UPPER GI BLEEDING

Dr. Atul Sharma

FCCCM Exam Student 2023
 OUTLINE
• Introduction
• Aetiology
• Treatment
• Presentation
• Complications
• Resuscitation
• Follow up
• Diagnosis
• Prognosis
1. History
2. Clinical • conclusion
examination
3. investigations
 INTRODUCTION

• Bleeding of GIT proximal to ligament of treitz.

• Ligament of treitz- a fibromuscular band which extends from right crus

of diaphragm to duodenojejunal flexure.
Presents as:
• Haematemesis,, malena, hematochezia or occult blood.

• Malena can present with loss of 50-60ml of blood.

• May be acute or chronic

• 100 cases per 100,000 person per year.

• Accounts for 3-5% of all hospitalizations

• The incidence is 2- fold greater in males but death rate is similar in both
sexes.

• Overall mortality from acute bleeding is 20% .

• Mortality & morbidity increases as age advances (>60 yrs)

 AETIOLOGY (COMMON CAUSES)

1. Peptic ulcer disease

≥ 50% of cases

• Duodenal ulcer
• Gastric ulcer
• Stomal ulcer
 AETIOLOGY (COMMON CAUSES)

2. Erosive gastritis,
esophagitis, duodenitis
15-30% of cases

Common causative factors are:

ETOH [alcohol], ASA, NSAID’S,STEROIDS.
 AETIOLOGY (COMMON CAUSES)

3. Esophageal and gastric varices

10-20% of cases

caused by portal hypertension

 AETIOLOGY (COMMON CAUSES)

4. Mallory- Weiss syndrome

• 5% of cases
• Characterized by longitudinal mucosal tear in the
cardioesophageal region.
• Result from repeated vomitting or retching.
• Common in male alcoholic patients
 AETIOLOGY

Less common Rare

• Oesophagitis • Duodenal tumous

• Malignant gastric tumor • Pancreatic tumors
• Benign gastric tumors • Arterial aneurysm
• Oesophageal ulcer • Blood dyscrasia
• Oesophageal tumors • Hereditary telangiectasia
• A-V malformations • Haemobilia
 MALIGNANCY

• In 3% of cases presentation is with upper GI bleeding

• Gastric cancer

• Oesophageal cancer
 CLINICAL PRESENTATION

A. Chronic upper GI bleeding

• Anemia.
• Weakness.
• Fatigueness.
• Pt :looks pale.
• Malena.
• Occult blood positive.
B. Acute upper GI bleeding
• Presents as emergency with hemetemesis or malena.
• Hypovolaemia:
i. Mild: no significant hypovolaemia.
ii. Moderate: hypovolaemia which responds to volume
replacement.
iii. Severe: hypovolaemia with continued active major bleeding
making resuscitation difficult even with blood transfusions.
These patients are difficult to manage.
Patients will show all signs of shock.
Note: all patients should be examined for stigmata of CLD.
• H/O drugs (NSAIDS).
• H/O ulcers.
• H/O alcohol abuse.
 RESUSCITATION

Initial management has 4 primary goals:

1. Quick assessment with attention to hemodynamic status

2. Appropriate resuscitation (ABC) & monitoring
3. Identify major source of bleeding
4. Specific therapeutic intervention.
RESUSCITATION (GENERAL MEASURES)
• Airway cleared of clot.
• Oxygen inhalation.
• Maintain IV line with at least 2 wide bore cannulae
• Sample to blood bank for cross matching.
• Class I + II hemorrhage replace with crystalloid.
• Class III + IV hemorrhage replace with crystalloid &
blood.
• Pass NG tube for diagnostic & therapeutic purpose.
• Catheterize the patient.
• Sedation may be needed.
 SEVERITY
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
 SPECIFIC MEASURES

• If stable following resuscitation, proceed for upper GI endoscopy.

• Endoscopy ideally done within 4-24 hrs.
• If patient could not be stabilized, an emergency laparatomy may be
necessary.
 DIAGNOSIS
History of:

• Epigastric pain or retrosternal burning

• hematemesis, melena, or hematochezia.
• Vomiting, weight loss, alteration of bowel habits.
• Aortic graft surgery
• Use of ASA, NSAID’S, steroids, alcohol addiction
 DIAGNOSIS

Physical examination

• Vital signs may show hypotension & tachycardia.

• Cool, clammy skin.
• Petechiael hemorrhage & purpura seen in coagulopathy.
• Signs of chronic liver disease.
• Proper abdominal & rectal examination.
 INVESTIGATIONS

• Upper GI endoscopy.
• Arteriography.
• Barium swallow
• Ultrasound
• Lab investigations
 ENDOSCOPY

• Most important investigation

• For diagnosis & intervention
• Establishes diagnosis in 90% of patients
• Can be repeated more than once.
 ARTERIOGRAPHY

• In pts who bleeds contineously & site can not be identified.

