Upper Gastro-Intestinal Bleeding

Gastrointestinal bleeding is a common reason for admission of patients to intensive care units. Etiology of upper gastrointestinal bleeding is diverse: peptic ulcer disease (most common, usually associated with the use of NSAIDS, Helicobacter pylori infection, stress and gastric acid), Mallory-Weiss syndrome (gastroesophageal junction tear, common in alcoholics and patients with Bulimia nervosa), esophageal varices (common in cirrhotic patients), arterial-venous malformations of the stomach, aorto-enteric fistula (after correction of abdominal aortic aneurysms), pancreatitis, hemobilia, Osler-Weber-Rendu syndrome (telangiectatic malformations in the small bowel), etc.
Patients usually presents with hematemesis (coffee-ground vomiting or fresh blood vomiting) and/or melena. Hematochezia, usually indicative of lower gastrointestinal bleeding, may be present in cases of rapid, severe bleeding. It is important to determine the severity of the bleeding. Severe bleeding is define as bleeding of 1 liter of blood or more. Patients may present with orthostatic changes (hypotension, tachycardia), tachypnea, cold extremities, oliguria and altered mental status. Laboratory tests may showed increased in BUN and, sometimes decreased levels of hemoglobin/hematocrit.
The very first step of treatment is to establish one or several IV access and restablished the intravascular volume with blood and crystalloids fluids (ie, Ringer lactate, Normal Saline). Patients should receive intravenous PPI's (to stabilize the clot and to increase the gastric pH above 6) and intravenous octeotride, a somatostatin-analogue that causes sphlacnic vasoconstriction and is useful in patients in whom esophageal varices are suspected as the source of bleeding. Ocassionally, the use of mechanical ventilation is require in patients with severe hematemesis and altered mental status. Patients with heart disease should keep the hemoglobin level above 8 g/dl. Main criteria for admission of patients with upper gastrointestinal bleeding to the intensive care units includes: hemodynamic instability, requirements of >2 units of PRBC's, decreased of >6% of hematocrit from the patient's baseline and advance age and presence of comorbid conditions. Mortality of upper gastrointestinal bleeding is <10%, but may increase in patients that are hemodynamically unstable and in those who have important comorbid conditions and advance age.
The gold standard for the diagnosis is the esophagogastroduodenoscopy (EGD). Also of value, arteriogram and nuclear medicine studies such as tecnectium-99 with labeled-red blood cells needs to be mention.
Most of the non-variceal upper gastrointestinal bleeding stops spontaneously, as opposed to bleeding cause by esophageal varices. Endoscopic features that may indicate high risk for re-bleeding includes: clot formation on top of the ulcer, non-bleeding vessel, arterial bleeding and oozing from a non-visible vessel.
Surgery is indicated in cases of failure of medical therapy and untractable, recurrent bleeding.
Another important condition is stress-related mucosal damage (SRMD), the most common cause of GI bleeding in patients admitted in the intensive care units. The main risk factors are the use of mechanical ventilation and patients with thrombocytopenia.