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Disorders of the Gallbladder and Bile Ducts chronically infected patients, and these patients are at higher risk for gallbladder cancer. e Symptoms of cholangitis include fever, jaundice, and Symptoms include biliary colic in early cancer and right-upper-quadrant pain right-upper-quadrant pain, nausea, vomiting, weight loss, or e Endoscopic retrograde cholangiopancreatography is the jaundice in advanced cancer. Gallbladder cancer should be preferred method for relieving obstruction due to a suspected if a mass is seen on CT or MRI. common bile duct stone. Early gallbladder cancer is most commonly diagnosed e Cholangitis is potentially life-threatening; antibiotics incidentally when cholecystectomy is performed for biliary targeting gram-negative Enterobacteriaceae should be colic. Incidental tumors invading the lamina propria (stage administered immediately, and identified common bile Tila) do not require further treatment; more advanced lesions duct stones should be removed urgently. require more extensive surgery.

chronically infected patients, and these patients are at higher risk for gallbladder cancer. e Symptoms of cholangitis include fever, jaundice, and Symptoms include biliary colic in early cancer and right-upper-quadrant pain right-upper-quadrant pain, nausea, vomiting, weight loss, or e Endoscopic retrograde cholangiopancreatography is the jaundice in advanced cancer. Gallbladder cancer should be preferred method for relieving obstruction due to a suspected if a mass is seen on CT or MRI. common bile duct stone. Early gallbladder cancer is most commonly diagnosed e Cholangitis is potentially life-threatening; antibiotics incidentally when cholecystectomy is performed for biliary targeting gram-negative Enterobacteriaceae should be colic. Incidental tumors invading the lamina propria (stage administered immediately, and identified common bile Tila) do not require further treatment; more advanced lesions duct stones should be removed urgently. require more extensive surgery. Treatment of choice for gallbladder cancer is surgery. Unresectable disease is treated with chemotherapy with or Gallbladder Polyps without radiation or with palliative care. Gallbladder polyps are usually found incidentally and can be seen on 1% to 5% of gallbladder ultrasounds. Neoplastic adeno- mas represent less than 0.5% of polyps. The best predictor of a Cholangiocarcinoma malignant lesion is size, with polyps 1 cm or greater more Cholangiocarcinoma is rare but has become an increasingly likely to be neoplastic. Gallbladder polyps associated with recognized malignancy over the last four decades. The gallbladder stones or primary sclerosing cholangitis are also three types are intrahepatic, perihilar, and distal: The intra- more likely to be neoplastic. Management of gallbladder pol- hepatic type is seen in bile ducts within the liver paren- yps is outlined in Figure 38. chyma; the perihilar type, at the confluence of right and left hepatic ducts; and the distal type, in the extrahepatic bile duct distal to the cystic duct. Risk factors for cholan- e Gallbladder polyps 1 cm or greater and those associated giocarcinoma include primary sclerosing cholangitis, with gallbladder stones or primary sclerosing cholangitis choledochal cysts, liver flukes, thorium dioxide exposure, are more likely to be neoplastic and should prompt con- metabolic syndrome, and hepatolithiasis. Symptoms, sideration of cholecystectomy. including jaundice, right-upper-quadrant pain, and consti- tutional symptoms, typically develop only with advanced- stage disease. Gallbladder Cancer Diagnosis of intrahepatic cholangiocarcinoma Gallbladder cancer is the most common biliary cancer in the requires CT or MRI and, typically, biopsy confirmation. An United States, but it is rare, with an incidence of 1 to 2 cases per elevated CA 19-9 level is supportive but insufficient for 100,000. The gallbladder is a reservoir for Salmonella typhi in diagnosis. First-line therapy for intrahepatic cholangiocar- cinoma is resection. Locoregional therapies, including transarterial chemoembolization, radioembolization, or Gallbladder polyp of any size external-beam radiation, may be options if patients are not Yes associated with gallstones or No biliary colic, or gallbladder candidates for resection. Chemotherapy may be offered to polyp >8 mm associated with patients who are not candidates for surgical or locore- primary sclerosing cholangitis gional therapies. Perihilar cholangiocarcinoma can be difficult to diagnose and may require both MRCP and ERCP. During ERCP, bile-duct Yes Vv brushings are obtained for cytologic examination. Fluorescence Repeat US in 12 months; cholecystectomy if Polyp <5 mm in situ hybridization may help diagnostically. Serial ERCP may increase in size be required every 2 to 3 months for diagnosis. First-line ther- No apy is resection. Patients with unresectable perihilar cholan-

