Liang Zhao Associate Professor

Hepatobiliary and Splenic Surgery Ward

Shengjing Hospital of CMU

Definition
1. Upper gastrointestional tract

*the digestive tract above the treitz ligament.

*includes esophagus, stomach, duodenal,

pancreas, and biliary tract, jejunum after
gastrojejunostomy is also in this range.
2. Massive upper gastrointestinal

hemorrha
ge
*rapid loss of sufficient blood (>1000ml) with
in several hours,or more than 20% of blood
volume to cause hypovolemic shock (hypote
nsion, tachycardia).

*manifestations: hematemesis( 呕血 ),
hematochezia （黑便） , etc.

*The mortality is 10% ， misdiagnosis rate of

etiology is 20%.
Etiology
*peptic ulcer
*rupture of varices of esop
hagus and fundus of stoma
ch
*acute erosive hemorrhagic
gastropathy
*gastric cancer
 Upper gastrointestinal diseases
 The rupture of varices of esophagus a
nd gastric fundus
 The disease of organ or tissue near the
upper gastrointestinal tract
 Systemic diseases
1.Upper gastrointestinal diseases
1.1 esophageal diseases
esophagitis (reflux esophagitis)
esophageal diseases

carcinima of eso
phagus

esophageal ulce
r
 esophageal diseases

esophageal damage
Mallory-Weiss syndrome
（食管贲门粘膜撕裂综合征）
peptic ulcer;
acute erosive-hemorrhagic gastropathy;
gastric cancer;
abnormal blood vessel of
stomach （ Dieulafoy disease ，杜氏病） ;
gastroduodenal diseases

Zollinger-Ellison syndrome
→Gastrinoma （胃泌素瘤）
 gastroduodenal diseases

other tumors on duodenal

or duodenal papilla
acute erosive duodenitis

gastric lesions after gastrectomy

2. The rupture of varices of esophagus a
nd gastric fundus
portal hypertensive gastropathy
3.The disease of organ or tissue n
ear the upper gastrointestinal tra
ct
3.1 biliary hemorrhage
3.2 pancreatic diseases
3.3 arterial tumor
3.4 mediastinal tumor （纵膈肿瘤） or a
bscess
4. Systemic diseases
4.1 disease of blood vessel
4.2 hematopathy
leukemia, hemophilia （血友病）
4.3 uremia
4.4 diseases of connective tissue
4.5 stress-related gastric mucosal injury
4.6 acute infection
1.Hematemesis and hematochezia

*All patients after the massive gastrointestinal he

morrhage have hematochezia, but not ev
eryone has hematemesis.

*The site of hemorrhage below the pylorus, there i

s only hematochezia, but above the pylorus, t
he hematochezia can be with hematemesis.
 however, if the lesion below pylorus, the hem
orrhage is very large and fast, the blood can refl
ux to stomach, the patient can has hematemesis
except hematochezia;

on the contrary, if the lesion above pylorus, bl

eeding is little and slow, the patient isn’t likely
with hematemesis.
 (1)The color of hematemesis
often dark brown, defined as melaneme
sis, or “coffee grounds” vomitting, because
blood react with gastric acid to form hemati
n.

If bleeding is huge, the blood don’t act with gastric aci

d,the hematemesis is bright red.
(2) Hematochezia
black, tarry, metallic -smelling stools,
because the iron of hemoglobin react
with sulfide in intestine to form ferric
sulfide （ rotten egg ） .
If bleeding is huge,stools may present
with dark red blood.
2.Hemorrhagic peripheral circulatory failure
*The extent of acute peripheral
circulatory failure is decided by amount
and speed of bleeding.
*If hemorrhage is large and fast,
circulation volume rapidly decreased
(cardiac output lessen).Patient may feel
dizziness, palpitation, sweating, thirst,
amaurosis, nausea or syncope.
 If bleeding is progressively exacerbation,
shock may occur, signs are pulse to be
weaken, fast(>120 times/min) and blood
pressure droping (systolic pressure <or
=90mmHg).
3. Anemia and hemogram
(1) Anemia
a. Hb, RBC, red-cell count, and hematocrit
（ Hct ） In the early stage, they are n
ormal.
After 3-4h, anemia appears (Tissue fluid
filter into blood vessel and make the blood
dilute).
b. Reticulated corpuscles——immature
RBC （网织红细胞）
Within 24h, it elevates,
After 4~7days, it elevates to 5%~15%, t
hen gradually descents to normal.
If the bleeding doesn’t cease, it can per
sistently elevate.

