Management of Upper

Gastrointestinal Bleeding
By: Natnael Habtamu

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Introduction
• Although 80% of UGIB resolves spontaneously without treatment,
20% will recur.

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Principles of management

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Approach to Management
• Pre-Endoscopic
• Endoscopic
• Post-Endoscopic

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Pre-endoscopic management
• Assessment and resuscitation
• Assessment for instability
• Air way compromise from hematemesis
• Hypoxia
• Hypotension
• Reduced level of consciousness
• Other causes: Decompensated Liver Disease

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Pre-endoscopic management
• Assessment and resuscitation
• Resuscitation
• Ensure a safe airway,
• Secure IV for fluid resuscitation (at least two 16–18G intravenous cannulae),
• Alternatives if its fails?
• Standard blood tests including clotting and a crossmatch
• Blood gas sampling  rapid haemoglobin estimate and indicate acid-base disturbances
(hyperlactataemia)

• For Hypotension, Poor tissue perfusion & Hgb <7:

• If Blood Available  Transfuse 2-4 pints whole blood or blood products until
hemodynamically stable & HCT>25%, CVP>6-12cm
• If Blood Unavailable  Infuse Synthetic colloid or crystalloid 1-2 liters with
pressure bag & proceed with volume replacement until blood arrives

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Pre-endoscopic management
• Assessment and resuscitation
• Resuscitation
• Avoid overtransfusion in patients with suspected variceal bleeding!
• Worsening of the bleeding.
• Transfusing patients with suspected variceal bleeding to a hemoglobin >10 g/dL (100 g/L)
should be avoided.
• Goal of transfusion: Maintaining Hbg
• > 7 for most patients
• > 9 if at increased risk of suffering adverse events in the setting of significant anemia, (e.g
Active bleeding)

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 Check Airway not protected
Acute UGIB Airway and or SPO2<90% after RSI
Spo2 max FiO2 by mask

• 2 large bore IV access HB%, PLT,PT,LFT,RFT,

Arrange
• NG tube Cross matching
blood as
• Urinary catheter (repeat Hb again after 72
needed
• CVPline (if highrisk) hrs)

Blood
unavailable • Infuse Synthetic colloid or
Hypotension & poor crystalloid 1-2 lts with pressure Haemodynamically
tissue perfusion bag & proceed with volume Stable
replacement until blood arrives
• Tranexamic acid 1g IV over I hour
Transfuse 2-4 pints whole then 500mg TID (if required)
blood or blood products until • PPI – Pantoprazole 80mg IV stat
haemodynamically stable & & continue Infusion
HCT> 25%, CVP>6-12cm
Emergency OGD
Persistant Hypotension Inotrope support (preferably within 4-24 hrs)
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Pre-endoscopic management
• Assessment and resuscitation
• Focused history and examination
• May determine an aetiology and/or complications related to AUGIB.
• Features of peritonitis and bowel obstruction  peptic ulcer perforation, c/I to endoscopy
• Investigations
• CBC, Hemoglobin, Serum Chemistries, Liver test, Coagulation studies
• Hgb  The initial hemoglobin level in patients with acute upper GI bleeding will often be at
the patient's baseline because the patient is losing whole blood
• BUN to Creatinine or Urea to Creatinine Ratio values >36:1 or >100:1 respectively, suggest
upper GI bleeding as the cause
• The higher the ratio, the more likely the bleeding is from an upper GI source.
• If at risk of myocardial infarction (e.g. pts with chest pain)  ECG, Cardiac Enzymes

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Pre-endoscopic management
• Risk Assessment
• To identify patients UGI bleeding at greatest risk for mortality and rebleeding.
• Commonly used modes of assessment:

Pre-endoscopy scoring systems Postendoscopy scoring system

Blatchford Score: Complete Rockall Score:
BP,BUN level, Hb, Heart rate , syncope, Clinical Rockall score +
Melena ,liver disease , Heart failure endoscopic findings.

Clinical Rockall Score: Patient’s age , * Correlates well with mortality

shock & coexisting illnesses & risk of rebleeding.

