UPPER GASTROINTESTINAL

BLEEDING

DR. TAHA KAMRAN

UPPER GASTROINTESTINAL BLEEDING

• BLEEDING FROM A LESION IN THE OESOPHAGUS, STOMACH OR DUODENUM ABOVE

THE LIGAMENT OF TREITZ IS CALLED UPPER GI BLEEDING.
• HEMATEMESIS MEANS VOMITING OF BLOOD.
• MELENA MEANS PASSAGE OF BLACK TARRY STOOLS.
• BOTH INDICATE UPPER GI BLEEDING.
• MELENA DEVELOPS AFTER AS LITTLE AS 50-100 ML OF BLOOD IN THE UPPER GIT,
BLACK COLOR IS DUE TO ALTERED BLOOD BY ACID.
• IF BLOOD REMAINS IN STOMACH IT BECOMES PARTIALLY DIGESTED AND APPEARS
BROWN IN THE VOMIT CALLED COFFEE GROUND VOMITING.
ETIOLOGY

COMMON CAUSES
• PEPTIC ULCERS
• MALLORY-WEISS TEAR
• OESOPHAGEAL VARICES
• GASTRITIS/GASTRIC EROSIONS
• DRUGS (NSAIDS, STEROIDS, THROMBOLYTICS,
ANTICOAGULANTS)
• OESOPHAGITIS
• DUODENITIS
• MALIGNANCY
• NO OBVIOUS CAUSE
CLINICAL EXAMINATION

• TAKE A BRIEF HISTORY AND EXAMINE TO ASSESS FOR SEVERITY

• ASK ABOUT PAST GI BLEEDS; KNOWN ULCERS; KNOWN LIVER DISEASE OR
OESOPHAGEAL VARICES; DYSPHAGIA; VOMITING; WEIGHT LOSS.
• CHECK DRUGS AND ALCOHOL USE.
IS THE PATIENT SHOCKED?

• PERIPHERALLY COOL/CLAMMY
• CAPILLARY REFILL TIME >2S
• URINE OUTPUT <0.5ML/KG/H
• TACHYCARDIC PULSE >100BPM
• SYSTOLIC BP <100MMHG; POSTURAL DROP >20MMHG
• THE INITIAL HAEMOGLOBIN AND HEMATOCRITS LEVEL WILL NOT ALTER UNTIL 24-72 HOURS UNTIL HAEMODILUTION
HAS OCCURRED.
• A REDUCED HEMATOCRITS ON ADMISSION TO HOSPITAL SUGGESTS CHRONIC BLEEDING PRIOR TO THE ACUTE EPISODE.
• A RAISED BLOOD UREA WITH A NORMAL SERUM CREATININE INDICATES LOSS OF AT LEAST 1 LITRE.
• THE PASSAGE OF A NG TUBE IS OF VALUE IN ASSESSING THE PERSISTENT RATE OF BLEEDING.
• CALCULATE THE ROCKALL SCORE.
 ROCKALL RISK SCORING FOR UPPER GI BLEEDS
Pre-endoscopy 0 pts 1 pt 2 pts 3 pts
Age <60yrs 60-79yrs ≥80 yrs
Shock: systolic BP BP >100mmHg BP >100mmHg BP <100mmHg
& pulse rate Pulse <100/min Pulse >100/min
Cormorbidity Nil major Heart failure; Renal failure Metastases
ischaemic heart Liver failure
disease
Post-endoscopy Mallory-Weiss All other diagnoses Upper GI
Diagnosis tear; no lesion; no malignancy
sign of recent
bleeding
Signs of recent None, or dark red Blood in upper GI
haemorrhage on spot tract; adherent clot;
endoscopy visible vessel
 GI BLEED MORTALITY BY ROCKALL SCORE
Score Mortality with initial scoring Mortality after endoscopy
0 0.2% 0%
1 2.4% 0%
2 5.6% 0.2%
3 11.0% 2.9%
4 24.6% 5.3%
5 39.6% 10.8%
6 48.9% 17.3%
7 50.0% 27.0%
8+ - 41.1%
ACUTE MANAGEMENT