Treatment of choice for gallbladder cancer is surgery. Unresectable disease is treated with chemotherapy with or Gallbladder Polyps without radiation or with palliative care. Gallbladder polyps are usually found incidentally and can be seen on 1% to 5% of gallbladder ultrasounds. Neoplastic adeno- mas represent less than 0.5% of polyps. The best predictor of a Cholangiocarcinoma malignant lesion is size, with polyps 1 cm or greater more Cholangiocarcinoma is rare but has become an increasingly likely to be neoplastic. Gallbladder polyps associated with recognized malignancy over the last four decades. The gallbladder stones or primary sclerosing cholangitis are also three types are intrahepatic, perihilar, and distal: The intra- more likely to be neoplastic. Management of gallbladder pol- hepatic type is seen in bile ducts within the liver paren- yps is outlined in Figure 38. chyma; the perihilar type, at the confluence of right and left hepatic ducts; and the distal type, in the extrahepatic bile duct distal to the cystic duct. Risk factors for cholan- e Gallbladder polyps 1 cm or greater and those associated giocarcinoma include primary sclerosing cholangitis, with gallbladder stones or primary sclerosing cholangitis choledochal cysts, liver flukes, thorium dioxide exposure, are more likely to be neoplastic and should prompt con- metabolic syndrome, and hepatolithiasis. Symptoms, sideration of cholecystectomy. including jaundice, right-upper-quadrant pain, and consti- tutional symptoms, typically develop only with advanced- stage disease. Gallbladder Cancer Diagnosis of intrahepatic cholangiocarcinoma Gallbladder cancer is the most common biliary cancer in the requires CT or MRI and, typically, biopsy confirmation. An United States, but it is rare, with an incidence of 1 to 2 cases per elevated CA 19-9 level is supportive but insufficient for 100,000. The gallbladder is a reservoir for Salmonella typhi in diagnosis. First-line therapy for intrahepatic cholangiocar- cinoma is resection. Locoregional therapies, including transarterial chemoembolization, radioembolization, or Gallbladder polyp of any size external-beam radiation, may be options if patients are not Yes associated with gallstones or No biliary colic, or gallbladder candidates for resection. Chemotherapy may be offered to polyp >8 mm associated with patients who are not candidates for surgical or locore- primary sclerosing cholangitis gional therapies. Perihilar cholangiocarcinoma can be difficult to diagnose and may require both MRCP and ERCP. During ERCP, bile-duct Yes Vv brushings are obtained for cytologic examination. Fluorescence Repeat US in 12 months; cholecystectomy if Polyp <5 mm in situ hybridization may help diagnostically. Serial ERCP may increase in size be required every 2 to 3 months for diagnosis. First-line ther- No apy is resection. Patients with unresectable perihilar cholan- giocarcinoma smaller than 3 cm and without extrahepatic Repeat US in 6 months, ba av! spread can be evaluated for liver transplantation at centers then yearly; Polyp 6-9 cholecystectomy if Bue ee with neoadjuvant chemoradiation protocols. In patients with increase in size perihilar cholangiocarcinoma, percutaneous or transluminal No biopsy excludes liver transplantation because of the risk for

giocarcinoma smaller than 3 cm and without extrahepatic Repeat US in 6 months, ba av! spread can be evaluated for liver transplantation at centers then yearly; Polyp 6-9 cholecystectomy if Bue ee with neoadjuvant chemoradiation protocols. In patients with increase in size perihilar cholangiocarcinoma, percutaneous or transluminal No biopsy excludes liver transplantation because of the risk for v v tumor seeding. Cholecystectomy |< | Polyp 21 cm Distal cholangiocarcinoma is diagnosed by the same modalities as for perihilar cholangiocarcinoma. Preferred FIGURE 38. Management of gallbladder polyps. treatment is pancreaticoduodenectomy. 74

Gastrointestinal Bleeding Because of late symptom development, 5-year survival for patients with cholangiocarcinoma (except liver transplant e Upper gastrointestinal bleeding is more common, is more recipients), including those who undergo resection, is low severe, and has a higher mortality rate than lower gas- (20% to 30%). trointestinal bleeding.