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 Blood Urea Nitrogen(mmol/L) •Other markers
6.5 – 7.9 2 Pulse ≥ 1 0 0 (per m in) 1
8 – 9.9 3 Presentation with melena 1
10 – 24.9 4 Presentation with syncope 2
Hepatic disease 2
≥25 6
Cardiac failure 2
Haemoglobin (g/dL) for men
12-12.9 1 •Score from 0 to 23
10-11.9 3 •Scores ≥
<10 6 •1 – H i g h r i s k
Haemoglobin (g/dL) for •6 – 50% risk of needing an
women intervention.
10-11.9 1
Score is"0" if :
<10 6 •Hemoglobin level
> 1 2 . 9 g/dl(men) or
Systolic BP(mm Hg)
> 11 . 9 g/dl(women)
◦ 100–109 1 •Systolic blood pressure > 1 0 9 m m Hg
◦ 90–99 2 •Pulse < 1 0 0 / m i n u t e
•BUN level < 6 . 5 m m o l / L
◦ <90 3 •No melena or syncope
•No liver disease or heart failure
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Blatchford O, Murray WR, Blatchford M: Lancet 2000; 356:1318-21.
Rockall Score

Score:
• >5 – High risk of mortality &
rebleeding
• 3-5 – Intermediate risk
• <3 – Low risk of Hemorrhage of
mortality & rebleeding

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 Pre-endoscopic management:
Other assessment
AIMS65 score
• Composed of
• Albumin (< 3 g/L)
• INR > 1.5,
• Mental state alteration
• Systolic blood pressure < 90,
• Age > 65.
• Compared to pre-endoscopic
Rockall and Blatchford scores
• It is superior in predicting inpatient
mortality, length of stay, and need for
intensive care admission
Modified Glasgow Blatchford score
• Calculated using only
• blood urea nitrogen,
• hemoglobin,
• systolic blood pressure,
• Pulse
• Better predictive score than Rockall
score interms of clinical intervention,
rebleeding and mortality
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Pre-endoscopic management
• Pre-endoscopic medical management
• Following risk assessment, patients should be referred for endoscopy once
medically optimized.
• Pharmacologic management should be classified to
• Nonvariceal Bleeding specific
• Proton pump inhibitors (PPI)
• Variceal Bleeding specific
• Vasopressor  Terlipressin
• Antibiotics
• Both:
• Vasopressor  Octreotide/Somatostatin
• Prokinetics

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Pre-endoscopic management
• Pre-endoscopic medical management
• Proton pump inhibitors (PPI)
• PPIs are the only drugs that can maintain a gastric pH >6 and thus prevent
anticoagulating effects of gastric acid (i.e. platelet aggregation, impairing clot formation
& fibrinolysis of clot)
• H2 antagonist /Sucralfate has not been shown to be effective in UGIB
• In patients initially treated with a bolus infusion of omeprazole/ pantaprazole 80 mg
followed by a continuous infusion 8mg/hr,and the need for endoscopic therapy has
reduced.

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Pre-endoscopic management
• Pre-endoscopic medical management
• Proton pump inhibitors (PPI)
• It’s generally mandatory post-endoscopic in all UGIB
• The guidance on whether to administer PPI therapy prior to endoscopy is conflicting.
• Supporting thoughts: PPIs before endoscopy significantly reduced stigmata of recent
hemorrhage at index endoscopy and the need for endotherapy without affecting rates of
rebleeding, surgery, or mortality.
• Conflicting thoughts:
• It doesn’t improve clinical outcomes such as further bleeding, surgery or death.
• This approach may mask targets for therapy;
• Thus, NICE and BSG do not recommend routine PPI administration
• Conclusion:
• However, following cost-effectiveness analyses, ESGE recommends pre-endoscopic PPI
infusion. (Since it’s most cost-effective strategy to employ it in patients with nonvariceal
bleeding from a suspected high-risk lesion)

