Upper GI Bleed with Case

00:01 We'll now start our next case.

00:03 We have a 45-year-old man, seen in the ED for 3 episodes of melena in the last 2 days.

00:10 He has not had any abdominal pain.

00:12 He has no history of bleeding disorders, alcoholism, chronic liver disease or cancer.

00:18 His medical conditions include hypertension and prediabetes.

00:22 This is his first episode of melena.

00:24 He takes high dose aspirin for chronic knee pain.

00:28 His vitals are notable for a heart rate of 110, blood pressure is 125/62 while supine and 99/55 while standing.

00:37 His abdominal exam is unremarkable and rectal exam identifies melena.

00:42 Lab studies show a hemoglobin of 10 but are otherwise normal.

00:47 So what is the best next step in management? Let's go through some key items in this case.

00:53 So he has melena, he has no significant past medical history that would place him at risk for developing melena.

01:01 He does, however, have high dose aspirin use which is a risk factor for GI bleeding.

01:07 And on his exam, this is notable for resting tachycardia, and he has orthostatic hypotension as you note the blood pressure change from supine to standin.

01:17 This indicates that he already has moderate intravascular volume loss.

01:21 So before we answer the question, let's go through a differential for him.

01:27 So as we mentioned in our approach to GI bleeds, there's a very broad differential for upper GI bleeds.

01:34 In this case, if we think through his risk factors, we know that he has a history of chronic NSAID use which puts him at risk for gastric or duodenal ulcers.

01:44 Also, he's at risk for erosive esophagitis, gastritis or duodenitis Although this is rare, he could have an arteriovenous malformation so this should always be on your differential.

01:58 And although he's fairly young, you should always put malignancy on your differential and make sure that you have ruled it out.

02:04 The other causes listed here including esophageal gastric varices or portal hypertensive gastropathy are less likely in him because he does not have a history of cirrhosis.

02:15 In addition, a Mallory-Weiss tear is also pretty unlikely in this case because it does not describe a history of frequent vomiting prior to his bleeding episode.

02:26 So, if we return to our case, we know that he is a 45 year old man,with melena, no particular significant past medical history but he does have high dose NSAID use.

02:37 So the best next step in management includes recognizing that he has moderate hypovolemia so the first step, as always, is to fluid resuscitate and then consult GI for endoscopy.

02:51 Our case now continues.

02:53 The patient is fluid resuscitated, he has no further episodes of melena.

02:58 He undergoes an upper endoscopy which does not visualize a source of bleeding.

03:03 He then undergoes a video capsule endoscopy followed by push enteroscopy as so shown here.

03:10 So first, this is a video capsule endoscopy, so the patient swallow a small capsule that then allows us to visualize the small bowel.

03:20 Here, you see a small amount of bleeding in the jejunum.

03:25 The next step after doing a video capsule is to do push enteroscopy which is a method by which we can then visualize the small bowel which is otherwise very difficult to access.

03:36 So here you see an image from his push enteroscopy that shows a small area of angiodysplasia in the jejunum which probably corresponds to the area that was bleeding on the video capsule.

03:50 And the next step, he then undergoes argon plasma coagulation which is a method of hemostasis to stop the bleeding.

03:58 And after this vessel is coagulated, he then has resolution of his bleeding.

04:04 So let's talk a bit about angiodysplasia or arteriovenous malformations.

04:10 While they are rare, they can cause up to 47% of GI bleeds and they're caused by a vascular abnormality.

04:18 So, as you can see here on the right, normally a capillary bed is made by an arterial and a venule coming together, that's, on top, you can see a normal blood vessel.

04:29 On the bottom on the other hand, these blood vessels may form abnormally and cause an abnormal connection which is an AVM.

04:38 So patients with AVMs may have either overt or occult GI bleeding and usually their bleeding is unmasked by things like aspirin, NSAIDs or anticoagulants.

04:52 The diagnosis as with all GI bleeds is done by endoscopy.

04:58 And with endoscopy, you can also treat.

05:01 So we have various hemostasis interventions to stop the vessel from bleeding including injecting epinephrine, doing coagulation, or placing a clip on the bleeding vessel to stop it from bleeding.

05:17 You might encounter the term "Dieulafoy's lesion".

05:20 A Dieulafoy's lesion is just a particular type of AVM.

05:25 It refers to a dilated abnormal vessel that erodes into the epithelium without causing an ulcer.

05:31 It is usually referred to in the proximal stomach but can really be found anywhere in the GI tract.