Role of Early Endoscopy in the Management of Upper Gastrointestinal Bleeding

Introduction

Upper gastrointestinal bleeding is a common cause to get admitted to a hospital as an emergency. With the help of upper endoscopy, which is a slender long tube along with a camera and light is passed down from the mouth to the upper gastrointestinal area, it helps in diagnosing and treating the bleeding from the upper digestive system. Before the endoscopy, the patient should be stabilized, and appropriate resuscitation (waking up an unconscious person) should be considered.

What Is Upper Gastrointestinal Bleeding?

Upper gastrointestinal bleeding is the loss of blood from the gastrointestinal area above the ligament of Treitz, which is a band of tissue that is present in the abdomen and extends to the first part of the small intestine called the duodenum which is called duodenojejunal flexure (a sharp part where the duodenum and jejunum meet). Acute upper gastrointestinal bleeding is the passage of a huge amount of blood from the mouth, which is a life-threatening situation and requires immediate treatment.

What Are the Symptoms of Upper Gastrointestinal Bleeding?

The symptoms of upper gastrointestinal bleeding are:

• Hematemesis (blood in vomit), which can be from bright red to coffee ground color.

• Hematochezia (passage of fresh, bright blood through the anus or along with stools).

• Melena (dark black stools).

• Due to blood loss, the patient can have weakness or syncopal episodes (loss of consciousness which occurs due to a decrease in blood supply to the brain).

What Are the Common Causes of Upper Gastrointestinal Bleeding?

The most common causes of upper gastrointestinal bleeding are:

• Peptic ulcer disease (gastric or duodenal) is when the acid produced by the layer of the digestive tract erodes the inner surface causing open sores with bleeding.

• Erosive esophagitis (reflux of stomach acids causing damage to the inner mucosal layer).

• Upper gastrointestinal Angio ectasias (a type of vascular lesion that causes bleeding).

• Gastric or duodenal erosions.

• Gastric or esophageal varices occur due to enlarged veins in the food pipe.

• Upper gastrointestinal tumors.

• Mallory-Weiss tear (tears at the junction of stomach and esophagus due to forceful vomiting or coughing).

• Dieulafoy lesion (an abnormally enlarged blood vessel that can cause bleeding).

What Are Early Endoscopy and Urgent Endoscopy?

Early endoscopy is done the next morning or within 24 hours when first consulted by a gastrointestinal specialist. Active bleeding is a common condition for individuals undergoing early endoscopy. In case of unstable patients, resuscitation should be done, and immediate endoscopy should be performed within 24 hours. An urgent endoscope is done within the first six hours of consultation, which is done in case of severe bleeding, hemodynamic instability, or if the patient has a liver disease such as cirrhosis (chronic inflammation of the liver).

How Is the Risk Assessment Performed in Upper Gastrointestinal Bleeding?

The reason for bleeding and the signs and symptoms are important in evaluating mortality, morbidity rate, and re-occurrence of bleeding. Therefore risk assessment should be done and two systems are used which are:

• Rockall Scoring System: It is used to assess the re-occurrence of bleeding and the mortality rate, in which a score of 0 or less than 3 is considered a low risk of re-occurrence of bleeding, and the patient can be discharged as soon as possible. A score of more than 4 has a high risk of mortality and re-bleeding.

• Glasgow-Blatchford Scoring System: It helps in evaluating the prognosis, need for transfusion, re-bleeding rate, and need for endoscopy in non-variceal gastrointestinal bleeding (bleeding that occurs from the stomach, esophagus, or the first part of the duodenum). A score of 0 includes no history of melena, cardiac failure, syncope, or hepatic disease (liver disease), and these patients are considered low-risk and require the least need for endoscopy, transfusion, or surgery. A score of 1 or more involves high-risk patients, and early endoscopy should be performed within 24 hours of the first consultation.

What Is the Role of Early Endoscopy in the Management of Upper Gastrointestinal Bleeding?

Endoscopy can help in the diagnosis of upper gastrointestinal bleeding along with the treatment of active bleeding. Therefore endoscopic treatment can reduce the need for surgery. An initial resuscitation process is carried out before the endoscopic approach. The role of endoscopy in the management of upper gastrointestinal bleeding includes:

• In case of acute variceal bleeding, endoscopy should be done within twelve hours.

• Patients with liver cirrhosis and hematemesis should undergo urgent endoscopy.

• Patients who have a high score of Glasgow-Blatchford Score should undergo rapid proton pump inhibitor (PPI) therapy (which reduces stomach acids) along with fluid therapy before endoscopy.

• Before an endoscopy, the vital signs and hemodynamic status is evaluated and fluid therapy is given.

• In case of high pulse rate, high blood urea nitrogen level, previous history of acute bleeding, decreased urine volume, and if, in hypovolemic shock, blood transfusion and fluid therapy are done before endoscopy.

• Endoscopic hemostasis is achieved by injecting diluted epinephrine of 1:10000 to 1:20000 or a sclerosing agent with the help of contact or non-contact thermal devices such as heat probes, unipolar or bipolar electrocoagulation, or argon plasma coagulation (coagulation done with the help of ionized argon gas and a high-frequency electric current); or with the help of mechanical devices such as band ligation and endoscopic clips.

The treatment depends on the cause of the bleeding, such as:

1. Peptic Ulcer Bleeding: The endoscopic approach involves Injection, thermal, and mechanical therapy. The use of all these therapies decreases the risk of recurrence of bleeding and the need for surgery. After the treatment, a high dose of PPI can help in preventing the re-occurrence of bleeding.

2. Variceal Bleeding: It is a severe complication of portal hypertension. Apart from prior stabilization of the patient, hemodynamic stability should be maintained, and a hemoglobin level of at least 7-8 g/dL should be present. Vasoactive drugs such as Somatostatin or Octreotide and prophylactic antibiotics such as Ceftriaxone or Quinolone are administered. Endoscopic variceal ligation (EVL) until varix eradication (absence of the enlarged vein) is the standard treatment for esophageal variceal bleeding. This requires two to four sessions.

3. Diverticular Bleeding: This occurs due to traumatic injury to the vasa recta, and some medications such as anticoagulants, Aspirin, and nonsteroidal anti-inflammatory drugs (NSAIDs) are associated with this bleeding. Band ligation is the effective endoscopic hemostatic method in case of diverticular bleeding.

4. Angio Dysplastic Bleeding: The use of contact and non-contact thermal coagulation with the help of argon plasma is considered an efficient approach to treat angiodysplasias.

Conclusion

With the help of an endoscope, the cause of gastrointestinal bleeding can be determined. Factors such as shock, low hemoglobin levels, severe bleeding, fresh blood at the time of consultation, and a large ulcer can cause failure in the endoscopic approach. The prognosis depends on successful hemostasis, and clinicians nowadays are practicing prophylactic second-look endoscopy in case of high risk of re-occurrence of bleeding.