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Pre-endoscopic management
• Pre-endoscopic medical management
• Octreotide/Somatostatin
• It inhibits both acid and pepsin secretion while reducing gastroduodenal mucosal blood
flow.
• It’s not routinely recommended as a sole or adjunctive agent to endoscopy in patients with
nonvariceal.
• A meta-analysis has suggested that intravenous administration of somatostatin or its
long-acting form octreotide decreases the risk of rebleeding from peptic ulcers when
compared with placebo or an H2 receptor blocker. (A meta-analysis. Ann Intern Med
2010; 127:1062-71)

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Pre-endoscopic management
• Pre-endoscopic medical management
• Terlipressin
• A vasopressin analog thus produces vasoconstriction which increases systemic vascular
resistance, reduces cardiac output, and reduces portal pressures
• Compared with
• Somatostatin, Octreotide, or endoscopic interventions, terlipressin showed similar efficacy for
the control of acute variceal hemorrhage
• Octreotide in patients with bleeding varices, terlipressin had more sustained hemodynamic
effects
• Physicians should be aware of contraindications to terlipressin which include arterial
disease, hyponatremia, myocardial ischemia, severe cardiac failure and prolonged QTc
interval.
• Somatostatin or octreotide may be considered for patients with contraindications

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Pre-endoscopic management
• Pre-endoscopic medical management
• Antibiotics
• Why?
• Bacterial infections are common in cirrhotic patients with acute upper GI bleeding
• Infection is associated with significantly increased rebleeding risk and mortality
• American Association for the Study of Liver Diseases (AASLD) guidelines recommend a
short-term course (maximum of 7 days) of prophylaxis with oral norfloxacin or
intravenous ciprofloxacin for all patients with cirrhosis who are hospitalized for variceal
hemorrhage. (In areas of quinolone resistance, initiate Ceftriaxone instead)
• It should be initiated preferably before endoscopy

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Pre-endoscopic management
• Pre-endoscopic medical management
• Prokinetics
• Help to clear the stomach of blood.
• Importance: For adequate mucosal visualization and reductions in the need for second-
look endoscopy (and related length of stay).
• ESGE recommends a 250 mg erythromycin infusion 30–120 min pre-endoscopy in
patients with clinically severe/ongoing AUGIB

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Endoscopic management
• Endoscopy at an early stage enables the determination of the cause
of bleeding, prognosis and therapeutic interventions to stop bleeding.
• Thus is Diagnostic, Prognostic & Therapeutic.
• It is worth emphasizing that endoscopy is routinely performed with
oxygen delivered via nasal cannulae.
• Patients who remain hypoxic despite this may benefit from anesthetic
input for airway intubation if endoscopy is urgently indicated.

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Endoscopic management
• Timing of endoscopy:
• Urgent Endoscopy: <12 hours of bleeding.
• Indication:
• Persistent active bleeding (e.g. Hematemesis on presentation)
• History of malignancy or cirrhosis
• Hemodynamic instability (Hypotension, Tachycardia…)
• Hemoglobin < 8
• Elective Endoscopy: <24 – 48 hours of bleeding.
• Indication: No indications for urgent endoscopy, if rebleeding (not always).

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Endoscopic management
• Pre-requisites for endoscopy
• Bloody Endoscopy field
• Step 1: Nasogastric tube (Esp. Wide bore) aspiration
• Aspirate may categorize these pts – Low/Intermediate/High (E.g. is there clot?, crude estimation of rapidity of
bleeding)
• A negative aspirate (16%) doesn’t exclude upper GI bleeding (For Example in case of duodenal ulcer due to
absence of duodenogastric reflux aspirate is clear)
• Step 2: Gastric Lavage  Requires alert cooperative patient or secured airway with ET tube to avoid
broncho-pulmonary aspiration.
• Saline with or without water
• Step 3: Prokinetic agents
• Gastric Lavage is also therapeutic
• Increases PH of stomach and hence decreases clot desolution due gastic acid dilution.
• Another factor that can help in visualization of blood in GI tract is to use double
channel or large channel endoscopes, which allow for vigorous aspiration.

