Management of non variceal

bleeding
B.Shyam prasad
naik
Final year MBBS
Part-2
NON-VARICEAL BLEEDING :
Peptic Ulcer disease 30-50% .
Mallory-Weiss tears 20% .
Gastritis/Duodenitis/Esophagitis ~20% .
A-V malformation,Tumours,others 10%.
PORTAL HYPERTENSION BLEED :
Gastroesophageal varices >90%
Hypertensive portal gastropathy, <5 %
Isolated Gastric varices rare
BLEEDING RELATED TO NONVARICEAL
1.Duodenal ulcer
2.Gastric ulcer
3.Mallory-Weiss tears
4.Stress gastritis
5.Esophagitis
6.Dieulafoy lesion
7.Gastric antral vascular ectasia
DUODENAL ULCER
● The most significant hemorrhage occurs when duodenal or gastric ulcers
penetrate into branches of the gastroduodenal artery or left gastric arteries,
respectively.

Endoscopic THERAPY:
● Endoscopic therapy is instituted if bleeding is active or, when bleeding has
already stopped, if there is a significant risk of rebleeding.
● Endoscopic therapy is recommended in cases of active bleeding as well as
for a visible vessel (Forrest I-IIa).
● In cases of an adherent clot (Forrest IIb), the clot is removed and the
underlying lesion.
● Management includes - epinephrine injection,heater probes, coagulation ,
application of clips.
1 .Epinephrine injection (1 : 10,000) to all four quadrants of the lesion is successful in
controlling the hemorrhage.
2.It has been shown that large-volume injection (>13 mL) is associated with better
hemostasis, suggesting that the endoscopic injection works, in part, by compressing the
bleeding vessel and inducing tamponade.
3.The standard practice as recommended by international consensus guidelines is to
provide combination therapy.
4.This usually means the addition of thermal therapy to the injection.
5.The most commonly used energy sources are electrocoagulation for bleeding ulcers
and argon plasma coagulation (APC) for superficial lesions.
6.In those who rebleed, a second attempt at endoscopic control has been validated and
is recommended.
Non-variceal endoscopy management :
-Patients with low risk ulcers can be fed promptly, put on oral PPI therapy.
-Patients with ulcers requiring endoscopic therapy should receive PPI for 72 hours
which, significantly reduces rebleeding rate.
-Note: there may not be major advantage with high dose,over non-high dose PPI
therapy.
-Determine H. pylori status in all ulcer patients
-Discharge patients on PPI (once to twice daily), duration dictated by underlying etiology
and need for NSAIDs/aspirin.
-In patients with cardiovascular disease on low dose aspirin: restart as soon as bleeding
has started.
SURGICAL TREATMENT:
1.Approximately 10% of patients with bleeding ulcers still require surgical
intervention for effective hemostasis.
2.The clinical factors to consider are shock and a low hemoglobin level at
presentation.
3.Ulcers larger than 2 cm, posterior duodenal ulcers, and gastric ulcers have
significantly higher risk of rebleeding.
4.Most surgeons still consider an ongoing blood transfusion requirement in excess
of 6 units an indication for surgical intervention, particularly in the elderly, although
an 8- to 10-unit loss may be more acceptable for the younger population.
● The first step in the operative management for a duodenal ulcer is exposure of the
bleeding site.
● Because most of these lesions are in the duodenal bulb, longitudinal inscision is
performed.
● Hemorrhage can typically be controlled initially with pressure and then direct suture
ligation with nonabsorbable suture.
● When ulcers are positioned anteriorly, four-quadrant suture ligation is done.
● A posterior ulcer eroding into the pancreaticoduodenal or gastroduodenal artery
may require suture ligature of the vessel.
● Because the pylorus has often been opened in a longitudinal fashion to control the
bleeding, closure as a pyloroplasty combined with truncal vagotomy is the most
frequently used operation for bleeding duodenal ulcer.
GASTRIC ULCER
● control of bleeding is the immediate priority.
● initially require gastrotomy and suture ligation
● As there is 10% incidence of malignancy, gastric ulcer resection is generally
indicated.
● Distal gastrectomy is generally preferred .
● Options include distal gastrectomy combined with resection of a tongue of
proximal stomach to include the ulcer or vagotomy and pyloroplasty combined
with either wedge resection.
Mallory-Weiss tears
● Mucosal and submucosal tears that occur near the gastroesophageal junction
Lesser curvature>Greater curvature.
● Develop in alcoholic patients after a period of intense retching and vomiting ,
also in patients with repeated emesis.
● Forceful contraction of the abdominal wall against an unrelaxed cardia,
resulting in mucosal laceration of the cardia as a result of the increase
intragastric pressure.
● Dx : Based on History and endoscopy.
● Treatment - Self limited , supportive therapy (mucosa heals with in 72 hours).
● In case of severe bleeding in Mallory weiss tear - Endoscopic therapy,
Angiographic embolization,high gastrotomy and suturing of the mucosal tear.
Stress Gastritis
● Appearance of multiple superficial erosions of the entire stomach body result
from the combination of acid , pepsin injury and Nsaids.
● Significant bleeding is rarely encountered.
● Mx: Acid suppressive therapy is often successful in controlling the
hemorrhage .
● In Refractory cases: Octreotide or vasopressin is given,endoscopic therapy
and angiographic embolization are done.
 Esophagitis :
● Causes include the following :
● GERD and Infectious agents(in immunocompromised host),Radiation, Drugs
and Crohn’s disease.
● Rx: Acid control, Electrocautery and heater probe.

DIEULAFOY LESION :
● Dieulafoy lesions are vascular malformations found primarily along
the lesser curve of the stomach within 6 cm of the
gastroesophageal junction, although they can occur elsewhere in
the GI tract.
Treatment:
Injection therapy, a thermal probe, or clip device or by band
ligation. Large case series have reported an initial hemostasis
rate of approximately 90%, with the need for surgery in 4% to
16% of cases.
DIEULAFOY LESION
GASTRIC ANTRAL VASCULAR ECTASIA
● Also known as watermelon Stomach.
● Characterized by a collection of dilated venules appearing as linear red
streaks converging on the antrum in longitudinal fashion.

Treatment :
● Endoscopic therapy is indicated for persistent, transfusion-dependent
bleeding.
● The preferred endoscopic therapy is APC.
● Patients failing to respond to endoscopic therapy should be done.
THANK YOU