PRESENTER- PRASANNAKUMAR KAMBLE

MODARATOR- DR H M VIJAYKUMAR
 A common ,potentially DEADLY condition .

 Accounts for 170 cases/100000

 1-2% of all admissions

 Men > women .3:1

 Mortality 10%.
Sabiston
 Bleeding from a source proximal to the ligament of
Trietz .
 Upper: Lower GI bleeding = 5:1
 Incidence: 50-100 per 100,000 pts.
 100 per 100,000 hospital admission.
 30% pts are older than 65 years

 80% are self-limited.

 20% of pts who have recurrent bleeding

(within 48-72 hrs) have poor prognosis.

 1) Peptic ulcer disease - most common
cause
A) duodenal ulcers 29%
will rebleed in 10% of cases within
24-48h
B) gastric ulcers 16%
more likely to rebleed
C) stomal ulcers <5%
 2) Erosive gastritis, esophagitis, duodenitis
some causes are ETOH, ASA, NSAID’s
 3) PORTAL HYPERTENSION RELATED

◦ esophageal varices
◦ gastric varices
◦ portal hypertensive gastropathy
 4) Mallory-Weiss syndrome – longitudinal

mucosal tear in the cardioesophageal

region
caused by repeated retching
 WATER MELON STOMACH

 ESOPHAGITIS –INFECTION

 DIEULAFOY S LESION

 AORTODUODENAL FISTULA

 ANGIODYSPLASIAS

 CROHN S DISEASE

 HEMOBILIA

 HEMORRHAGE FROM PANCREATIC SOURCE.

 Get to patient’s bedside, assess ABC
 Can the patient protect his airway?
◦ Does he need to be intubated?
 Is the patient hemodynamically unstable?
◦ 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
◦ To confirm if the bleeding source is upper GI
look for need for blood transfusion
Estimated Fluid and Blood Losses in Shock

Class 1 Class 2 Class 3 Class 4

Blood Loss,
Up to 750 750-1500 1500-2000 >2000
mL

Blood Loss,%
Up to 15% 15-30% 30-40% >40%
blood volume

Pulse Rate,
<100 >100 >120 >140
bpm

Blood
Normal Normal Decreased Decreased
Pressure

Respiratory Normal or
Decreased Decreased Decreased
Rate Increased

Urine
Output, 14-20 20-30 30-40 >35
mL/h

CNS/Mental Slightly Mildly Anxious, Confused,

Status anxious anxious confused lethargic

Fluid
Crystalloid Crystalloid
Replacement, Crystalloid Crystalloid
and blood and blood
3-for-1 rule
 Criterion Score
 Age <60 years 0
60-79 yrs 1
>80 years 2
 Shock None 0
Pulse & sBP >100 1
sBP <100 2
 Co-morbidity None 0
Cardiac/any major 2
Renal/liver/malig. 3

 Total initial score (max = 7)

Initial risk score (pre-endoscopy)
Score Mortality
0 0.2%
1 2.4%
2 5.6%
3 11.0%
4 24.6%
5 39.6%
6 48.9%
7 50.0%

Rockall TA et al Gut 1996; 38: 316-21

 Signs of shock
Cold clammy extremities
Poor mentation
 Rectal examination
Occult blood
Gross blood
Bright red blood per rectum
Melena
Blood coating stools versus within stools
Bloody diarrhea
 CBC; BUN, Cr; LFT, PT, PTT in all cases
 Others as indicated:

◦ Type and crossmatch

◦ AST, ALT, GGTP, bilirubin
◦ Albumin, total protein
Packed cells are the preferred

Aim -restore blood volume and pressure and to

correct anaemia to maintain the oxygen
carrying capacity.

Fresh frozen plasma given prothrombin time is

at least 1.5 times higher than the control value.

