Dr RAJESH SISODIYA

HISTORY
prior episodes of upper gastrointestinal bleeding
(ulcers or varices), liver disease, intestinal polyps or
cancer, and blood transfusions.
Alcohol abuse and illicit drug use should also be
investigated.
medication use including aspirin, nonsteroidal anti-
inflammatory drugs (NSAIDs), and anticoagulation
drugs (warfarin, heparin).
Clinical presentation
hematemesis,
hematochezia,
hypotension-related symptoms as dizziness, light-
headedness, weakness, pallor, palpitations,
tachycardia, orthostatic hypotension, shock, and
melena or with a positive screening fecal occult blood
test (FOBT) or
chronic iron-deficient anemia with no obvious source
of blood loss
Symptoms such as abdominal pain, nausea, vomiting,
early satiety, anorexia, and weight loss should be
sought.

GPE
signs of chronic liver disease, such as jaundice, caput
medusae, spider telangiectasia, and/or ascites.
digital rectal examination and an NG tube aspiration.
Video capsule endoscopy
a small capsule (11 mm with camera, lens, and
transmitter) is ingested orally
can diagnose a site of bleeding in over 50% of patients
be considered, especially in patients with obscure
bleeding in whom an exploratory operation is the next
step.
should not be used in patients with suspected
strictures or known extensive adhesions.
Radionucleotide scans
with either Technetium pertechnate-labeled
autologous red blood cells or Technetium sulfur
colloid can detect bleeding at a rate of 0.10.4 ml/min.
Angiography
Angiography can detect a bleeding rate of greater than
0.5 ml/min
show abnormal vessels or vascular blushes even in the
absence of active bleeding.
embolization with gelfoam, polyvinyl alcohol, or a
solid blocking material


Operative exploration/intraoperative
enteroscopy
EMERGENT MANAGEMENT
a large-bore intravenous (IV) catheter
Resuscitation
the hematocrit should be kept above 30%, while in
young, healthy patients, the target hematocrit should
be above 20%.
GASTRIC LAVAGE
ESOPHAGOGASTRODUODENOSCOPY
Red blood cell-tagged radionucleotide scan
Video capsule endoscopy
Peptic Ulcers
Endoscopy is the first line therapy
if the patient requires more than 46 units of blood
and the bleeding is not controlled endoscopically, the
patient should be managed operatively.
hemodynamically unstable and have ongoing
hemorrhage should also be treated operatively.
Other criteria for operative intervention include a
rebleeding ulcer that is not controlled by endoscopy
and medical therapy and possibly those patients with
giant ulcers and a visible vessel.
For duodenal ulcers, vessel ligation through a
longitudinal duodenotomy over the site of the ulcer is
performed.
high-dose, intravenous PPI therapy.
H. pylori, antibiotic eradication should be initiated
and later confirmed.
Variceal Bleeding
Endoscopic hemostasis with band-ligation, injection
sclerotherapy, or clip placement
Concomitant drug therapy with octreotide,
somatostatin, or glypressin
Sengstaken Blakemore tube
a transjugular intrahepatic portosystemic shunt (TIPS)
to decompress the portal system.
not candidates for liver transplantation and who are
stable should undergo a distal splenorenal shunt,
amesocaval graft, a porto-caval shunt, or a gastric
devascularization with esophageal transection
Hemorrhagic Gastritis
PPIs, H2 receptor blockers, antacids, and/or sucralfate.
If medical treatment fails, administration of
vasopressin via the left or right gastric arteries.
If severe bleeding persists, a total or sub-total
gastrectomy
Mallory-Weiss Tears
result from repeated vomiting
most patients, the bleeding stops without therapy.
If bleeding persists, endoscopic coagulation
high anterior gastrotomy
Dieulafoy lesions
intermittent, recurrent, acute upper GI bleeding.
abnormally large-caliber submucosal artery becomes
exposed at the surface of the mucosa and then
ruptures, usually in the stomach.
Diagnosis may be quite difficult as lesion is focal and
bleeds only intermittently.
endoscopic visualization or demonstration by
angiography.
banding, clipping, electrocautery, cyanoacrylate glue
injection, sclerosant injection, epinephrine injection,
heat probe, banding, and laser therapy.
Hemobilia
Loss of blood through biliary tree directly into the
duodenal lumen
secondary to operative trauma, prior percutaneous
biliary intubation.
Melena, jaundice and abdominal pain
angiography and treated by arterial embolization
Thanks