1. UPPER GI BLEED

2. DEMARCATION OF UPPER AND
LOWER GUT
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The World Organization of Gastroenerologists defines
acute upper GI bleeding as:
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The anatomic cut-off for upper GI bleeding is
the ligament of Treitz, which connects the
fourth portion of the duodenum to the splenic
flexure of the colon.

3. ETIOLOGY
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Epidemiology
Accounts for 350,000 hospitalizations in U.S.
yearly
Risk factors
Aspirin or NSAID use (most common cause)
Helicobacter Pylori infection
Elderly (especially over age 70 years)

4. Adults with acute massive GI Bleeding
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Duodenal Ulcer (30-37%)
Gastric Ulcer (19-24%)
Esophageal Varices (6-10%)
Gastritis or Duodenitis (5-10%)
Esophagitis or esophageal ulcer (5-10%)
Mallory-Weiss tear (3-7%)
Gastrointestinal malignancy (1-4%)

5. 
Dieulafoy's Lesion (1%)
Artery at gastric fundus may bleed heavily
 Difficult to identify on endoscopy
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Gastric antral vascular ectasia (0.5 to 2%)
Longitudinal erythematous stripes on gastric mucosa
 Known as Watermelon stomach
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Arteriovenous malformation
Angiodysplasia of stomach or duodenum,

6. Adults with chronic intermittent
GI Bleeding
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Gastritis (18 to 35%)
Esophagitis (18 to 35%)
Gastric Ulcer (18 to 21%)
Duodenal Ulcer (3 to 15%)
Angiodysplasia (5 to 23%)
Gastric Cancer

7. Adults - most commonly missed upper
GI sources
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Large Hiatal Hernia Erosions
Arteriovenous malformation
Peptic Ulcer Disease

9. POSTERIOPR WALL DUODENAL
ULCER

10. GASTRIC ULCER IN ANTRUM

11. VARICEAL BLEED

12. HISTORY
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Has the patient been vomiting or retching before
the episode of haematemesis? -> Mallory-Weiss
tear
Enquire about the colour of the vomitus
Was there a previous incident of peptic ulcer or
haematemesis/melaena?
Heartburn -> Reflux oesophagitis
Drug history (including aspirin and over the
counter medicines -> peptic ulcer)
Alcohol -> Liver failure -> oesophageal varices ->
upper GI bleed

13. ASSESSMENT
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One should first determine the amount of blood
loss, and the site of bleeding.
The measurement of vital signs provides the only
accurate assessment of blood loss (orthostatics, heart
rate, complaints of weakness or dizziness, syncope).
An NG tube should be placed as part of the
assessment. The gastric lavage may aid the endscopist
to obtain a clear view of the bleeding site.

14. PHYSICAL EXAMINATION
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Vital signs, in order to determine the severity of
bleeding and the timing of intervention
Abdominal and rectal examination, in order to
determine possible causes of hemorrhage
Assessment for portal hypertension and stigmata
of chronic liver disease in order to determine if
the bleeding is from a variceal source.

15. DIAGNOSIS
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Sometimes, the source can be naso-or
oropharyngeal. A careful exam of the nares
and oral pharynx should be done.
The presence of "coffee ground emesis
represents blood altered by gastric contents
and usually means that there has been slow
bleeding from the region between the
esophagus and the duodenum.

16. 
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A positive NG tube aspirate for blood usually
signifies that the site of bleeding is proximal to
the ligament of Treitz.
Other characteristics of upper GI bleeding are
elevated BUN and hyperactive bowel
sounds.
The source of bleeding can be identified in 90%
of cases if endoscopy is done within the first 24
hours.

17. Upper GI Bleeding Score
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Criteria
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Blood Urea Nitrogen (BUN)
BUN 18.2 to 22.4 mg/dl: Score 2
 BUN 22.4 to 28 mg/dl: Score 3
 BUN 28 to 70 mg/dl: Score 4
 BUN >70 mg/dl: Score 6
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18. 
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Hemoglobin
Men
Hemoglobin 12 to 13 g/dl: Score 1
 Hemoglobin 10 to 12 g/dl: Score 3
 Hemoglobin <10 g/dl: Score 6
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Women
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Hemoglobin 10 to 12 g/dl: Score 1
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Hemoglobin <10 g/dl: Score 6

19. 
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Systolic Blood Pressure (SBP)
SBP 100 to 109 mmHg: Score 1
SBP 90 to 99 mmHg: Score 2
SBP <90 mmHg: Score 3

20. 
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Miscellaneous Markers
Pulse >100 per minute: 1
Presentation with Melena: 1
Presentation with Syncope: 2
Hepatic disease: 2
Cardiac function: 2

21. Interpretation
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Assesses probability for intervention
Endoscopy
 Surgery
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Score predicting resolution without intervention:
<4
Score predicting intervention: >5

22. MANAGEMENT
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INITIAL:
Nasogastric Tube with aspirate
Fresh blood suggests persistant bleeding
Avoid lavage due to aspiration risk
If severe bleeding and suspected variceal source
See Esophageal Varices
Octreotide 50 ug bolus, then 50 ug/hour

23. Management: General Measures
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Helicobacter Pylori management
Empiric acid reduction (Proton Pump Inhibitor)
Not proven in-vivo to aid clotting
No proven benefit in mortality and other
outcomes
Does not lower overall Incidence of re-bleeding
Omeprazole may heal ulcer if near-achlorhydria

24. Management: Low risk patients
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Indications
Hemodynamically stable within 1 hour of
Resuscitation
Minimal Blood Products required (2 PRBC or
less)
No evidence of active bleeding
Nasogastric Tube aspirate without blood
No active comorbid medical conditions

25. 
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Protocol
Consider for rapid protocol
Immediate
Upper Endoscopy Evaluation of GI Bleeding
 Discharge to home if low-risk endoscopy results
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Admit if rapid protocol not available
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Follow moderate risk patient protocol below
General measures as above

26. Management: High risk patients
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Indications
Active ongoing bleeding
Hypotension persists despite Resuscitation
Severe active comorbid condition exascerbation
Liver disease exascerbation
Endotracheal Intubation for airway protection

27. 
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Protocol
General measures as above
Admit to intensive care unit for first 24 hours
Observe in hospital for 48 to 72 hours or more
Urgent upper endoscopy when stabilized
See
Upper Endoscopy Evaluation of GI Bleeding
Consider arteriography if source not evident

29. Outcomes
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Overall Mortality: 2-15% (often related to
comorbidity)
Bleeding stops and does not recur: 70% (<2%
Mortality)
Bleeding after initially stopped: 25% (10%
Mortality)
Continued active bleed: 5% (30% Mortality)

30. Predictors
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Bleeding characteristic predictors of poor
outcome
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Emesis or nasogastric aspirate contains red blood
Low initial Hematocrit
Coagulopathy (low platelets or high INR)

31. 
Comorbid condition predictors of poor outcome
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Active Coronary Artery Disease
Congestive Heart Failure
Active lung disease
Renal Failure
Sepsis
Metastatic cancer
Advanced liver disease
Advanced age

32. Thanks