.
(2) WBC
2~5h,WBC elevates to (10~20)x109/L, it
descents to normal after the bleeding ceas
es 2 － 3 days.
If the patient with hypersplenism （脾功
能亢进） , WBC can’t elevate.
 4. Fever
* low grade fever(<38.5oC), persist
3~5days.

*The mechanism is unclear,may be

obstruction of heat-regulating center
causing by circulation volume reducing
and peripheral circulatory failure.
5. Azotemia （氮质血症）
*Serum urea nitrogen frequently elevated
after the massive bleeding, definited as
enterogenous azotemia.

*The mechanisms :
(1) A large amount blood entered
intestine and digestive product of blood
is absorbed.
(2) Volume of renal blood flow decreased.
a. Within 24~48h, BUN elevates to peak,
commonly not more than14.3mmol/L (4
0mg/dl), persist 3~4 days.
b. BUN persistently elevates more than 3~
4days,
or obviously more than 17.9mmol/L
(50mg/dl),
the active bleeding had ceased, blood v
olume is corrected and the amount of urin
e is still little,
the renal failure should be considered b
ecause the time of shock is long and has
kidney disease in the past.
Diagnosis
1.The establishment of bleeding of upper
gastrointestinal tract
(1) Manifestations;
(2) Occult test of vomit and stool is intensive
positive;
(3) Hb, red-cell count, and hematocrit （ Hc
t）;
(4) The following situations must be noticed:
a. To exclude the bleeding factors outside
digestive tract
i. Bleeding of respiratory tract
the differentiated diagnosis of emptysis
（咳血） and hematemesis （呕血） ;

ii. Bleeding of mouth, nose, and laryngeal

part of pharynx

iii. Melena （黑便） caused by taking food.

b. Estimation of the bleeding from
upper gastrointestinal tract or l
ower gastrointestinal tract
a. Hematemesis
b. Melena
c. Bloody stool （ haemorrhoids
）
2. Evaluation of severe extent of ble
eding and estimation of state
of peripheral circulatory
(1) Evaluation of severe extent of bleeding

*positive occult blood test of stool indicates

amount of bleeding >5~10ml/day;
*melena >50~100ml/day;
*little hematemesis >250~300ml;
*systemic symptoms >400-500ml;
*peripheral circulatory failure >1000ml.
(2) Estimation of state of peripheral circulatory
Bp and rate of heart are the key indexes:
a. Dynamic observation;
b. Amount of blood isn’t enough from lying to sitt
ing:
The declining extent of Bp >15~20mmHg;
The elevating extent of HR>10 times / min.
c. Shock
systolic pressure < 90mmHg;
HR > 120 times/ min;
the manifestations of shock.
3.Manifestation of persisting hemorrhage

* repeating hematemesis, or frequency of

melena increasing, watery stool, with the
hyperactive bowel sounds;

* manifestations of peripheral circulatory f

ailure doesn’t obviously improve after act
ive treatment;
* Hb, red-cell count, hematocrit persistently
decline;

* reticulated corpuscles persistently elevates

* Serum BUN persistently elevates or raise

again in the condition of enough fluid
infusion and amount of urine.
4. Etiological diagnosis of hemorrhage
(1) Clinical manifestation and Lab. exami
nation
*chronic,periodic and rhythmic epigastric
pain;

*alcoholism or chronic liver disease, with

ascites, jaundice, hepatomegaly,
splenomegaly;
*Ingestion of nonsteriodal anti-inflam
mtory or history of acute stress;

*a patient : middle age, epigastric p

ain, weight loss and anorexia.
(2)Endoscopy

The first performed examination.

