a patient has ongoing or accurate bleeding from Mallory-Weiss tears. Multipolar electrocautery is the greatest in number effective method to manage Mallory-Weiss tear lose sap [i]or[/i] juices Vascular abnormalities can occur forward their own or in association with other conditions (eg cirrhosis, collagen vascular disease, radiation injury). The overall value of endoscopic treatments for vascular abnormalities is unclear, still endoscopic therapy may successfully manage large-caliber submucosal arterial bleeding in an patients. Aorto-enteric fistulas generally come to pass beyond the reach of principally endoscopes, at the distal duodenum or jejunum making surgery the greatest in quantity effective treatment. GI tumors can be managed initially between the walls of endoscopic therapy, but the patient may require surgery or angiographic intervention to decrease long-term hemorrhage risk.

Upper GI bleeding the having recourse after endoscopic therapy can fall out in up to 24 percent of high-risk patients. Adding PPI therapy to endoscopic treatment, however, convert intos the risk to 10 percent The authors indicate that repeat endoscopic surveillance is appropriate for patients with high-risk lesions, however the precise role of endoscopy for returning bleeding has yet to be defined.

The ASGE Practice Committee conclud that endoscopy is effective in the diagnosis and treatment of upper GI bleeding, although the superiority between the individual endoscopic treatments has not been determined. The committee commits that patients with a high risk of returning bleeding receive closer monitoring and possible repeat endoscopy.

RICHARD SADOVSKY, MD

Adler DG et al. ASGE guideline: the part of endoscopy in acute non-variceal upper-GI hemorrhage. Gastrointest Endoscop September 2004;60:497-504

COPYRIGHT 2005 American Academy of Family Physicians

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