• Has accuracy of 50-90%.
• Accuracy is increased if there is active bleeding during
investigation.
• Demonstrates bleeding of 0.5-1.0ml/min
• With technetium-labelled RBC, 0.1-0.5ml/min
• Embolisation may be done at same time
 BARIUM SWALLOW / MEAL

• Used when endoscopy is not available

• Double contrast study is ideal
• May show varices, esophagitis, peptic ulcers, gastric tumors etc
ABDOMINAL ULTRASOUND SCAN

• To assess both liver architecture and portal circulation

• More widely available than Arteriography
• Should be performed before more invasive procedures
 LAB INVESTIGATIONS

• CBC
• Electrolytes
• Glucose
• Coagulation studies
• Liver function studies
• Blood grouping and cross-match
 LAB INVESTIGATIONS

• CBC, urea/creatinine, S/Electrolytes, ABGs.

• ed urea/ creatinine in upper GI bleeding.
• Iron deficiency anemia in chronic blood loss.
 TREATMENT ( PEPTIC ULCER
DISEASE)
At endoscopy

• 10ml epinephrine at ulcer base

• Thermal treatment with bipolar diathermy
• Laser photocoagulation
• Rebleed is treated similarly
• A second rebleed is treated by surgery
Post endoscopy treatment

• Continuous intravenous infusion of Octretide (somatostatin analogue)

• Proton pump inhibitors

• H. pylori treatment may be required.

 SURGERY- PUD

Surgical options are:

• Truncal vagotomy & drainage
• Highly selective vagotomy
• Partial gastrectomy
 SURGERY - PUD

Indications for surgery are:

• Exsanguinating hemorrhage
• Visible spurting arterial bleed
• Concomitant perforation
• Pts >60 yrs, who rebleed once or need 4 units at resuscitation or 8 units
in 48 hrs
• Younger pts requiring 8 units at initial resuscitation or 12 units in 48 hrs
• Rare blood group
 TREATMENT
GASTRIC EROSIONS / STRESS
ULCERS

• Treatment of underlying cause

• Intraluminal antacids
• IV proton pump inhibitors
• Bleeding usually subsides in 24-48 hrs
 TREATMENT
ESOPHAGEAL VARICES
1. Endoscopic sclerotherapy
• Repeated at 3 weeks interval then 3 monthly until varices disappear

• Some sclerosing agents are ethanolamine oleate,

sodium morrhuate, 3% tetradecyl sulphate, absolute
alcohol
2. Rubber band ligation

3. Vasoconstriction therapy (octreotide, vasopressin,

propranolol)
4. Balloon tamponade: if above measures fail
Modified Sengstaken- Blakemoore tube
Minnesota tube, Linton tube, Foley catheter

• Balloon tamponade applied for 12 hrs

• Stop bleeding in 80% of cases
• Must be followed by surgery as bleeding is likely to recur after removal.
 SURGERY – ESOPHAGEAL
VARICES
• TIPS: in refractory bleed
Shunt established between portal vein & Rt or middle hepatic
vein
• Stapling transection of esophagus at CEJ
• Distal splenorenal shunt
• Portosystemic shunts
• Spleenectomy in hypersplenism
• Liver transplantation
 TREATMENT

• Mallory- weiss
observe
if persist, suture mucosal tear
• Esophagitis
Observe
• Benign gastric tumors
Excise
• Dieulafoy’s lesion
Endoscopic electrocoagulation, sclerotherapy
 COMPLICATIONS

• Of presenting problem
• Of resuscitative measures
• Of underlying disease
• Of treatment
 COMPLICATIONS OF
MASSIVE HEMORRHAGE

• Hemorrhagic shock
• Acute renal shut down
• MODS
• Death
 COMPLICATIONS OF
RESUSCITATION
• Fluid overload
• Pulmonary edema
• CCF
• Blood transfusion reaction
• Cardiac arrest
• Hypothermia
• Esophageal perforation
 COMPLICATIONS OF
UNDERLYING DISEASES

• Rebleed in PUD & varices

• Gastric outlet obstruction in PUD
• Progressive CLD causing portal hypertension, ascites & coagulopathies
 COMPLICATIONS OF
DEFINITIVE SURGERY
• PUD
Early & late dumping
gastric tumors
Iron deficiency anemia

• Bypass procedures for portal hypertension

mucosal ulceration
Hepatic encephalopathy
 FOLLOW-UP

• To monitor progress of non- surgical treatment

• To prepare pts for elective definitive surgery
• To look out for, and treat complications of surgery
 PROGNOSIS

Depends upon
ROCKALL scoring system
this includes :
• The state / time of presentation of pt
• energetic resuscitation
• underlying disease
• Co morbidities
ROCKALL SCORING SYSTEM
ADVERSE PROGNOSTIC FACTORS
 CONCLUSION

• Upper GI bleeding is not uncommon & may be life threatening.

• Prompt intervention could be life saving.
• It require multidisciplinary approach.
• Definitive treatment depends upon the final diagnosis.
THANK YOU