Because of late symptom development, 5-year survival for patients with cholangiocarcinoma (except liver transplant e Upper gastrointestinal bleeding is more common, is more recipients), including those who undergo resection, is low severe, and has a higher mortality rate than lower gas- (20% to 30%). trointestinal bleeding. e Resection is first-line treatment for cholangiocarcinoma. Upper Gastrointestinal Bleeding e Selected patients with unresectable perihilar cholangio- UGIB can present in various ways: hematemesis (vomiting of carcinoma smaller than 3 cm and without extrahepatic bright red blood or clots), coffee-ground emesis (vomiting of spread may be candidates for liver transplantation. dark granular material resulting from the action of gastric acid on blood), melena (black, tarry stool with a distinctive odor), and hematochezia (passage of red blood or clots from the rectum). Gastrointestinal Bleeding Causes Overview Common causes of UGIB include peptic ulcer disease, gastroe- In the United States, gastrointestinal bleeding is a common sophageal varices, and Mallory-Weiss tear. Peptic ulcer disease gastrointestinal cause of hospitalization. Upper gastrointesti- is the most common cause (50%), with most gastroduodenal nal bleeding (UGIB) is defined as bleeding from the esophagus, ulcers caused by Helicobacter pylori or NSAID use. Erosive stomach, or duodenum. The mortality rate for patients with esophagitis is a common endoscopic finding but infrequently UGIB varies from 2% to 10%, with much of the mortality causes clinically important UGIB. Therefore, in a patient with occurring in patients with significant comorbid medical con- significant UGIB and erosive esophagitis, alternative causes for ditions. Lower gastrointestinal bleeding (LGIB) occurs in the the bleeding should be sought. colon or anorectum. It is less common, is typically less severe, Bleeding gastroesophageal varices typically occur in the and has a lower mortality rate than UGIB. Suspected small- distal esophagus or proximal stomach in individuals with bowel bleeding, in which bleeding does not appear to origi- advanced liver disease. Bleeding risk of varices is proportional nate from the upper or lower gastrointestinal tract following to varix size. upper and lower endoscopy, accounts for less than 10% of A Mallory-Weiss tear is a mucosal disruption at the gas- gastrointestinal bleeding. In 25% of these patients, however, troesophageal junction and typically forms after repeated epi- the upper or lower gastrointestinal source of bleeding was sodes of severe vomiting or retching. missed on initial endoscopy. Less common causes of UGIB are listed in Table 41.

e Resection is first-line treatment for cholangiocarcinoma. Upper Gastrointestinal Bleeding e Selected patients with unresectable perihilar cholangio- UGIB can present in various ways: hematemesis (vomiting of carcinoma smaller than 3 cm and without extrahepatic bright red blood or clots), coffee-ground emesis (vomiting of spread may be candidates for liver transplantation. dark granular material resulting from the action of gastric acid on blood), melena (black, tarry stool with a distinctive odor), and hematochezia (passage of red blood or clots from the rectum). Gastrointestinal Bleeding Causes Overview Common causes of UGIB include peptic ulcer disease, gastroe- In the United States, gastrointestinal bleeding is a common sophageal varices, and Mallory-Weiss tear. Peptic ulcer disease gastrointestinal cause of hospitalization. Upper gastrointesti- is the most common cause (50%), with most gastroduodenal nal bleeding (UGIB) is defined as bleeding from the esophagus, ulcers caused by Helicobacter pylori or NSAID use. Erosive stomach, or duodenum. The mortality rate for patients with esophagitis is a common endoscopic finding but infrequently UGIB varies from 2% to 10%, with much of the mortality causes clinically important UGIB. Therefore, in a patient with occurring in patients with significant comorbid medical con- significant UGIB and erosive esophagitis, alternative causes for ditions. Lower gastrointestinal bleeding (LGIB) occurs in the the bleeding should be sought. colon or anorectum. It is less common, is typically less severe, Bleeding gastroesophageal varices typically occur in the and has a lower mortality rate than UGIB. Suspected small- distal esophagus or proximal stomach in individuals with bowel bleeding, in which bleeding does not appear to origi- advanced liver disease. Bleeding risk of varices is proportional nate from the upper or lower gastrointestinal tract following to varix size. upper and lower endoscopy, accounts for less than 10% of A Mallory-Weiss tear is a mucosal disruption at the gas- gastrointestinal bleeding. In 25% of these patients, however, troesophageal junction and typically forms after repeated epi- the upper or lower gastrointestinal source of bleeding was sodes of severe vomiting or retching. missed on initial endoscopy. Less common causes of UGIB are listed in Table 41. TABLE 41. Less Common Causes of Upper Gastrointestinal Bleeding

