upper g i bleed

1. Dr. KASTURI BANEREE..

3. INTRODUCTION
Acute gastrointestinal bleeding is a potentially life-threatening abdominal

emergency that remains a common cause of hospitalization.
Upper gastrointestinal bleeding (UGIB) is defined as bleeding derived
from a source proximal to the ligament of Treitz.

Can be categorized as either variceal or non-variceal. V
ariceal is a
complication of end stage liver disease. While non variceal bleeding
associated with peptic ulcer disease or other causes of UGIB.

UGIB is 4 times as common as bleeding from lower GIT, with a higher
incidence in male.
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4. 
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5. Esophageal causes:

Esophageal varices
Esophagitis
Esophageal cancer
Esophageal ulcers
Mallory-Weiss tear
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CAUSES
Gastric causes:

Gastric ulcer
Gastric cancer
Gastritis
Gastric varices
Dieulafoy's lesions
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6. 
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MALLOR-WEISS SYNDROME
• SECONDARY TO
LONGITUDINAL MUCOSAL
TEAR AT THE
GASTROESOPHAGEAL
JUNCTION.
• RETCHING, MULTIPLE
EPISODES OF VOMITING,
DKA, CHEMOTHERAPY,
BINGE DRINKING ALCOHOL.
•BRIGHT RED HEMAEMESIS.
•Dx : ENDOSOPY
• Rx : EVL, SCLEROTHERAPY

7. 
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
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DIEULAFOY LESIONS
• GI TRACT ARTERIES PROTRUDING
THROUGH THE SUBMUCOSA.
• COMMONLY FOUND IN THE
LESSER CURVAURE/ WITHIN 6cm OF
THE GASTROESOPHAGEAL JUNCTION.
•NO STANDARD PREDISPOSING
FACTORS.
•INERMITTENT MASSIVE BLEED.
•DIFFICULT TO DIAGNOSE
ENDOSCOPICALLY.
•MULTIPLE Dx MANEUVERS WITH
NEGEIVE REPORTS

8. Duodenal causes:

Duodenal ulcer
Vascular malformation including
aorto-enteric fistulae
Hematobilia, or bleeding from the
biliary tree-fistua b/w splanchnic
circulation & intrahepatic or
extrahepatic biliary system.
Hemosuccus pancreaticus, or
bleeding from the pancreatic duct
due to rupture, pseudoaneurysm,
sx, trauma.
Severe superior mesenteric artery
syndrome
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CAUSES
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10. :SIGNS AND SYMPTOMS
•Hematemesis
• Melena
• Hematochezia
• Syncope
• Tachycardia
• Tachyphoea
• Dyspepsia
• Epigastric pain
• Diffuse Abdominal Pain
• Dysphagia
• Weight loss
• Pallor
• Icterus
• Paradoxical Bradycardia

11. 



PARADOXICAL BRADICARDIA
• Relative bradycardia is defined as a heart rate
(HR) <90 bpm in the setting of hemorrhage, and
paradoxical bradycardia is the phenomenon with
HR <60 bpm
• Afferent branches of the vagus and
glossopharyngeal nerves located in the aortic arch
detect a drop in pulse pressure during the initial
phase of hemorrhage (10% to 15% blood loss).
• Activation of the baroreceptors causes a
withdrawal of the efferent vagal activity, increasing
the HR.
• Once the blood loss reaches 20% to 25%,
efferent branches of the vagal nerve activity
increases, which slows the HR to allow the

12. :PRESENTATION
Hematemesis: vomiting of blood ,could be: Digested blood in
the stomach(coffee-ground emesis that indicate slower rate
of bleeding) or fresh/unaltered blood (gross blood and clots,
indicates rapid bleeding)
1.
Melena: stool consisting of partially digested blood (black
tarry, semi solid, shiny and has a distinctive odor, when its
present it indicates that blood has been present in the GI
tract for at least 14 h. The more proximal the bleeding site,
the more likely melena will occur.
2.
Hematochezia usually represents a lower GI source of
bleeding, although an upper GI lesion may bleed so briskly
that blood does not remain in the bowel long enough for
melena to develop.
3.

