Management of Acute Upper GI

bleeding

Dr. Adnan MH Hamawandi

Professor of Pediatrics
School of Medicine
University of Sulaimani
Definitions

Upper gastrointestinal bleeding

is bleeding originating proximal to the
ligament of Treitz; in practice from the
oesophagus, stomach and duodenum.
Definitions

Haematemesis (and coffee-ground vomitus)

Haematemesis is vomiting of blood from the upper
gastrointestinal tract or occasionally after swallowing
blood from a source in the nasopharynx. Bright red
haematemesis usually implies active haemorrhage
from the oesophagus, stomach or duodenum.
Coffee-ground vomitus refers to the vomiting of black
material which is assumed to be blood. Its presence
implies that bleeding has ceased or has been
relatively modest.
Definitions

Melaena
Melaena is the passage of black tarry stools usually
due to acute upper gastrointestinal bleeding but
occasionally from bleeding within the small bowel or
right side of the colon.
Hematochezia
Hematochezia is the passage of fresh or altered
blood per rectum usually due to colonic bleeding.
Occasionally profuse upper gastrointestinal or small
bowel bleeding can be responsible.
Causes
 Peptic ulcer disease.
 Esophageal and gastric varices.
 Hemorrhagic gastritis.
 Esophagitis.
 Duodenitis.
 Mallory-Weiss tear.
 Angiodysplasia.
 Upper gastrointestinal malignancy.
 Anastomotic ulcers (after PUD surgery or bariatric surgery).
 Dieulafoy lesion.
 Portal hypertensive gastropathy.GIT pictures
 Postprocedural: nasogastric tube erosions, endoscopic biopsy,
endoscopic polypectomy, EMR, endoscopic sphincterotomy.
Key aspects in the initial assessment
of the patient who has acute
gastrointestinal bleeding

 Bleeding severity
 Bleeding acuity
 Bleeding activity
 Bleeding location: upper versus lower
gastrointestinal bleeding
 Variceal versus nonvariceal upper
gastrointestinal bleeding
 Associated coagulopathy
Assessment

 Patients with acute GI bleeding should have

continual assessment and appropriate
management of airway, breathing and
circulation.
 History.
 Physical examination.
 Laboratory.
 Triage.
History-focused

 Prior history of GI bleeding

 GI symptoms
 Character of GI bleeding
 GI medications
 Gastrotoxic medications
 Anticoagulants
 Social habits
 Medical comorbidities
 Other relevant history
Physical Examination
 Hemodynamic stability:
Tachycardia, thready pulse ,hypotension, orthostatic hypotension,
hypoxia.
 Careful abdominal examination
Bowel sounds, Abdominal tenderness, Ascites shifting dullness
 Signs of chronic liver disease or portal hypertension
Hepatomegaly, Splenomegaly, Palmar erythema, Caput medusa,
Spider angiomata, Peripheral edema
 Signs of shock
Cold clammy extremities, Poor mentation, weak pulse, hypotension
 Rectal examination
Occult blood, Gross blood, Bright red blood per rectum, Melena,
Burgundy stools, Blood coating stools versus within stools, Bloody
diarrhea
Laboratory

 Blood group and Rh.

 Hematocrit. Serial
 Blood urea and serum creatinine.
 Coaggulation profile.
 CBC.
 LFT.
 Others.
Key early decisions in the medical management
of acute upper gastrointestinal bleeding

 Triage
Admit to hospital versus discharge from emergency room
Admit to ICU versus monitored bed versus unmonitored hospital bed
Emergency versus routine gastroenterology consult;
Surgical consult or not
 Intensive monitoring
Nasogastric tube insertion or not; Foley insertion or not
Central venous line or Swann-Ganz catheter or not
 General supportive therapy
Endotracheal intubation or not; Transfuse packed erythrocytes or not
Transfuse other blood products or not; PPI therapy or not;
Octreotide therapy or not
 Endoscopy
Emergency versus elective endoscopy; Endoscopic therapy or not
Specific modality of endoscopic therapy
Early Management
 General supportive measures.
 Fluid resuscitation.
 Blood transfusions.
 Empiric pharmacotherapy before endoscopy.
Proton pump inhibitor (PPI) therapy is recommended
before endoscopy.
 Early endoscopic examination should be
undertaken within 24 hours of initial
presentation, where possible. Emergency
endoscopy is recommended for massive
bleeding.
Nasogastric aspiration