e Resection is first-line treatment for cholangiocarcinoma. Upper Gastrointestinal Bleeding e Selected patients with unresectable perihilar cholangio- UGIB can present in various ways: hematemesis (vomiting of carcinoma smaller than 3 cm and without extrahepatic bright red blood or clots), coffee-ground emesis (vomiting of spread may be candidates for liver transplantation. dark granular material resulting from the action of gastric acid on blood), melena (black, tarry stool with a distinctive odor), and hematochezia (passage of red blood or clots from the rectum). Gastrointestinal Bleeding Causes Overview Common causes of UGIB include peptic ulcer disease, gastroe- In the United States, gastrointestinal bleeding is a common sophageal varices, and Mallory-Weiss tear. Peptic ulcer disease gastrointestinal cause of hospitalization. Upper gastrointesti- is the most common cause (50%), with most gastroduodenal nal bleeding (UGIB) is defined as bleeding from the esophagus, ulcers caused by Helicobacter pylori or NSAID use. Erosive stomach, or duodenum. The mortality rate for patients with esophagitis is a common endoscopic finding but infrequently UGIB varies from 2% to 10%, with much of the mortality causes clinically important UGIB. Therefore, in a patient with occurring in patients with significant comorbid medical con- significant UGIB and erosive esophagitis, alternative causes for ditions. Lower gastrointestinal bleeding (LGIB) occurs in the the bleeding should be sought. colon or anorectum. It is less common, is typically less severe, Bleeding gastroesophageal varices typically occur in the and has a lower mortality rate than UGIB. Suspected small- distal esophagus or proximal stomach in individuals with bowel bleeding, in which bleeding does not appear to origi- advanced liver disease. Bleeding risk of varices is proportional nate from the upper or lower gastrointestinal tract following to varix size. upper and lower endoscopy, accounts for less than 10% of A Mallory-Weiss tear is a mucosal disruption at the gas- gastrointestinal bleeding. In 25% of these patients, however, troesophageal junction and typically forms after repeated epi- the upper or lower gastrointestinal source of bleeding was sodes of severe vomiting or retching. missed on initial endoscopy. Less common causes of UGIB are listed in Table 41. TABLE 41. Less Common Causes of Upper Gastrointestinal Bleeding Lesion Pathogenesis Presentation Treatment |