Platelet transfusion platelet count is below

50 000/mm3.
 Age >60 yr
 Comorbid disease
 Renal failure
 Liver disease
 Respiratory insufficiency
 Cardiac disease
 Magnitude of the hemorrhage
 Systolic blood pressure <100 mm Hg on
presentation
 Transfusion requirement >4 units
 Persistent or recurrent hemorrhage
 Onset of hemorrhage during hospitalization
 Need for surgery
 History
 NG Tube
 EGD
 Colonoscopy
 Tagged RBC Scan
 Angiography
HISTORY
Probable Source of GI Bleeding Within the Gut

Probability Probability
Clinical
of Upper GI of Lower GI
Indicator
Source Source

Almost
Hematemesis Rare
certain

Melena Probable Possible

Hematochezia Possible Probable

Blood- Almost
Rare
streaked stool certain

Occult blood
Possible Possible
in stool
Effect of the Color of the Nasogastric Aspirate and of the Stool on
UGIB Mortality Rate

Nasogastric Stool Mortality

Aspirate Color Color Rate, %

Brown
Clear 6
or red

Brown
Coffee-ground 8.2
or black

Red 19.1

Red blood Black 12.3

Brown 19.4

Red 28.
 PHARMACOLOGICAL
 ENDOSCOPIC
 Topical treatment
 Injection treatment
 Mechanical treatment
 Thermal treatment
 ANGIOGRAPHIC
 SURGICAL
 Most common cause ~ 25 %
 Mortality rates slight declining !
 5 % initial manifestation.
 20 % at least once.
 Hemorrhage lethal ; 80 % deaths due to acute
episode..
 H.PYLORI INFECTION
 NSAID’S
 ANTICOAGULANTS
 CHONIC SYSTEMIC DISEASES
 HOSPITALISED PATIENTS
 ETHANOL
 GLUCOCORTICOIDS
 COX-2 INHIBITORS
 ZOLLINGER SYNDROME
 Ongoing bleed
 Low systolic pressure ( i. e.,<100 mmhg excluding
othostatic measures)
 Elevated prothrombin time (i.e.,>1.2 times the
control)
 Altered mental status
 Presence of co morbid disease ( define)

Presence of any one 3 fold risk ,independent of

endoscopy findings
 Clean ulcer base (rebleed <1%) Black spots ulcer base (rebleed 5%)

Fresh clot (rebleed 30%) Visible vessel (rebleed 50%) Bleeding vessel (rebleed 80%)
 Nuclear Medicine Techniques in the
Diagnosis of Gastrointestinal Bleeding

After the intravenous injection of either sulfur colloid

or
labeled red blood cells, images are made over the
upper and lower abdomen

. Bleedingrates as low as 0.1 ml per minute may be

detected.
 H. pylori eradication

• 1st line
 • PPI + clarithromycin (500mg OD) +
amoxicillin (1000mg BID) or metronidazole
(500mg) if patient has a penicillin allergy

• 2nd line
 • PPI + bismuth + metronidazole + tetracycline
INJECTION THERAPY

Adrenaline
The ethanol is injected slowly, in amounts of
0.1 to 0.2 ml per injection, at three or four
sites surrounding the bleeding vessel and 1 or
2 mm from the vessel .
Sclerosants

1% polidocanol, alcohol and ethanolamine .

Polidocanol causes haemostasis by inducing

bowel wall spasm and early oedema with
subsequent inflammation and thrombosis of
the vessel.

Absolute alcohol stops bleeding by causing

rapid dehydration and fixation of the tissue,
thus obliterating the bleeding vessel.
Procoagulants (Thrombogenic Agents)

Human thrombin and fibrin sealant

Technique
video-gastroscope (3.7 or 4.2mm working
channel) with a disposable 23 or
25 gauge sclerotherapy needle is
recommended.