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Endoscopic management
• Stigmatas on Endoscopy  Prognostic
indicators
• Described using the Forrest and Finlayson’s
Classification
• Class I – Spurting hemorrhage and oozing
hemorrhage
• Indicate an acute hemorrhage.
• Class II – Non bleeding visible vessel, an
Adherent clot, and a Flat pigmented spot
are
• Signs of a recent hemorrhage.
• Class III – Clean ulcer base
• indicate lesions without active bleeding

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Endoscopic management
• Stigmatas on Endoscopy
• Active bleeding, Non Bleeding visible vessel & Adherent Clot are high risk
stigmatas

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Endoscopic Management
• Do we use endoscopic therapy on all patients?
• Do we admit all patients? If so, is it to the wards or ICU? Or We just
making a big deal out it?

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Endoscopic Management
• Suggested Algorithm for patients with AUGIB

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Endoscopic Management
• Suggested Algorithm for patients with AUGIB
• Risk assessment scores are good ways to approach
as well. For instance Based on Rockall score:
• Low risk:
• 80% recover spontaneously with Medical Treatment +
Hospitalization for 24 hours and may be discharge if
uneventiful
• Intermediate risk:
• Medical Treatment + Hospitalization for atleast 72 hours
• High risk:
• Medical Treatment + Hospitalization in ICU.

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Endoscopic management
• The treatment of bleeding lesions varies according to whether it’s
from a Variceal or Non variceal source

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Endoscopic management
• Non-Variceal Upper GI bleeding
• Comprises of
• Injection Therapy
• Thermal Treatment  Preferred mode for small vessels < 2mm
• Mechanical Treatment  Preferred mode for larger vessels
• Spray Therapy

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Endoscopic management
• Non-Variceal Upper GI bleeding
• Comprises of
• Injection Therapy
• Injection of Adrenaline into and around the point of bleeding will reduce the rate of
rebleeding
• It’s recommended to use adrenaline with an additional hemostatic technique.
• Thermal Treatment
• Mechanical Treatment
• Spray Therapy

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Endoscopic management
• Non-Variceal Upper GI bleeding
• Comprises of
• Injection Therapy
• Thermal Treatment
• Contact: applying pressure and heat via a heater probe using monopolar diathermy
• Aim is to compress and seal a bleeding lesion
• Non-contact: includes argon plasma coagulation, which is sufficient for the treatment for
superficial angiodysplastic lesions
• Mechanical Treatment
• Spray Therapy

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Endoscopic management
• Non-Variceal Upper GI bleeding
• Comprises of
• Injection Therapy
• Thermal Treatment
• Mechanical Treatment
• It’s by using Endoclip or Haemoclip to provide mechanical compression to the bleeding
• It’s superior to injection therapy but comparable to thermal treatment.
• Spray Therapy

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Endoscopic management
• Non-Variceal Upper GI bleeding
• Comprises of
• Injection Therapy
• Thermal Treatment
• Mechanical Treatment
• Spray Therapy
• Hemospray are agents that achieve hemostasis by mechanically adhering to a bleeding site
resulting in mechanical tamponade & by activating coagulation factors to promote thrombus
formation.
• Advantage: Ability to cover large areas with multiple bleeding points without need for precise
lesion targeting.
• Thus it’s a promising alternative treatment for difficult to access bleeding lesion (or
atleast an adjunct)

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Endoscopic management
• Variceal Upper GI bleeding
• Comprises of
• Sclerotherapy
• Mechanical Treatment  Variceal Band Ligation (VBL)
• Cyanoacrylate (‘Glue’) & Thrombin
• Balloon Tamponade
• Oesophageal Stenting

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Endoscopic management
• Variceal Upper GI bleeding
• Comprises of
• Sclerotherapy
• Used to be the mainstay of therapy for Esophageal Varices but now it’s replaced by the
superior VBL
• Mechanical Treatment  Variceal Band Ligation (VBL)
• Cyanoacrylate (‘Glue’) & Thrombin
• Balloon Tamponade
• Oesophageal Stenting

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Endoscopic management
• Variceal Upper GI bleeding
• Comprises of
• Sclerotherapy
• Mechanical Treatment  Variceal Band Ligation (VBL)
• Currently the mainstay.
• involves attaching a small plastic tube to the end of the endoscope, around which small
rubber bands are placed and the rubber band is deployed to induce strangulation &
thrombosis of the varix.
• #1 complication of VBL is Post-band Ulceration.
• Cyanoacrylate (‘Glue’) & Thrombin
• Balloon Tamponade
• Oesophageal Stenting

