UPPER GI

BLEEDING
ARISAH NGOZI ULUMMA

House Officer,Gastroenterology
Unit, Internal Medicine
University of Benin Teaching
Hospital (UBTH), Edo State.
 OUTLINE
 INTRODUCTION
 EPIDEMIOLOGY
 AETIOLOGY
 RISK FACTORS
 MANAGEMENT
 HISTORY/CLINICAL FEATURES
 INVESTIGATIONS
 TREATMENT
 PROGNOSIS
 PREVENTION
 CONCLUSION
INTRODUCTION

 Upper gastrointestinal bleeding is a potentially

life-threatening abdominal emergency.

 It is bleeding from the GI tract, between the

oesophagus and the ligament of Treitz

INTRODUCTION
 It has two forms of presentations, namely:
a) Acute UGIB
 It is a medical emergency which could be
life-threatening
 Requires emergency management

b) Chronic UGIB
 It has a slower and insidious course

 It could be superimposed by an acute bleed

INTRODUCTION

 Furthermore, bleeding from the UGIT occurs with

either of the following:
i. Presence of haemodynamic disturbances
ii. At least 2 units of blood required for
transfusion to resuscitate patient after bleed
iii. Drop in patient’s PCV by at least 6%
(assuming PCV was earlier known).
EPIDEMIOLOGY
 Globally, using United States as a focus country, UGIB
accounts for up to 20,000 deaths annually.
 The overall incidence of acute UGIB has been estimated at
50 to 100 per 100,000 patients per year
 In addition, it accounts for annual hospitalisation rate of
approximately 100 per 100,000 hospital admissions.
 Besides, the incidence of UGIB is increasing in elderly
people; one study found that those over 65 years of age
comprised over 30% of those with UGIB.
EPIDEMIOLOGY
 Locally, using a study carried out at Akwa Ibom State
Teaching Hospital by Adisa et al (2006), the following
important findings were made:

i. 4.3% of patients scoped had UGIB.

ii. Males were more affected than females with a ratio

of 3:1
iii. Majority of the patients (81%) are <60 years
iv. Bleeding PUD (37.5%) was the commonest cause
AETIOLOGY
A. At the oesophagus
1. Oesophagitis
2. Mallory-Weiss tears at GE junction (5%)
B. At the stomach
1. Gastritis/Duodenitis (15-30%)
2. Dieulafoy’s lesion (1-3%)
C. At the small intestine
1. Peptic ulcer disease (>50% of cases)
AETIOLOGY
C. At the small intestine
2. Osler-Weber-Rendu disease (Hereditary Haemorrhagic
Telangiectasia)
3. Varices from portal hypertension
D. Other causes
1. Malignancy
2. Aortoenteric fistula, angiodysplasia, hemobilia, hemosuccus
pancreaticus,
3. Drugs (NSAIDs use, Aspirin, Thrombolytics, Anticoagulants
RISK FACTORS
1) History of previous UGIB

2) Infection with Helicobacter pylori

3) Chronic liver disease

4) Chronic kidney disease

5) Chronic NSAIDs ingestion

6) Prolonged hospital admission

7) Anticoagulation or antiplatelet therapy

8) Excessive alcohol intake
MANAGEMENT (OF ACUTE UGIB)
 Acute UGIB is a medical emergency; thus, there’s need
to follow the traditional ABC of resuscitation
 Secure airways

i. Suction if there’s need for suctioning

ii. Use high flow oxygen (through non-rebreatheable

face mask), maintaining SPO2 at 98 – 100%

 If patient is unconscious pass oropharyngeal tube

 Secure IV access using bilateral 14 – 16G cannulae
MANAGEMENT (CONTINUED)
 Take blood for FBC, SEUCR, RBS, LFT, Clotting profile
and grouping and crossmatching of 4-6 units of blood
 Give IV fluids, to restore intravascular volume while waiting
on blood
 Insert Foley’s urinary catheter to monitor urine output
 Organise instrumental investigation
 Transfuse the patient as soon as blood is available
 Place patient on nil per oral
 Monitor vital signs hourly (pulse, BP, etc) hourly
HISTORY (CLINICAL FEATURES OF UGIB)
a. History of weakness, dizziness, syncope, epigastric pain

