UPPER GI BLEEDING

INTRODUCTION
• Upper gastrointestinal (UGI) bleeding is
proximal to the ligament of Treitz.
• UGI bleeding typically presents with
– Hematemesis (vomiting of blood or coffee ground-
like material)
and/or
– Melena (black and tarry stools).
• Ligament of Treitz a thin band of tissue
(peritoneum) that connects and supports the
end of the duodenum and beginning of the
jejunum in the small intestine.
• It's also called the suspensory muscle of
duodenum.
• Contracts to help peristalsis.
• Helps anchor the duodenum.
Ligament of Treitz
Etiology
 •Swallowed maternal blood
•Vitamin K-deficient bleeding
•Stress gastritis or ulcer

Neona
•Esophagitis
•Trauma (e.g., nasogastric tube)
•Vascular anomalies

te •Gastrointestinal duplications
•Coagulopathy (e.g., associated with
infection)
•Milk protein intolerance
•Congenital coagulation factor deficiency
 •Stress gastritis or ulcer
•Acid peptic disease
•Mallory–Weiss tear (associated with
vomiting)
•Esophagitis
Infant •Vascular anomalies
•Gastrointestinal duplications
•Gastric or esophageal varices
•Duodenal or gastric webs
•Bowel obstruction
•Milk protein allergy
 •Mallory–Weiss tear (associated with

Child vomiting)
•Acid peptic disease
•Drug induced, NSAIDs induced ulcers

or •Gastric or esophageal varices

•Esophagitis
•Foreign body

adoles •Caustic ingestion

•Vasculitis (e.g., Henoch–Schönlein
purpura)

cent •Crohn’s disease

•Bowel obstruction
•Hemobilia
 Signs & Symptoms
• Hematemasis • Diffuse abdominal
• Melena pain
• Hematochezia • Dysphagia
• Syncope • Weightloss
• Dyspepsia • Jaundice
• Epigastric pain
• Heart burn
 Hematemasis
Vomiting of blood

Digested blood in stomach Fresh blood

coffee-ground colour Gross blood & clots

Indicates a slower rate of Indicates a higher rate of

bleeding bleeding
 •Stool with partially digested
blood
•Black,tarry,semi solid
Melen •A distinctive odour
•Indicates blood in gi tract for
a >14 hrs.
•The more proximal the
bleeding site more likely
melena will occur.
 •Rare in UGI bleed , more in
Hemat lower GI
•But if present indicates severe
ochezi UGI bleeding as bleeding is so
massive that it doesn’t remain
a in bowel for long enough for
melena to develop.
 Diagnostic workup
1. Is it really blood
2. Assessment of severity
3. Establishing the clinical setting of bleeding
4. Identification of specific site
 Is it really blood

Red vomitus Black stool

• Red food colour agent • Iron
• Fruit juice • Chocolate
• Antibiotic syp , laxative , • Blueberries
phenytoin , rifampin • Spinach
• Candy
 Assessment of severity
• Approximate assessment of blood volume
• Bright red : rapid rate of bleeding
• Hematemasis & melena together indicates
massive blood loss
• Clinical assessment of
– Pallor
– Pulse
– BP
 Vitals Blood loss % Interpretation
Normal <10% Minor
Postural hypotension 10-20% Moderate
Shock >20% Massive
Establishing the clinical setting of bleeding

• H/O drug ingestion : NSAIDS

• ICU stay : Stress ulcer
• H/O pain abd preceding bleeding : Gastritis
• H/O vomiting & rerching : Mallory Weiss
• Present/past h/o liver disease : Variceal
 Identification of specific site

• Engorged veins : CLD

• Bleeding from other sites : Coagulopathy
• Cutaneous hemangioma : Malformations
• Spleenomegaly : Liver d/s
• Ascites : Portal HTN
 Investigation
• HB , HCT , TPC • USG/Doppler
• BG & Cross matching • CT/ANGIOGRAPHY
• LFT , RFT • Radionucleotide
• PT , INR , Aptt • Apt Downy Test
• Endoscopy
• Chest X-RAY
• ABD X-RAY
 Apt Downy Test
• Purpose
– To differintiate between feta & maternal blood.
• Procedure
– Blood is placed in a test tube , sterile water is
added to hemolyse RBC yielding free Hb .This
solution then mixed with 1% sodiom hydroxide.
• Interpretation
– Yellow –brown : Maternal Hb
– No change in colour : Fetal Hb
Endoscopy
Management
 Octreotide

• 1–2 μg/kg IV bolus followed by

• Continuous infusion @1–2 μg/kg/hour

(maximum 4 μg/kg/hour)

• Diluent: 5% dextrose or 0.9% NaCL

 Pantoprazole dose
5–15 kg 2 mg/kg/dose IV and then 0.2
mg/kg/hour IV

>15–40 kg 1.8 mg/kg/dose IV and then 0.18

mg/kg/hour IV

>40 kg 80 mg/dose IV and then 8 mg/hour

Maximum infusion duration: 72 hours

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