e Resection is first-line treatment for cholangiocarcinoma. Upper Gastrointestinal Bleeding e Selected patients with unresectable perihilar cholangio- UGIB can present in various ways: hematemesis (vomiting of carcinoma smaller than 3 cm and without extrahepatic bright red blood or clots), coffee-ground emesis (vomiting of spread may be candidates for liver transplantation. dark granular material resulting from the action of gastric acid on blood), melena (black, tarry stool with a distinctive odor), and hematochezia (passage of red blood or clots from the rectum). Gastrointestinal Bleeding Causes Overview Common causes of UGIB include peptic ulcer disease, gastroe- In the United States, gastrointestinal bleeding is a common sophageal varices, and Mallory-Weiss tear. Peptic ulcer disease gastrointestinal cause of hospitalization. Upper gastrointesti- is the most common cause (50%), with most gastroduodenal nal bleeding (UGIB) is defined as bleeding from the esophagus, ulcers caused by Helicobacter pylori or NSAID use. Erosive stomach, or duodenum. The mortality rate for patients with esophagitis is a common endoscopic finding but infrequently UGIB varies from 2% to 10%, with much of the mortality causes clinically important UGIB. Therefore, in a patient with occurring in patients with significant comorbid medical con- significant UGIB and erosive esophagitis, alternative causes for ditions. Lower gastrointestinal bleeding (LGIB) occurs in the the bleeding should be sought. colon or anorectum. It is less common, is typically less severe, Bleeding gastroesophageal varices typically occur in the and has a lower mortality rate than UGIB. Suspected small- distal esophagus or proximal stomach in individuals with bowel bleeding, in which bleeding does not appear to origi- advanced liver disease. Bleeding risk of varices is proportional nate from the upper or lower gastrointestinal tract following to varix size. upper and lower endoscopy, accounts for less than 10% of A Mallory-Weiss tear is a mucosal disruption at the gas- gastrointestinal bleeding. In 25% of these patients, however, troesophageal junction and typically forms after repeated epi- the upper or lower gastrointestinal source of bleeding was sodes of severe vomiting or retching. missed on initial endoscopy. Less common causes of UGIB are listed in Table 41. TABLE 41. Less Common Causes of Upper Gastrointestinal Bleeding Lesion Pathogenesis Presentation Treatment | Cameron erosion Mechanical trauma to mucosal Typically chronic Gl bleeding Includes medical therapy with PPI folds of hiatal hernia presenting as iron deficiency and iron; surgical repair of hiatal anemia hernia

Cameron erosion Mechanical trauma to mucosal Typically chronic Gl bleeding Includes medical therapy with PPI folds of hiatal hernia presenting as iron deficiency and iron; surgical repair of hiatal anemia hernia Dieulafoy lesion Dilated, aberrant submucosal Included in differential diagnosis of Endoscopic vessel recurrent, often massive bleeding without clear source Gastric antral Most idiopathic; some associated Acute bleeding or iron deficiency Endoscopic vascular ectasia with cirrhosis and systemic sclerosis anemia Aortoenteric fistula Direct communication between “Herald” bleeding followed by Surgical aorta and Gl tract massive exsanguination Hemosuccus Erosion of pancreatic pseudocyst Upper GI bleeding in setting of Mesenteric angiography with coil pancreaticus or tumor into a vessel with pancreatic disease embolization bleeding into pancreatic duct Hemobilia Bleeding from the hepatobiliary Triad of jaundice, biliary colic, and Angiography or surgical tract often caused by arteriobiliary Gl bleeding fistula from trauma or liver biopsy Upper Gl tumors Benign or malignant neoplasms Slow or massive hemorrhage Palliative radiographic, endoscopic techniques, surgery Portal hypertensive Portal hypertension Usually slow/chronic blood loss; Medical therapy (B-blocker, gastropathy occasionally significant octreotide); rarely transjugular | |

Upper Gl tumors Benign or malignant neoplasms Slow or massive hemorrhage Palliative radiographic, endoscopic techniques, surgery Portal hypertensive Portal hypertension Usually slow/chronic blood loss; Medical therapy (B-blocker, gastropathy occasionally significant octreotide); rarely transjugular | | hemorrhage intrahepatic portosystemic shunting | | } Gl = gastrointestinal; PP| = proton pump inhibitor. } 75