13. APPROACH
 History:
Abdominal pain
Haematamesis
Haematochezia
Melaena
•
•
•
•
Features
anemia
Features
jaundice,
of blood loss: shock, syncope,
•
of underlying cause: dyspepsia,
weight loss
•

14. Drug history: NSAIDs, Aspirin, corticosteroids,
anticoagulants, (SSRIs) particularly fluoxetine and
sertraline.
•
History of epistaxis or hemoptysis to rule out the GI
source of bleeding.
•
Past medical :previous episodes of upper
gastrointestinal bleeding, diabetes mellitus; coronary
artery disease; chronic renal or liver disease; or
chronic obstructive pulmonary disease.
•
Past surgical: previous abdominal surgery
•

15. APPROACH:
.CONT
Examination :

General examination
examinations
and systemic
•
VITALS:
Pulse = Thready pulse
BP = Orthostatic Hypotension
•
SIGNS of shock:
Cold extremeties, Tachycardia, Hypotension
Confusion, Delirium, Oliguria
•
.

16. SKIN changes:
Cirrhosis – Palmer erythema, spider nevi
Bleeding disorders – Purpura /Echymosis
Coagulation disorders – Haemarthrosis, Muscle
hematoma.
•
Signs of dehydration (dry mucosa, sunken eyes, skin
reduced).
turgor
•
Signs of a tumour may be present (nodular liver, abdominal
mass, lymphadenopathy, and etc.
•
fresh blood, occult blood, bloody diarrhea
•
•

17. :LAB DIAGNOSIS
CBC with Platelet Count, and Differential
A complete blood count (CBC) is necessary to assess the
level of blood loss. CBC should be checked frequently(q4-6h)
during the first day.
•
Hemoglobin Value, Type and Crossmatch Blood
•
The patient should be crossmatched for 2-6 units, based on
the rate of active bleeding.The hemoglobin level should be
monitored serially in order to follow the trend. An unstable
Hb level may signify ongoing hemorrhage requiring further
intervention.

18. LFT- to detect underlying liver disease
•
RFT- to detect underlying renal disease
•
Calcium level- to detect hyperparathyroidism
and in monitoring ionised calcium in patients
receiving multiple transfusions of citrated blood
•
•

19. The BUN-to- creatinine ratio increases with upper
•
gastrointestinal bleeding (UGIB). A ratio of greater than
36 in a patient without renal insufficiency is suggestive of
UGIB.
The patient's prothrombin time (PT), activated partial
•
thromboplastin time, and International Normalized Ratio
(INR) should be checked to document the presence of a
coagulopathy

20. Prolongation of the PT based on an INR of more than
1.5 may indicate moderate liver impairment.
•
A fibrinogen level of less than 100 mg/dL also indicates
advanced liver disease with extremely poor synthetic
function
•
ROUTINE ABDOMINAL AND CHEST RADIOGRAPHS ARE OF
LIMITED VALUE.
BARIUM CONTRAST STUDIES ARE CONTRAINDICATED
BECAUSE BARIUM MAY HINDER SUBSEQUENT ENDOSCOPY
OR ANGIOGRAPHY.

21. :ENDOSCOPY
Initial diagnostic examination
presumed to have UGIB
for all patients
•
Endoscopy should be performed 6-24 hrs in unstable
patients if adequately resuscitated & 12-36 hrs in
stable patients reduces chances of mortality.
•

24. :IMAGING
CHEST X-RAY-Chest radiographs should be
ordered to exclude aspiration pneumonia, effusion,
and esophageal perforation.
•
Abdominal X-RAY- erect and supine films should
be ordered to exclude perforated viscous and ileus.
•

25. Computed tomography (CT) scanning and
ultrasonography may be indicated for the evaluation
of liver disease with cirrhosis, cholecystitis with
hemorrhage, pancreatitis with pseudocyst and
hemorrhage, aortoenteric fistula, and other unusual
causes of upper GI hemorrhage.
•
•

26. ANGIOGRAPHY
:
Angiography may be useful if bleeding
persists and endoscopy fails to identify a
bleeding site.

Angiography along with transcatheter arterial
embolization (TAE) should be considered for
all patients with a known source of arterial
UGIB that does not respond to endoscopic
management, with active bleeding and a
negative endoscopy.