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Endoscopic management
• Variceal Upper GI bleeding
• Comprises of
• Sclerotherapy
• Mechanical Treatment  Variceal Band Ligation (VBL)
• Cyanoacrylate (‘Glue’) & Thrombin
• Superior to VBL in achieving Hemostasis and reducing rebleeding.
• Balloon Tamponade
• Oesophageal Stenting

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Endoscopic management
• Variceal Upper GI bleeding
• Comprises of
• Sclerotherapy
• Mechanical Treatment  Variceal Band Ligation (VBL)
• Cyanoacrylate (‘Glue’) & Thrombin
• Balloon Tamponade
• It is indicated in failure of hemostasis with bleeding esophageal varices.
• Because it’s poorly tolerable & risk of aspiration, patients often require heavy sedation and
intubation prior to usage
• Oesophageal Stenting

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Endoscopic management
• Variceal Upper GI bleeding
• Comprises of
• Sclerotherapy
• Mechanical Treatment  Variceal Band Ligation (VBL)
• Cyanoacrylate (‘Glue’) & Thrombin
• Balloon Tamponade
• Oesophageal Stenting
• Indicated when refractory bleeding oesophageal varice occurs.

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Post-Endoscopic Management
• Aim:
• To monitor and manage rebleeding and medical comorbidity
• Non-Variceal Upper GI bleeding
• PPI Therapy
• Detection and Eradication of H.pylori
• Consider Iron Replacement prior to discharge
• Don’t resume Antithrombotic drugs and Anticoagulants after AUGIB
• Rebleeding
• Follow – up

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Post-Endoscopic Management
• Aim:
• To monitor and manage rebleeding and medical comorbidity
• Non-Variceal Upper GI bleeding
• PPI Therapy
• Patients with peptic ulcers with flat pigmented spot (Forrest IIc) or clean base (Forrest III)
to be discharged with once daily oral PPI.
• Detection and Eradication of H.pylori
• Consider Iron Replacement prior to discharge
• Don’t resume Antithrombotic drugs and Anticoagulants after AUGIB
• Rebleeding
• Follow – up
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Post-Endoscopic Management
• Aim:
• To monitor and manage rebleeding and medical comorbidity
• Non-Variceal Upper GI bleeding
• PPI Therapy
• Detection and Eradication of H.pylori
• Consider Iron Replacement prior to discharge
• It’s not necessary but still there are studies indicating patients often discharged from
hospital with anemia after AUGIB
• Don’t resume Antithrombotic drugs and Anticoagulants after AUGIB
• Rebleeding
• Follow – up
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Post-Endoscopic Management
• Aim:
• To monitor and manage rebleeding and medical comorbidity
• Non-Variceal Upper GI bleeding
• PPI Therapy
• Detection and Eradication of H.pylori
• Consider Iron Replacement prior to discharge
• Don’t resume Antithrombotic drugs and Anticoagulants after AUGIB
• Exception: - Prophylaxis of Cardiovascular and thrombotic events with low dose aspirin.
• Rebleeding
• Follow – up

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Post-Endoscopic Management
• Aim:
• To monitor and manage rebleeding and medical comorbidity
• Non-Variceal Upper GI bleeding
• PPI Therapy
• Detection and Eradication of H.pylori
• Consider Iron Replacement prior to discharge
• Don’t resume Antithrombotic drugs and Anticoagulants after AUGIB
• Rebleeding
• Occurs in 13 – 23% of cases
• Repeat endoscopy to patients who rebleed or if there is doubt regarding adequate
hemostasis at index endoscopy.
• If it fails again, consider interventional radiology or surgery
• Follow – up

