Upper Endoscopy Evaluation of GI Bleeding

Aka: Upper Endoscopy Evaluation of GI Bleeding, Upper GI Endoscopic Evaluation of Bleeding, Esophagogastroduodenoscopy in GI Bleeding, EGD Findings in Upper GI Bleeding, Upper Gastrointestinal Bleeding Evaluation with Esophagogastroduodenoscopy, Gastrointestinal Bleeding Evaluation with Upper Endoscopy

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II. Indications

  1. Upper GI Bleeding
  2. See Upper GI Bleeding Score

III. Preparation

  1. Consider Erythromycin 250 mg IV before endoscopy
    1. May allow better visualization if active bleeding
    2. Does not alter rate of identifying lesion
    3. Sears (1996) Gastrointest Endosc 43:A269 [PubMed]

IV. Techniques: Measures used to coagulate bleeding sites

  1. Indications: Active Upper Gastrointestinal Bleeding site
    1. Peptic Ulcer bleeding
    2. Arteriovenous Malformation
    3. Mallory-Weiss tear
    4. Dieulafoy Ulcer
  2. Efficacy
    1. All methods appear to be equally efficacious
    2. Many endoscopists both inject and coagulate lesions
  3. Thermal Contact
    1. Heater probe
    2. Multipolar electrocoagulation
  4. Surgical Clips
    1. Endoclips
  5. Bleeding site injection (typically combined with other measures)
    1. Epinephrine injection
    2. Alcohol injection (sclerosing agent)
      1. Higher risk of perforation
  6. Laser (rarely used)
    1. Nd:YAG Laser
    2. Argon Laser

V. Interpretation: Low Risk Findings

  1. Ulcer with clean base under 2 cm (5% rebleeding risk)
  2. Nonbleeding Mallory-Weiss Tear
  3. Esophagitis
  4. Gastritis
  5. Duodenitis
  6. Endoscopy negative for any lesion or fresh blood
    1. Failure to find source only adverse in over age 80
    2. Otherwise not related to adverse risk

VI. Interpretation: Moderate risk findings

  1. Ulcer with clean base over 2 cm in diameter
  2. Ulcer with clot or pigmented spot (10% risk of rebleed)
  3. Bleeding Mallory-Weiss tear with effective treatment
  4. Arteriovenous Malformation with successful treatment
  5. Portal gastropathy without Esophageal Varices
  6. Tumor identified on endoscopy
  7. Higher risk ulcer location
    1. Ulcer on lesser curvature of the Stomach
    2. Ulcer on posterior duodenal bulb

VII. Interpretation: High risk findings

  1. Actively bleeding ulcer or other bleeding lesion (12% Prevalence)
    1. Rebleeding rate without endoscopic treatment: 90%
    2. Rebleeding rate with successful endoscopic treatment: 15-30%
  2. Vessel visible on endoscopy (22% Prevalence)
    1. Rebleeding rate without endoscopic treatment: 50%
    2. Rebleeding rate with successful endoscopic treatment: 15-30%
  3. Adherent clot (10% Prevalence)
    1. Rebleeding rate without endoscopic treatment: 33%
    2. Rebleeding rate with successful endoscopic treatment: 5%
  4. Esophageal Varices with active bleeding

VIII. Management: Post-procedure

  1. Rebleeding occurs in 20% of cases despite treatment and requires repeat endoscopy
  2. Second-look endoscopy in 24 hours may be recommended
  3. Failed attempt to stop bleeding
    1. See Upper Gastrointestinal Bleeding
    2. Arteriography with embolization
    3. Surgery for severe ongoing bleeding

IX. References

  1. Forrest (1974) Lancet 2(7877): 394-7 [PubMed]
  2. Terdiman (1998) Postgrad Med 103(6):43-64 [PubMed]
  3. Fallah (2000) Med Clin North Am 84(5):1183-208 [PubMed]
  4. Zimmerman (1995) Scand J Gastroenterol 30(4): 327-31 [PubMed]

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