27. NASOGASTRIC LAVAGE
A nasogastric tube is an important diagnostic
tool.
This procedure may confirm recent
(coffee ground appearance), possible
bleeding
active
bleeding (red blood in the aspirate that does
not clear), or a lack of blood in the stomach
(active bleeding less likely but does not
exclude an upper GI lesion).

29. BENEFITS OF LAVAGE :
Better visualization during endoscopy
Give crude estimation of rapidity of bleeding
Increases PH of stomach, and hence,
decreases clot desolation due to gastric acid
dilution
1
.
2
.
3
.
.
During gastric lavage use saline. Not in
large volume.

Gastric lavage should be done in alert and
cooperative
patient to avoid bronco-pulmonary aspiration


30. ASSESSMENT OF
SEVERITY
ROCKALL SCORE

31. RISK CATEGORY

Rockall’s score> 0= requires endosopy


32. MANAGEMENT
Priorities are:
1. Stabilize the patient:
circulation.
2. Identify the source of
protect airway, restore
bleeding.
3. Definitive treatment of the cause.
Resuscitation and initial management
Protect airway: position the patient on
IV access: use 1-2 large bore cannula
side
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33. Transfuse blood for:
o
o
o
o
Obvious massive blood loss
Hematocrit < 25% with active bleeding
Transfuse when Hb <= 7g/dl in most pts & <=
10g/dl in old pt /with comorbs
Platelet transfusions should be offered to patients
who are actively bleeding and have a platelet count of
<50000.
o
Fresh frozen plasma should be used for patients
who have either a fibrinogen level of less than 1
g/litre, or (INR) greater than 1.5 times normal.
o
o

34. Massive Transfusion Protocol
• >10 U of PRBC over 24hrs or >4U in <4hrs with on
going bleed.
• Assesment of blood consumption score
• Penetrating injury
• positive FAST
• BP <90
• HR>120
• If >= 2 is present >90% specificity for transfusion

35. • draw blood before transfusion..
• Initial resuscitation with isotonic / balanced crystalloid fluid
• Solutions containing lactate or acetate are considered balanced
crystalloids because they are buffered and have a lower chloride
concentration compared to normal saline. Balanced crystalloids yield
better clinical outcomes compared to normal saline
• Crystalloid solutions are isotonic but hypo-oncotic, because they lack the
large protein molecules present in the plasma. Low oncotic pressure
results in shift of crystalloid to the extravascular space.
• stop crystalloids to prevent coagulopathies.
• loss of 1 L of blood (about 15% to 20% of total circulating blood volume)
would require about 3 L of isotonic crystalloid to restore normovolemia,
assuming no ongoing blood loss.
• UPT for all female in child bearing age.
• Continous monitoring vitals, urine outpput, blood gas, lab values (every 4-
6hrs)

37. • PRBCs and FFP contain citrate that can complex
calcium, producing life-threatening
hypocalcemia.
• Most massive transfusion protocols include the
administration of calcium and/or monitoring of
ionized calcium.
• Calcium chloride is preferred over calcium
gluconate because a well-perfused liver is
required to liberate more free calcium from
calcium gluconate.
• Maintain ionized calcium levels at or above 0.9
mmol/L

38. Monitor urine output.

Watch for signs of fluid overload (raised JVP, pul.
edema, peripheral edema)

 Keep the pt nill by mouth for the endoscopy


39. PPI
• OMEPRAZOLE 80mg Iv bolous  8mg/hr
• NON VARICEAL BLEEDING
• For clot formation the gastric pH >6.
• Maintains a neutral gastric pH

40. OCTREOTIDE
• Long acting somatostatin analogue.
• It inhibits the secretion of gastric acid.
• Reduces blood flow to the gastroduodenal mucosa
• Causes splanchnic vasoconstriction.
• 50mcg bolus followed by a continuous infusion of 25
to 50 micrograms/h.