 Nasogastric aspiration with saline lavage is

beneficial to detect the presence of
intragastric blood, to determine the type of
gross bleeding, to clear the gastric field for
endoscopic visualization, and to prevent
aspiration of gastric contents
Endoscopic Therapy

 Endoscopic therapy should only be delivered to

actively bleeding lesions, non-bleeding visible
vessels and, when technically possible, to ulcers
with an adherent blood clot.
 Combinations of endoscopic therapy comprising
an injection of at least 10 ml of 1:10,000
adrenaline coupled with either a thermal or
mechanical treatment are recommended in
preference to single modality.
Therapeutic options
 Endoscopic thermal probe can treat bleeding ulcers and other
abnormalities by burning (coagulating) the blood vessel or abnormal tissue.
 Argon plasma coagulation and radiofrequency ablation are other types
of thermal techniques used to treat abnormal blood vessels in the stomach,
small intestine and colon.
 Endoscopic clips can be used to close a bleeding vessel or other
defective tissue.
 Endoscopic band ligation uses special rubber bands to treat bleeding
vessels and varices in the esophagus.
 Endoscopic cryotherapy freezes abnormal blood vessels in the stomach.
 Endoscopic intravariceal cyanoacrylate injection uses a special glue to
treat difficult bleeding from abnormal blood vessels in the stomach.
 Angiographic embolization injects particles directly into a blood vessel to
stop bleeding.
Repeat endoscopy

Endoscopy and endo-therapy should be

repeated within 24 hours when initial
endoscopic treatment was considered
sub-optimal (because of difficult access,
poor visualisation, technical difficulties) or in
patients in whom rebleeding is likely to be
life threatening.
REBLEEDING FOLLOWING
ENDOSCOPIC THERAPY

 Non-variceal upper gastrointestinal

haemorrhage not controlled by
endoscopy should be treated by repeat
endoscopic treatment, selective arterial
embolisation or surgery.
Pharmacological therapy
 Patients with peptic ulcer bleeding should be tested for
Helicobacter pylori (with biopsy methods or urea C13 breath
test or stool antigen) and a one week course of eradication
therapy prescribed for those who test positive. A further
three weeks ulcer healing treatment should be given.
 High-dose intravenous proton pump inhibitor therapy (e.g.
omeprazole or pantoprazole 40 mg bolus followed by 8
mg/hour infusion for 72 hours) should be used in patients
with major peptic ulcer bleeding (active bleeding or non-
bleeding visible vessel) following endoscopic haemostatic
therapy.
Management of acute variceal upper
gastrointestinal bleeding

 Patients with confirmed oesophageal

variceal haemorrhage should undergo
variceal band ligation.
 Patients with confirmed gastric variceal
haemorrhage should have endoscopic
therapy, preferably with cyanoacrylate
injection.
VASOACTIVE DRUG THERAPY FOR
ACUTE VARICEAL HAEMORRHAGE

 Prior to endoscopic diagnosis,

terlipressin should be given to patients
suspected of variceal haemorrhage.
 After endoscopic treatment of acute
oesophageal variceal haemorrhage
patients should receive vasoactive drug
treatment (terlipressin for 48 hours,
octreotide, or highdose somatostatin each for
three to five days).
antibiotic therapy

 Antibiotic therapy should be commenced

in patients with chronic liver disease who
present with acute upper gastrointestinal
haemorrhage.
Management of bleeding varices not
controlled by endoscopy

 Transjugular intrahepatic portosystemic

stent shunting is recommended as the
treatment of choice for uncontrolled
variceal haemorrhage.
 Balloon tamponade should be considered
as a temporary salvage treatment for
uncontrolled variceal haemorrhage.
Risk factors associated with poor
outcome

The following factors are associated with a poor outcome,

defined in terms of severity of bleed, uncontrolled bleeding,
rebleeding, need for intervention and mortality
 Age.
 Comorbidity.
 Liver disease.
 Inpatients.
 Initial shock.
 Continued bleeding.
 Haematemesis.