b. Hematemesis
 Vomiting of blood
 Can be of either 2 presentations

i. Gross blood and blood clots, representing rapid

bleeding or

ii. Coffee-ground emesis signifying chronic

bleeding
HISTORY (CONT’D)
 Hematemesis is the result of bleeding from the
oropharynx to the ligament of Treitz
c. Melena
 Passage of black and tarry stool, caused by digested
blood
 As little as 50-60mL of blood in the GI tract produces
melena
 Melena can persist from 5-7 days after a 2 unit bleed
and stools can remain occult positive up to 3 weeks
 HISTORY
Bleeding etiology Historical clues
Mallory-Weiss tear Emesis before hematemesis, alcoholism
Esophageal ulcer Odynophagia, GERD, esophagotoxic pill ingestion
Peptic ulcer Epigastric/RUQ pain, NSAID or aspirin use
Stress gastritis Patient in an ICU, gastrointestinal bleeding occurring
after admission, respiratory failure, multiorgan failure
Varices, portal Alcoholism, cirrhosis
gastropathy
Gastric antral Renal failure, cirrhosis
vascular ectasia
Malignancy Recent involuntary weight loss, dysphagia, cachexia,
early satiety
Angiodysplasia Chronic renal failure, hereditary hemorrhagic
telangiectasia
Aortoenteric fistula Known aortic aneurysm, prior abdominal aortic
aneurysm repair
EXAMINATION
 Signs on examination, depending on aetiology,
include:
A. Hemodynamic Instability (Evaluation)
i. Pallor
ii. Tachycardia, thready pulse(>100Bpm)
iii. Hypotension ( Systolic Bp <90mmHg)
iv. Orthostatic hypotension
v. Hypoxia
EXAMINATION
B. Careful abdominal examination
i. Abdominal tenderness
ii. Ascites (evidenced by shifting dullness)

C. Signs of chronic liver disease or portal hypertension

i. Hepatomegaly
ii. Splenomegaly
iii. Palmar erythema
EXAMINATION

iv. Caput medusa

v. Spider angiomata
vi. Peripheral edema
vii. Icterus
viii. Gynaecomastia

D. Signs of shock
i. Pallor
ii. Cold clammy extremities
iii. Loss of consciousness
iv. Palpitations/Tachycardia
EXAMINATION

E. Rectal examination
i. Occult blood
ii. Bright red blood per rectum
iii. Melena
INVESTIGATIONS

A. Laboratory
1) Full blood count
 It is pertinent to take note of the folowing:
a. During rapid haemorrhage, initial PCV may not
accurately reflect the magnitude of blood loss
b. There’s mild leucocytosis and there’s also
thrombocytosis within 6 hours after the onset of
bleeding
2) Grouping and crossmatching of at least 4 -6 units of
blood (1 unit per g/dl less than 14g/dl)
INVESTIGATIONS

A. Laboratory
3) Coagulation profile (Prothrombin Time,
Activated Partial Thromboplastin Time,
International Normalised Ratio)
4) SEUCR
5) Liver Function Test
6) Gastrin level (to rule out Gastrinoma)
INVESTIGATIONS (CONT’D)

B. Instrumental
1) Endoscopy
 Both diagnostic and therapeutic
 For delineating source and site of bleeding
2) Chest radiograph
 To exclude aspiration pneumonia, effusion and
oesophageal perforation
3) Ultrasound scan/CT scan
 To exclude the following:
INVESTIGATIONS (CONT’D)

i. CLD/Portal HTN
ii. Cholecystitis with haemorrhage
iii. Pancreatitis with
pseudocyst/haemorrhage (haemosucrus
pancreatitis – bleeding from the
ampulla of Vater)
iv. Aortoenteric fistula
Illustration of endoscopy of the Upper GI
Illustration of endoscopic finding in Upper GI bleeding
ROCKALL SCORE
 Rockall score is a risk stratification scoring
system used for UGIB
 It helps in identifying patients at risk of
adverse outcome following acute UGIB
 A score < 3 carries good prognosis
 A score > 3 carries high risk of mortality
ROCKALL SCORE
Variable Score 0 Score 1 Score 2 Score 3