To identify the bleeding site in

80~95%.
 Emergency endoscopy:
Examination is done within 24~48h after
bleeding.
a. to increase the veracity of bleeding e
tiology;
b. to determine if the bleeding is persist
ent or the dangerous of bleeding again;
c. to make hemostasis treatment under
endoscopy.
(3) Imaging
GI barium meal examination.

(4) Other examination

Selective angiography
ECT bleeding
Small intestinal endoscopy of small i
Capsule endoscopy ntestine
Prognosis
1. Age > 60 years old;
2. Severe incidental diseases (dysfunction
of heart, lung, liver, and kidney);
3. Bleeding is huge this time and repeat bl
eeding in a short time;
4. Special etiology and site of bleeding;
5. Peptic ulcer with active bleeding under
endoscopy, or the stigmata of recent he
morrhage.
Treatment
 1. General measures
*bed rest
*fasting (active bleeding)
*oxygen inhalation
*intake and output volume
*vital signs(BP,P,R,T)
*the situation of bleeding
*Hb, red-cell count, hematocrit, and BUN
2.complement with blood volume
*detection of blood group and matching
blood at once
*to immediately establish transfusion
tract of vein and supplement blood volume
*treat with balanced salt solution,
glucose salt.
*If shortage of blood, instead of colloid
or other plasma replacement agents
*the speed of transfusion must be
fast at beginning and amount is bas
ed on the amount of bleeding.
The index of emergency blood transfusion:
(1) Changing posture, appears syncope,
palpitation, blood pressure dropping and
heart rate fast;
(2) Hemorrhagic shock;
(3) hemoglobin <7g/L, or specific volume
of red-cell<25%.
notice: anemia, urine volume
Cirrhosis: fresh blood
 3. Hemastatic treatment
(1)rupture of varices of esophagus and
gastric fundus
*oral drugs:
NA(noradrenalin)4mg +50ml NS;
thrombase1000u+50ml NS, first time
should drink 2000u.
yunnan baiyao powder
 *Injection
a. Vasopressin
Mechanism: to contract the vessel of
internal organ, decrease the blood flow
of portal vein, decline the pressure of p
ortal vein and collateral circulation.
Dosage:
first time, 0.2U iv drip persistently,
then on the treatment effect, increase to 0.
4U/min iv drip.
Hemastatic rate is 50~70%.
Side effect:
Abdominal pain, to elevate blood press
ure, arrhythmia, angina pectoris, severe c
ase myocardial infarction

nitroglycerin(0.6mg sublingually, q30mi

n ) to avoid abdominal pain, arrythmia hyp
ertension, myocardial ischemia.
b. Somatostatin （生长抑素）
Mechanism:
lessen portal tension
decrease gastric acid
selective contract vessel
inhibit pancreatic juice.

Result:
To decrease the flow of portal vein trunk: 2
5%— 35%
To decrease pressure of portal vein:
12.5%—16.7%
*hemostasis by compression
Sengstaken-Blakemore tube （ three-cavity-
two-capsule tube ）
*hemostasis under endoscopy
a. sprinking hemostat such as
NE(Norepinephrine), thrombase to the
wound
b. Sclerotherapy and ligation of esophagu
s varices.
食管曲张静脉套扎后溃疡形成
* surgical operation or Tips
(2)The other method of upper gastrointestinal blee
ding treatment
also named nonvaricose vein –upper gastrointest
inal bleeding
*inhibition of gastric acid
pH>6, >20h, blood platelet aggregation and plas
m blood coagulation.
pH<4, the fresh forming blood coagulation mass i
s digested.
* under endoscopy treatment
laser, injection ， heater probe, microwave, etc.
* operation

* intervening treatment
angio-embolism by selective
mesentery arterigraphy
Thank You