Gastrointestinal Bleeding Evaluation increased risk for aspiration should be considered for endotra- The initial step in evaluation is risk assessment to determine cheal intubation. severity. This assessment includes measuring vital signs and reviewing patient factors. Tachycardia (pulse rate >100/min), Pre-Endoscopic Care hypotension (systolic blood pressure <100 mm Hg), age older Intravenous erythromycin given before endoscopy improves than 60 years, and major comorbid medical conditions are gastric visualization and decreases the need for repeat endos- associated with increased risk for rebleeding and death. copy, but it should be administered only when requested Several clinical scores (e.g., the Glasgow-Blatchford and by the endoscopist. Nasogastric tube lavage is not required Rockall scores) are available to help predict risk for recurrent because there is no evidence of clinical benefit. bleeding and mortality. Intravenous proton pump inhibitor (PPI) therapy initiated Findings of stigmata of chronic liver disease suggest a before endoscopy decreases high-risk endoscopic stigmata in possible variceal source of bleeding. peptic ulcer disease and may reduce the need for endoscopic therapy (Figure 39 and Figure 40), but it does not influence Management outcomes, such as rebleeding or death. Hemodynamic status should be assessed in all patients, and Octreotide, a somatostatin analogue that decreases resuscitative measures must be initiated with the goal of splanchnic blood flow and lowers portal pressure, should be hemodynamic stabilization before endoscopy. Adequate intra- initiated if variceal hemorrhage is suspected. Initiation of anti- venous access, usually with two large-bore peripheral intrave- biotics, such as ceftriaxone or quinolone, at the time of hospi- nous catheters (minimum 18-gauge), should be established. talization for gastrointestinal bleeding is recommended for all Hemoglobin levels should be measured in all patients. A patients with cirrhosis. Nearly 50% of patients with cirrhosis restrictive transfusion strategy is recommended and initiated who are hospitalized with UGIB have a bacterial infection, when the hemoglobin level is below 7 g/dL (70 g/L) in hemo- such as pneumonia and urinary tract infection, and antibiotics dynamically stable patients without preexisting cardiovas- reduce the rates of rebleeding and death. Balloon tamponade cular disease. Patients with hypotension due to severe, may be necessary as a temporizing measure for management ongoing UGIB and those with concomitant cardiovascular of variceal bleeding until more definitive interventions are disease should be considered for transfusion before the available. hemoglobin level decreases below 7 g/dL (70 g/L) to prevent In patients receiving warfarin with significant hemor- the decreases below 7 g/dL (70 g/L) that may occur with rhage, warfarin should be discontinued and anticoagulation fluid resuscitation alone. Care should be taken in patients reversed with prothrombin complex concentrate with vitamin with variceal hemorrhage because overtransfusion can pre- K. Endoscopy, however, should not be delayed for anticoagula- cipitate variceal rebleeding due to increased portal pressure. tion reversal. In patients receiving direct oral anticoagulants, Patients with altered mental status, massive hematemesis, or the anticoagulant should be discontinued on presentation,

The initial step in evaluation is risk assessment to determine cheal intubation. severity. This assessment includes measuring vital signs and reviewing patient factors. Tachycardia (pulse rate >100/min), Pre-Endoscopic Care hypotension (systolic blood pressure <100 mm Hg), age older Intravenous erythromycin given before endoscopy improves than 60 years, and major comorbid medical conditions are gastric visualization and decreases the need for repeat endos- associated with increased risk for rebleeding and death. copy, but it should be administered only when requested Several clinical scores (e.g., the Glasgow-Blatchford and by the endoscopist. Nasogastric tube lavage is not required Rockall scores) are available to help predict risk for recurrent because there is no evidence of clinical benefit. bleeding and mortality. Intravenous proton pump inhibitor (PPI) therapy initiated Findings of stigmata of chronic liver disease suggest a before endoscopy decreases high-risk endoscopic stigmata in possible variceal source of bleeding. peptic ulcer disease and may reduce the need for endoscopic therapy (Figure 39 and Figure 40), but it does not influence Management outcomes, such as rebleeding or death. Hemodynamic status should be assessed in all patients, and Octreotide, a somatostatin analogue that decreases resuscitative measures must be initiated with the goal of splanchnic blood flow and lowers portal pressure, should be hemodynamic stabilization before endoscopy. Adequate intra- initiated if variceal hemorrhage is suspected. Initiation of anti- venous access, usually with two large-bore peripheral intrave- biotics, such as ceftriaxone or quinolone, at the time of hospi- nous catheters (minimum 18-gauge), should be established. talization for gastrointestinal bleeding is recommended for all Hemoglobin levels should be measured in all patients. A patients with cirrhosis. Nearly 50% of patients with cirrhosis restrictive transfusion strategy is recommended and initiated who are hospitalized with UGIB have a bacterial infection, when the hemoglobin level is below 7 g/dL (70 g/L) in hemo- such as pneumonia and urinary tract infection, and antibiotics dynamically stable patients without preexisting cardiovas- reduce the rates of rebleeding and death. Balloon tamponade cular disease. Patients with hypotension due to severe, may be necessary as a temporizing measure for management ongoing UGIB and those with concomitant cardiovascular of variceal bleeding until more definitive interventions are disease should be considered for transfusion before the available. hemoglobin level decreases below 7 g/dL (70 g/L) to prevent In patients receiving warfarin with significant hemor- the decreases below 7 g/dL (70 g/L) that may occur with rhage, warfarin should be discontinued and anticoagulation fluid resuscitation alone. Care should be taken in patients reversed with prothrombin complex concentrate with vitamin with variceal hemorrhage because overtransfusion can pre- K. Endoscopy, however, should not be delayed for anticoagula- cipitate variceal rebleeding due to increased portal pressure. tion reversal. In patients receiving direct oral anticoagulants, Patients with altered mental status, massive hematemesis, or the anticoagulant should be discontinued on presentation, FIGURE 39. Duodenal ulcers. Left: Duodenal ulcer with nonbleeding visible vessel (arrow) that is at high risk for rebleeding and must be treated endoscopically. Right: Duodenal ulcer (solid arrow) with active arterial spurting (dotted arrow). This lesion is at the highest risk for rebleeding and must be treated endoscopically.