41. TERLIPRESSIN
• Terlipressin is a synthetic analogue of vasopressin.
• It mainly acts on the V1 receptors which are mainly
located in the arterial smooth muscle within the
splanchnic circulation, causes vasoconstriction
reducing flow into portal vein reduces pressure in
portal vein& collaterals (gastroesophageal colat) controlling
variceal bleeding.
• Terlipressin is given as a 2 g bolus dose every 4 hours
during the first 2 d. The dose is halved after bleeding is
controlled and can be maintained for up to 5 d.

42. 
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ANTIBIOTICS
• Patients with cirrhosis, reduced immunity
• gut bacteria translocation during aute
episode of bleed.
• Prophylactic antibiotics (e.g., ciprofloxacin 400
milligrams IV or ceftriaxone 1 gram IV) reduce
infectious complications.

43. PROMOTILITY AGENT
• Erythromycin and metoclopramide are
examples of promotility agents used to
enhance endoscopic visualization

45. BALLOON TAMPONADE
• effective short-term solution for life-
threatening variceal bleeding.
• temporary stabilization of patients for transfer
to an appropriate institution or until
endoscopy can be done.
• The Sengstaken-Blakemore tube (which has a
250-mL gastric balloon, an esophageal
balloon, and a single gastric suction port) and
the Minnesota tube (with an added
esophageal suction port above the
esophageal balloon)

46. BLEEDING
1. Oesophageal varices:
Band ligation
Stent insertion is effective for selected
patients
 Transjugular intrahepatic portosystemic shunts (TIPS)
should be considered if bleeding from oesophageal
varices is not controlled by band ligation.
2. Gastric varices:
 Endoscopic injection of N-butyl-2-cyanoacrylate
should be used.
 TIPS should be offered if bleeding from gastric varices is
not controlled by endoscopic injection of N-butyl-2-
cyanoacrylate

47. (Stent)
Porta Vein
Hepati
c
Vein
Shunt
l

50. TREATMENT OF NON-VARICEAL
BLEEDING
For the endoscopic treatment of non-variceal UGIB, one
the following should be used:
of

A mechanical method (clips) with or without adrenaline
(epinephrine)
1.
Thermal coagulation with adrenaline (epinephrine)
2.
Fibrin or thrombin with adrenaline (epinephrine)
3.
Interventional radiology should be offered to unstable
patients who re-bleed after endoscopic treatment. Refer
urgently for surgery if interventional radiology is not
immediately available.


52. SURGERY
1. Persistent hypotension
2. Failure of medical treatment or endoscopic
homeostasis
3. Coexisting condition ( perforation, obstruction,
malignancy)
4. Transfusion requirement (4 units in 24 hr)
5. Recurrent hospitalizations

53. COMPLICAT
IONS
Can arise from
example:
treatments administered for
Endoscopy:
1. Aspiration pneumonia
2. Perforation

3. Complications
treatments
from coagulation, laser
Surgery:
1. Ileus
2. Sepsis
3. Wound problems
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54. PREVENTION
The most important factor to consider is
treatment for H. pylori infection.

1st line therapy PPT

( omeprazole, lansoprazole, pantoprazole)
two of these three AB
+
( clarithromycin, amoxicillin, metronidazole)
2n
d
line therapy - PPT

-
-
-
bismuth
metronidazole
tetracycline
For 7 days

55. :RESOURCES
MacLeod's clinical examination 12th edition
1.
Davidson’s principle and practice of
medicine th21 edition
2.
Oxford handbook of emergency medicine
Upper GIT bleeding
http://www.patient.co.uk/doctor
3.
4.
5. www.medscape.com
6.
MacLeod's clinical examination
Tintinalli’s emergency medicine 19th edition