The general approach to upper gastrointestinal bleeding (UGIB) from an esophageal source does not differ from the approach for bleeding from other sources and is addressed in more depth in Chap. i70, "Gastrointestinal Bleeding." Resuscitation proceeds concurrently with the diagnostic effort of history, physical examination, and laboratory evaluation. Gastric lavage through a nasogastric tube or larger-bore gastric tube is generally accepted, and early airway management should be considered. Prompt mobilization of resources—including blood products, gastroenterology consult for endoscopy, and an appropriate inpatient level of care—is important.
About 60 percent of variceal bleeding will resolve with supportive care alone. 27 The rate of spontaneous cessation is higher for nonvariceal sources of UGIB. Patients who continue to bleed need specific intervention. Early endoscopy is generally accepted in patients with UGIB for its diagnostic and therapeutic applications. Pharmacologic treatment with an intravenous vasopressin/nitroglycerin combination, somatostatin, or octreotide can be used as well. Balloon tamponade is generally considered a last-resort therapy when pharmacologic management has failed and endoscopy is either not feasible secondary to massive bleeding or is ineffective. Surgical treatment also remains an option.
Varices develop in patients with chronic liver disease in response to portal hypertension. Around 60 percent of patients with chronic liver disease will develop varices. Of patients who develop varices, 25 to 30 percent experience hemorrhage.28 Patients who develop varices from alcohol abuse have a higher risk of bleeding, especially if there is ongoing alcohol consumption. About two-thirds of patients who have an index bleed experience recurrent hemorrhage, 50 percent occurring within 6 weeks of the initial episode.
With variceal bleeding, endoscopic therapy is often successful in controlling the hemorrhage. Sclerotherapy and ligation are the main alternatives, though in Europe the use of injected Histoacryl (a tissue adhesive) to obstruct the variceal lumen has gained popularity. Shunting procedures performed transvenously or by surgical approach should also be considered.29 Mortality is significant in esophageal variceal bleeding, quoted at 40 percent. 28 Concurrent hepatic failure is a risk factor for poor outcome.
Mallory-Weiss syndrome is arterial bleeding from longitudinal mucosal lacerations of the distal esophagus/proximal stomach. The majority of these lacerations are located at the GE junction, with only 10 percent found in the lower esophagus proper. Mallory-Weiss tears are responsible for between 5 to 15 percent of upper GI hemorrhage. They can occur at any age but are most common in the fourth through sixth decades. The pathophysiology of Mallory-Weiss syndrome is thought to be a transient, large pressure gradient between thorax and stomach, experienced maximally at GE junction.
Acute onset of upper GI bleeding is the usual presentation, though some patients can present with melana or hematochezia. Rarely the presentation will be one of isolated abdominal pain or syncope. Less than half of patients with Mallory-Weiss tears will report a history of vomiting prior to hematemesis. The spectrum of severity of bleeding is broad, but overall a low relative incidence of surgical intervention or adverse outcome is seen. Initial treatment is supportive as the vast majority of Mallory-Weiss tears stop bleeding spontaneously. Ongoing hemorrhage can require treatment with electrocoagulation, sclerotherapy, and laser photocoagulation. Angiographic embolization or surgical intervention remain options as well.
Esophageal cancer often results in heme-positive stools but is an uncommon cause of significant upper or lower GI bleeding. CHAPTER REFERENCES
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