FIGURE 39. Duodenal ulcers. Left: Duodenal ulcer with nonbleeding visible vessel (arrow) that is at high risk for rebleeding and must be treated endoscopically. Right: Duodenal ulcer (solid arrow) with active arterial spurting (dotted arrow). This lesion is at the highest risk for rebleeding and must be treated endoscopically. Courtesy of Louis M. Wong Kee Song, MD, Mayo Clinic. 76

Gastrointestinal Bleeding in patients with a recent acute coronary syndrome or coronary stent placement should be made with a cardiologist. In patients with significant hemorrhage in whom the P2Y12 receptor antag- onist must be discontinued, aspirin should be continued. Patients with hemodynamic instability, active bleeding (hematemesis or recurrent large-volume hematochezia), or sus- pected variceal hemorrhage should be admitted to an ICU. Most other patients can be admitted to a regular hospital ward. Several decision rules and predictive models have been developed to identify patients at low risk for recurrent or life-threatening UGIB. The modified Glasgow-Blatchford bleeding score is cal- culated using blood urea nitrogen level, hemoglobin level, systolic blood pressure, and pulse rate. It predicts the need for clinical intervention, rebleeding, and mortality. Patients at low risk with a modified Glasgow-Blatchford score of 1 or less may be considered for early discharge or outpatient treatment.