Age <60 60 – 79 >80 -

Shock PR < 100 PR > 100 PR > 100 -

SBP > 100 SBP > 100 SBP <100

Co-morbidity Nil major IHD/CCF/ Renal failure/liver Metastasis

major failure
comorbidity

Diagnosis No lesion or All other GI malignancy -

Mallory-Weiss Diagnoses
tear

Endoscopic None or dark red - Blood in UGI -

findings spot tract/adherent clot,
TREATMENT OF UGIB
I. Medications
II. Specific treatment modalities
III. Surgical therapy

IV. MEDICATIONS
1) PPIs, Rabeprazole 40mg stat, 20mg 6 hourly
2) Vitamin K / FFP (for correcting clotting abnormality, if necessary)
3) IV Somatostatin analogue (Octreotide) at 50-100µg 6 hourly (up to
200µg can be used) into 200mls of N/S
4) IV Terlipressin 2mg bolus, then 1-2mg 4 hourly for 72 hours (in case
of variceal bleeds)
TREATMENT OF UGIB
II. SPECIFIC TREATMENT MODALITIES
A. Therapeutic endoscopic techniques
1. Injection of epinephrine or scleroscants e.g. ethanol,
polidocamol, tetracycline
2. Bipolar electrocoagulation
3. Band ligation
4. Heater probe coagulation
5. Constant probe pressure tamponade
6. Argon plasma coagulation
7. Laser photo coagulation
TREATMENT OF UGIB (CONT’D)
8. Application of haemostatic materials e.g. biologic
glues
9. Application of haemoclips or endoclips
10. Application of nanopowder

B. Others
1. Sengstaken-Blakemoore tube for tamponade
2. Transjugular Intrahepatic Portal Systemic Shunt
(TIPSS)
Illustration of endoscopic treatment of upper GI bleeding
Sengstaken-Blakemore Tube
TREATMENT OF UGIB (CONT’D)
III. SURGICAL THERAPY
 Surgical therapy is crucial in treatment of bleeding
peptic ulcer disease.
 Indications for its use in bleeding PUD include:
a. Severe life-threatening haemorrhage not responsive
to resuscitative effort
b. Failure of medical therapy/endoscopic haemostasis
c. Coexisting reason for surgery (perforation,
obstruction, malignancy)
TREATMENT OF UGIB (CONT’D)
d. Prolonged bleeding involving up to >50% of blood
volume
e. Initial Rockall score greater than or equal to 3 or final
score of greater than or equal to 6
 Surgical options include:
I. Truncal vagotomy + pyloroplasty with suture ligation of
bleeding
II. Truncal vagotomy + antrectomy with resection or ligation
of bleeding ulcer
III. Proximal highly selective vagotomy with duodenostomy
PREVENTION OF UGI BLEEDING
1) Use of PPIs e.g. Omeprazole in patients
who have peptic ulcer disease or CKD.
2) Avoidance of abuse and chronic use of
NSAIDs
3) Eradication of Helicobacter pylori
4) Prophylaxis in portal HTN, using Bands
Ligations
PROGNOSIS
 Prognosis depends on aetiology
 Poor prognostic factors include:
1. Age > 60 years
2. Comorbidity
3. Active bleeding
4. Blood transfusion > 6 units
5. In-patient at time of bleed
6. Severe coagulopathy
CONCLUSION
 Upper GI bleeding is a common medical
emergency, which requires immediate
medical attention.
 It is important to recognise its various
causes, presentation, as well as
management.
 REFERENCES
1) Kumar and Clark’s Clinical Medicine (8th Edition)
2) Harrison’s Textbook of Clinical Medicine 18th
Edition
3) www.medscape.com
4) European Journal of Scientific Research; Dec 2006
5) Upper Gastrointestinal Bleeding. Seminar
Presentation by Dr. Omeru Oghenenyerhovwo