2. Upper GI Bleeding
Overview
⢠Definitions
⢠Initial Patient Assessment
â ABC & Resuscitation
⢠Differential Diagnosis
⢠Identify the Source & Stop the Bleeding
â History & Physical
â Endoscopy & Potential Complications
â Other diagnostics tests
⢠Role of Surgery
⢠Prevention
3. Upper GI Bleeding
Definitions
⢠Upper GI Bleeding = proximal to ligament of
Treitz
⢠Hematemesis = vomiting blood
â This is diagnostic of upper GI bleeding
⢠Melena = passage of tarry or maroon stool
â Can be upper or lower (more commonly upper)
⢠Hematochezia = Bright red blood per rectum
â Usually characteristic of colonic hemorrhage
4. Upper GI Bleeding
Initial Patient Assessment
⢠Get to patientâs bedside, assess ABC
⢠Can the patient protect his airway?
â Does he need to be intubated?
⢠Is the patient hemodynamically unstable?
â Is he in hemorrhagic shock?
⢠2 large bore IV, Bolus 2L fluids, Type &
Cross blood, send CBC & Coags
⢠Place patient on O2 & continuous monitor
⢠Place an NGT and lavage with NS
â To confirm if the bleeding source is upper GI
5. Upper GI Bleeding
Differential Diagnosis
⢠Peptic Ulcer Disease (PUD) >50% cases
⢠Gastritis / Duodenitis (15-30%)
â Subset due to NSAID use
⢠Varices from portal hypertension (10-20%)
⢠Mallory-Weiss tears at GE junction (5%)
⢠Esophagitis (3-5%)
⢠Malignancy (3%)
⢠Nasopharyngeal bleed â swallowed blood
⢠Other- Aortoenteric fistula, angiodysplasia,
Crohnâs disease, hemophilia,
6. Upper GI Bleeding
History & Physical
⢠History of prior ulcers, NSAID use, stress
⢠History of Helicobacter pylori & treatment
⢠Alcohol abuse
â Retching -> Mallory Weiss tear
â Alcoholic cirrhosis -> portal hypertension and
varices
⢠On Physical Exam, assess hydration
⢠Look for stigmata of cirrhosis & portal HTN
7. Upper GI Bleeding
Management â Acute UGI Bleed
⢠Once again, make sure pt is resuscitated
⢠If anemic and symptomatic, give blood
⢠Place NGT/lavage (helps for endoscopy)
⢠Perform Upper endoscopy (EGD)
â For ulcers: if visible clot, visible vessel, or active
bleeding, should cauterize/coagulate and inject
sclerosing agent
â For acute variceal bleeding: sclerotherapy +
somatostatin or endoscopic band ligation. If
fail/rebleed: surgical shunt. Balloon tamponade is an
emergency temporizing measure
⢠Start proton pump inhibitor (PPI) infusion
8. Upper GI Bleeding
Potential Complications
⢠Perforation of esophagus
⢠Aspiration
⢠Desaturation or respiratory distress
⢠Adverse reaction to conscious sedation
⢠ârisk of complications with:
â Inadequate resuscitation or hypotension
â Comorbidities
⢠Consider elective intubation prior to EGD if
active bleeding, altered respiratory or
mental status
9. Upper GI Bleeding
Other Diagnostic Tests
⢠If bleeding is unresolved with endoscopy
or endoscopy is contraindicated
⢠1. Angiography (Diagnostic & Therapeutic)
â Intra-arterial vasopressin
â Embolization
⢠2. Tagged red blood cell (TRBC) scan
â Only diagnostic & usually for occult bleeding
â More sensitive than angiography
â Can detect bleeding rate of 0.1-0.5 mL/min
10. Upper GI Bleeding
Role of Surgery
⢠If medical and endoscopic therapy fail
⢠In the event that bleeding source is
unidentified -> exploratory laparotomy
⢠Recurrent bleeding peptic ulcers
â Anti-ulcer surgery (i.e. vagotomy/antrectomy,
or vagotomy/pyloroplasty, or selective vagot)
11. Upper GI Bleeding
Prevention
⢠After the acute situation is resolved,
educate patient on preventive measures
⢠Top 2 reasons for ulcers: Hpylori & NSAID
⢠1. Testing for H.pylori (i.e. antral biopsy
during endoscopy)
⢠2. Treat H.pylori (amoxicill, clarithromycin
x1wk plus PPI x4wk)
⢠3. Reduce intake of NSAID
12. Upper GI Bleeding
Take Home Points
⢠Always, always perform ABCâs first &
resuscitate with two #16ga IVâs & isotonic
crystalloids (blood if pt doesnât respond)
⢠NGT/lavage to confirm active bleeding
⢠Focused H&P looking for common
causes: ulcers, varices, â-itisâ, Mallory-
Weiss, AVM
⢠Endoscopy is 1st
line for acute UGIB
â Donât forget to start intravenous PPI infusion
⢠Endoscopy has associated complications
⢠Angio or surgery if still bleeding