• START BY PROTECTING THE AIRWAY AND GIVING HIGH-FLOW OXYGEN

• INSERT 2 LARGE BORE (14-16G) IV CANNULAE AND TAKE BLOOD FOR CBC, UR&CR,
ELECTROLYTES, LFT, CLOTTING AND CROSS MATCH
• GIVE IV FLUIDS TO RESTORE INTRAVASCULAR VOLUME WHILE WAITING FOR CROSS
MATCHED BLOOD. IF HAEMODYNAMICALLY DETERIORATING DESPITE FLUID
RESUSCITATION, GIVE GROUP O RH-VE BLOOD. AVOID SALINE IF CIRRHOTIC/VARICES.
• INSERT A URINARY CATHETER AND MONITOR HOURLY URINE OUTPUT
• ORGANISE A CXR, ECG AND CHECK ABG
• CONSIDER A CVP LINE TO MONITOR AND GUIDE FLUID REPLACEMENT
ACUTE MANAGEMENT

• TRANSFUSE (WITH CROSS-MATCHED BLOOD IF NEEDED) IF SIGNIFICANT HB DROP (<7G/DL)

• CORRECT CLOTTING ABNORMALITIES (VITAMIN K, FFP, PLATELETS)
• IF SUSPICION OF VARICES THAN GIVE TERLIPRESSIN IV
• CONTINUOUS IV INFUSION OF OCTREOTIDE (SANDOSTATIN) REDUCES BLEEDING BY DECREASING SPLANCHNIC BLOOD
FLOW AND THEREFORE PORTAL PRESSURE IN BLEEDING VARICES
• INITIATE BROAD SPECTRUM IV ANTIBIOTICS COVER
• MONITER PULSE, BP AND CVP (KEEP >5CMH2O) AT LEAST HOURLY UNTIL STABLE. CVP MAY MISLEAD IF THERE IS ASCITES OR
CCF.
• ARRANGE AN URGENT ENDOSCOPY
• IF ENDOSCOPIC CONTROL FAILS, SURGERY OR EMERGENCY MESENTERIC ANGIOGRAPHY/EMBOLIZATION MAY BE NEEDED
• FOR UNCONTROLLED OESOPHAGEAL VARICEAL BLEEDING A SENGSTAKEN-BLAKEMORE TUBE MAY COMPRESS THE
VARICES.
FURTHER MANAGEMENT

• ANATOMY IS IMPORTANT IN ASSESSING RISK OF REBLEEDING.

• POSTERIOR DUS ARE HIGHEST RISK AS THEY ARE NEAREST TO
GASTRODUODENAL ARTERY
• RE-EXAMINE AFTER 4H AND CONSIDER THE NEED FOR FFP IF >4 UNITS
TRANSFUSED
• HOURLY PULSE, BP, CVP, URINE OUTPUT (4HRLY IF HAEMODYNAMICALLY
STABLE MAY BE OK)
• TRANSFUSE TO KEEP HB >7G/DL
• CHECK CBC, UR&CR, ELECTROLYTES, LFT AND CLOTTING DAILY
• KEEP NIL BY MOUTH IF AT HIGH REBLEED RISK
SUMMARY

1. HISTORY AND EXAMINATION

2. MONITOR PULSE AND BP ATTACH OXYGEN FOR SHOCKED PATIENTS
3. TAKE BLOOD FOR CBC, UR&CR, ELECTROLYTES, GROUPING AND CROSS MATCHING
4. IV LINE, CENTRAL LINE IF BRISK BLEED
5. NORMAL SALINE/BLOOD TRANSFUSION
6. URGENT ENDOSCOPY
7. RE-ENDOSCOPY FOR CONTINUED BLEEDING
8. SURGERY IF BLEEDING PERSISTS.
THANKYOU