in patients with a recent acute coronary syndrome or coronary stent placement should be made with a cardiologist. In patients with significant hemorrhage in whom the P2Y12 receptor antag- onist must be discontinued, aspirin should be continued. Patients with hemodynamic instability, active bleeding (hematemesis or recurrent large-volume hematochezia), or sus- pected variceal hemorrhage should be admitted to an ICU. Most other patients can be admitted to a regular hospital ward. Several decision rules and predictive models have been developed to identify patients at low risk for recurrent or life-threatening UGIB. The modified Glasgow-Blatchford bleeding score is cal- culated using blood urea nitrogen level, hemoglobin level, systolic blood pressure, and pulse rate. It predicts the need for clinical intervention, rebleeding, and mortality. Patients at low risk with a modified Glasgow-Blatchford score of 1 or less may be considered for early discharge or outpatient treatment. FIGURE 40. Duodenal ulcer with adherent clot (arrow) that is at risk for rebleeding. This can be treated medically or by clot removal and endoscopic Endoscopic Evaluation and Treatment therapy in addition to standard medical therapy. Upper endoscopy is the primary diagnostic modality for evalu- Courtesy of Louis M. Wong Kee Song, MD, Mayo Clinic. ating UGIB. For patients hospitalized with UGIB, endoscopy should be performed within 24 hours of resuscitation; in those and, if significant hemorrhage is present, reversal with acti- with rapid bleeding or suspected variceal hemorrhage, it vated prothrombin complex concentrate or the appropriate should be done more emergently. agent (idarucizumab or andexanet alfa) should be considered. Endoscopy can determine the cause of bleeding and helps See MKSAP 19 Hematology for further information on reversal with risk stratification. Lesions at high risk for recurrent of anticoagulants. bleeding that require endoscopic treatment include actively In patients with active bleeding who have platelet counts bleeding peptic ulcers, ulcers with nonbleeding visible vessels less than 50,000/uL, platelets should be transfused. Aspirin for (see Figure 39), and ulcers with adherent clots (see Figure 40). primary prevention of cardiovascular disease should be discon- An adherent clot should be irrigated with the intention of tinued and not restarted because the risk for recurrent bleeding removing the clot; the ulcer base is then examined to exclude outweighs the benefit. Aspirin for secondary prevention in an underlying arterial vessel requiring endoscopic hemostasis. patients with high-risk cardiovascular disease should be discon- Lesions at low risk for rebleeding (clean-based ulcers, ulcers tinued only if necessary. Decisions about discontinuing dual with pigmented spots, and Mallory-Weiss tears) do not require antiplatelet therapy with a P2Y12 receptor antagonist and aspirin endoscopic treatment (Figure 41). Most Mallory-Weiss tears

FIGURE 40. Duodenal ulcer with adherent clot (arrow) that is at risk for rebleeding. This can be treated medically or by clot removal and endoscopic Endoscopic Evaluation and Treatment therapy in addition to standard medical therapy. Upper endoscopy is the primary diagnostic modality for evalu- Courtesy of Louis M. Wong Kee Song, MD, Mayo Clinic. ating UGIB. For patients hospitalized with UGIB, endoscopy should be performed within 24 hours of resuscitation; in those and, if significant hemorrhage is present, reversal with acti- with rapid bleeding or suspected variceal hemorrhage, it vated prothrombin complex concentrate or the appropriate should be done more emergently. agent (idarucizumab or andexanet alfa) should be considered. Endoscopy can determine the cause of bleeding and helps See MKSAP 19 Hematology for further information on reversal with risk stratification. Lesions at high risk for recurrent of anticoagulants. bleeding that require endoscopic treatment include actively In patients with active bleeding who have platelet counts bleeding peptic ulcers, ulcers with nonbleeding visible vessels less than 50,000/uL, platelets should be transfused. Aspirin for (see Figure 39), and ulcers with adherent clots (see Figure 40). primary prevention of cardiovascular disease should be discon- An adherent clot should be irrigated with the intention of tinued and not restarted because the risk for recurrent bleeding removing the clot; the ulcer base is then examined to exclude outweighs the benefit. Aspirin for secondary prevention in an underlying arterial vessel requiring endoscopic hemostasis. patients with high-risk cardiovascular disease should be discon- Lesions at low risk for rebleeding (clean-based ulcers, ulcers tinued only if necessary. Decisions about discontinuing dual with pigmented spots, and Mallory-Weiss tears) do not require antiplatelet therapy with a P2Y12 receptor antagonist and aspirin endoscopic treatment (Figure 41). Most Mallory-Weiss tears FIGURE 41. Ulcers at low risk for rebleeding, for which endoscopic therapy is not indicated. Left: Clean-based gastric ulcer with no blood vessels, pigmented spots/ protuberances, or clots in the base. Right: Nonprotuberant pigmented spot (arrow) in a duodenal ulcer bed. Courtesy of Louis M. Wong Kee Song, MD, Mayo Clinic.

FIGURE 41. Ulcers at low risk for rebleeding, for which endoscopic therapy is not indicated. Left: Clean-based gastric ulcer with no blood vessels, pigmented spots/ protuberances, or clots in the base. Right: Nonprotuberant pigmented spot (arrow) in a duodenal ulcer bed. Courtesy of Louis M. Wong Kee Song, MD, Mayo Clinic. 77