4-16 ml of 1:10,000 adrenaline,

in 0.5ml aliquots is injected into and around
the bleeding point until the bleeding stops
 Thermal Modalities

Contact and non-contact methods

. Monopolar electrocoagulation
Due to an unpredictable depth of coagulation,
monopolar electrocoagulation is no longer
recommended
Multipolar electrocoagulation
Consists of 3 pairs of electrodes arranged in a linear
array at the tip and connected to a power generator.
The flow of the electrical current is limited thus
avoiding problems with grounding and aberrant current.
Heater probe

Consists of a metal tip covered by

Teflon heated by a computer-controlled
coil to a temperature of 250°C.
 Practically this requires
(i)forceful tamponade using a 3.2mm probe and
(ii) sustained coagulation with 4 consecutive pulses
at 30J for at least 8 seconds .
The heater probe is useful because it includes a
water jet to wash away any blood.
Thermal non-contact methods

Argon Plasma Coagulation

Argon plasma coagulation (APC) is a special

electrosurgical modality in which high
frequency electric current is conducted
‘contact-free’ through ionized and thus
electrically conductive argon (argon plasma)
into the tissue to be treated.
 LASER

Nd:YAG and argon laser .

Have shown excellent results .

 FAILED ENDOSCOPY

 EVIDENCE OF EROSION OF MAJOR VESSEL

 BLOOD LOSS EXCEEDING HALF A BLOOD

VOLUME

 NO ENDOSCOPY.
 Vasopressin potent splanchnic vasoconstrictor.
I v bolus 20 u over 20 mins and then continuous
infusion of 0.2 to 0.4 u/min ,then taper to
0.1u/min .

 Causes hypertension, bradycardia decreased

cardiac output and coronary vasoconstriction.
Nitroglycerin adminstered simultaneously
40 micro g / min .
 Somatostatin 250 micro g I v bolus followed by
continuous infusion of 250 micro g / hr for 2-4 days.

 Now octreotide 50 micro g bolus plus infusion is being

used .
 Stress gastritis , acute mucosal ischemia, erosive
gastritis or stress ulcer
 Predominant in body
 Distinct from NSAID assoc mucosal erosion
 Sepsis, respiratory failure,coma following head injury

or intracranial operation
 10 % UGIB
 Tear in proximal gastric mucosa near esophagogastric
junction
 History vomiting, retching or coughing followed by
hemetemesis
 Mean age >60 years ; 80 % men
 90 % stop spontaneously
 Antisecretory drugs.
 Laporotomy for oversewing of the mucosal tear
through high gastrotomy
 Acid reducing procedure not required.

 Photo
 Bleed from cancer of the
gastrointestinal tract,
esophageal cancer,
gastric cancer gastric
lymphoma,
gastrointestinal stromal
tumors, and metastatic
tumors
Source Only 15%
 These lesions are unusually large submucosal or
mucosal vessels
 Rare cause
 Superficial erosion usually lesser curvature
 Sclerotherapy ,electrocoagulation not effective
 Surgical excision
 Recently recognised
 When arranged in linear pattern in antrum of the

stomach gastric antral vascular ectasia (GAVE)or

WATERMELON stomach
 Pathogenesis unknown.
 Surgical excision.
 Uncommon
 Inflammatory tract develops between aorta and GIT
 Infectious aortitis,or inflammatory aortic aneurysms or

following aortic replacements

 Endoscopy mandatory
 CT ,others emergency angiography
 Emergency laporotomy,control of proximal aorta.
 Extra anatomic vascular bypass.
 Protective role for nitric oxide no

 Video capsule endoscopy

 Endoloops detachable nylon snares.

 PillCam SB
– 11 mm x 26 mm
– 1 camera
– 2 frames per second
– Std optics / 1 lens
– Standard lighting control
– Standard angle of view (AOV)
140°
– Depth of field 0-30 mm
PillCam SB 2
– 11 mm x 26 mm
– 1 camera
– 2 frames per second
– New optics / 3 lenses
– Advanced Automatic Light Control
– Extra wide angle of view (AOV)
156°
– Depth of field 0-30 mm
Bleeding Suspected Crohn’s

Tumors Celiac Disease