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Post-Endoscopic Management
• Aim:
• To monitor and manage rebleeding and medical comorbidity
• Non-Variceal Upper GI bleeding
• PPI Therapy
• Detection and Eradication of H.pylori
• Consider Iron Replacement prior to discharge
• Don’t resume Antithrombotic drugs and Anticoagulants after AUGIB
• Rebleeding
• Follow – up
• Most patients don’t receive outpatient follow-up after NVUGIB but follow up for gastic
ulcers after 6 – 8 weeks is recommended (A gastric ulcer may harbor malignant change)

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Post-Endoscopic Management
• Aim:
• To monitor and manage rebleeding and medical comorbidity
• Variceal Upper GI bleeding
• Secondary Prophylaxis & Follow up
• Terlipressin
• Non – selective beta blockers (propranolol, carvedilol)
• Variceal Band Ligation (VBL)
• Rebleeding

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Post-Endoscopic Management
• Aim:
• To monitor and manage rebleeding and medical comorbidity
• Variceal Upper GI bleeding
• Terlipressin
• Some recommend to continue it for 5 days post endoscopy or until certainty of hemostasis
• Non – selective beta blockers (propranolol, carvedilol)
• Variceal Band Ligation (VBL)
• Rebleeding

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Post-Endoscopic Management
• Aim:
• To monitor and manage rebleeding and medical comorbidity
• Variceal Upper GI bleeding
• Terlipressin
• Non – selective beta blockers (propranolol, carvedilol)
• The main stay of pharmacologic secondary prophylaxis as an option, instead of VBL
• They reduce portal pressure through splanchnic vasoconstriction and reduced cardiac
output.
• Duration
• Variceal Band Ligation (VBL)
• Rebleeding

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Post-Endoscopic Management
• Aim:
• To monitor and manage rebleeding and medical comorbidity
• Variceal Upper GI bleeding
• Terlipressin
• Non – selective beta blockers (propranolol, carvedilol)
• Variceal Band Ligation (VBL)
• The main stay of non-pharmacologic secondary prophylaxis
• Patients should be scheduled for elective repeat endoscopy 2–4 weeks after variceal
haemorrhage until eradication of varices
• After successful eradication of varices, patients should be booked for endoscopy at 3
months, then 6-monthly thereafter.
• Rebleeding

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Post-Endoscopic Management
• Aim:
• To monitor and manage rebleeding and medical comorbidity
• Variceal Upper GI bleeding
• Terlipressin
• Non – selective beta blockers (propranolol, carvedilol)
• Variceal Band Ligation (VBL)
• Rebleeding
• Patients who rebleed should be considered for repeat endoscopy & VBL
• If rebleeding is difficult to control, Self Expanding Metal Stent can be attempted until TIPSS or
Surgical shunt surgery is performed.
• TIPSS (Trasnjugular intrahepatic portosystemic shunt)  Rapidly reduces portal pressure by
creating a portosystemic shunt across the liver parenchyma.
• Despite its superiority to VBL, it has increased rate of post-procedural encephalopathy.

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Key Points!!!
• Factors associated with rebleeding in general:
• Hemodynamic instability (systolic blood pressure less than 100 mmHg, heart rate
greater than 100 beats per minute)
• Hemoglobin less than 10 g/L
• Active bleeding at the time of endoscopy
• Large ulcer size (greater than 1 to 3 cm in various studies)
• Specific to PUD
• Ulcer location (posterior duodenal bulb or high lesser gastric curvature)
• Indications for surgery
• Hemodynamic instability despite vigorous resuscitation( >6 units transfusion)
• Failure at endoscopy to arrest bleeding
• Recurrent hemorrhage after initial stabilization
• Continued slow bleeding with a transfusion requirement of >3 units/day
• Shock ass. with recurrent hemorrhage

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Prevention
• Primary Prophylaxis in Variceal hemorrhage
• Routine screening by endoscopy of all patients with cirrhosis and managing
those with increased risk for bleeding by
• Variceal Band Ligation or
• Non Selective Beta blockers.
• Primary Prophylaxis in Peptic Ulcer induced UGIB
• Healing of peptic ulcers
• H.pylori eradiation
• PPI
• Discontinuation of NSAIDs

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54
•What is done in this hospital?

•What medications & endoscopic

procedures do we have here?

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