3. Introduction
• Definition; Refers to bleeding that
arises from the GI tract proximal to the ligament of Trietz
• Incidence 100/100000 per year in the US much higher in middle
east and Africa
• It is 4 times more common than LGIB
• 80% of significant GIT bleeding
• Overall mortality 6-10%
• Many factors have influenced GIT bleeding in the past 20yrs
i.e. H2 blockers ( SSRI ) (PPI) and AND agents to eradicate h
pylori.
• Over all effect is decrease in hospitalization
5. Introduction ctd
• Gastroesophageal varices
21.9
%
• Gastritis
• Peptic ulcer
• Esophagitis
• Gastric ca
• Gastric
erosions
21.7
%
30.2
%
5.9%
5.8%
3.9%
• Normal
findings
20.0
%
• Etiology of upper GIT bleeding following endoscopy at KBTH,
6. Introduction ctd’
• Gastritis and duodenitis
• Gastric and duodenal
ulcers
• Esophageal varices
• Gastric ca
• Esophageal ca
• Esophagitis
38.9
%
15.8
%
15.8
%
7.3%
3.1
%
3.0
%
• No cause was found for 15.8% of presentation
8. AETIOLOGYOFNONV
ARICEALBLEEDING
PEPTIC ULCER DISEASE( PUD )
• Accounts for 40% of nonvariceal bleeding
• Bleeding results from acid or peptic erosion
• Most bleeding stop spontaneously and require no intervention
• 60-70 % are associated with H. pylori infection
• Eradication of H- pylori is associated with reduced rebleeding and need
for long term acid suppression (Liu, 2013)
• Significant bleeding results when duodenal or gastric ulcers erode
into the gastroduodenal and left gastric artery respectively
9.
10. Aetiology ctd
Stress ulcers
• Stress related gastritis is characterised by multiple superficial erosions of
the entire stomach just as NSAID gastritis
• Results from injury from pepsin and acid in the setting of ischaemia from
hypoperfusion, e.g. severe sepsis, burns, trauma, respiratory and renal
failure etc.
Esophagitis
• An infrequent source of UPPER GIT bleeding
• Usually secondary to GERD
• This can result in mucosal ulceration with chronic blood loss from
insignificant bleed
11. Aetiology ctd
Mallory Weiss1-4cm longitudinal tear
in the gastric mucosa and submucosa near the GEJ
• Few extend into the distal oesophagus.
• Typical patient is an alcoholic ,who vomits gastric content and after prolonged vomiting or retching has
hematemesis
Dieulafoy lesion
• Vascular malformation usually along the lesser curvature within 6cm of gastroesophageal
junction
• Bleeding is from an unusually large vessel (1-3mm) in the submucosa after erosion of gastric mucosa
overlying vessel
• Mucosal defect is usually small (2-5mm) and difficult to identify
• Bleeding can be elusive and massive
12. Aetiology ctd
Malignant neoplasm of upper GIT
• Usually present as chronic anaemia or haemoccult positive blood
• Significant haemorrhage more likely for GIST, lymphomas and leiomyomas
• Rebleeding rates are high with endoscopic therapy
• Surgical resection is hence advised
• Typical case 55yrs old male with chronic anemia with constitutional sx
• Coomon add on sx early satiety epigastric pain
• Recently emerging incidence of young adults with…….
13. Aetiology
Heamobilia
• Diagnosis difficult to make
• Usually associated with trauma, recent instrumentation of the biliary tree,
liver biopsies and intraductal neoplasms
• Suspect in haemorrhage, right upper quadrant pain and jaundice
• Triad seen in 50% of patients
• Endoscopy shows bleeding from ampulla
• Angiography dx and tx of choice
14. Aetiology
Heamosuccus pancreaticus
• Very rare cause of upper GIT bleeding
• Bleeding from pancreatic duct
• Caused by erosion of pancreatic pseudocyst into the splenic artery
• High index of suspicion in a patient with abdominal pain, blood loss and previous history
of pancreatitis
• Angiography is diagnostic and permits embolization
• In cases amenable to distal pancreatectomy, the procedure results in cure
15. Portal hypertensive bleeding/varicealbleeding
• Complications of decompensated liver cirrhosis
• Bleeding is most commonly from reptured varices
• Develop in 30% of people with cirrhosis or PH
• 30% of people who develop gastroesophageal varices bleed
• Hematemesis is massive and associated with
increased risk of rebleeding, transfusion, prolonged
hospital
16. Principles of management
• Initial assessment and
resuscitation
• History and examination
• Localisation of bleeding
• Initiation of therapy
• Prevention of recurrence
17.
18. Initial assessmentandresuscitation
• Presentation of UGIT bleeding is varied, from
haemoccult positive stools on DRE to
exsanguinating haemorrhage, hence need for
structured assessment
ATLS Protocol
• A B C D
• Intubate if airway cannot be maintained :GCS <_8,
massive hematemesis
• Predominant concern is patients haemodynamic
status
• Assess pre-existing deficit and ongoing loss
19. A
TLSClassification of haemorrhagicshock
CLASS I II III IV
Blood loss <750MLS 15% 750MLS-1500MLS
15%-30%
1500MLS-2000MLS
30%-40%
>2000MLS
>40%
HR <100 >100 >120 >140
BP NORMAL NORMAL DECREASED DECREASED
PP NORMAL DECREASED DECREASED DECREASED
RR 14-20 20-30 30-40 >40
U.O >30 20-30 5-15 NEGLIGIBLE
CNS SLIGHTLY ANXIOUS MILDLY ANXIOUS ANXIOUS AND
CONFUSED
CONFUSED AND
LETHGARGIC
20. RESUSCIT
A
TION
• Class I and II = Crystalloids and or colloids
• Class III and IV = Blood + Crystalloids
• Elderly and patients on beta blockers
• Recommendation International Consensus Group is to initiate blood transfusion
Hb <7g/dl for hemodynamically stable patients
Hb <9g/dl for patients with increased risk of adverse outcome in setting of
significant anaemia .e.g. unstable angina, ongoing active bleeding
21. RESUSCIT
A
TION
• Elevate legs about 15 degrees
• Secure 2 IV access with size 16 or 18 cannula, and blood is taken for GXM,
FBC, BUE, LFT, Clotting profile
• 1.0L crystalloid is given in 45mins , the rate is adjusted depending on the CVP,
¼ hrly pulse, BP, venous filling, moistness of mucous membranes and more
importantly urine output
• Use 3 to 1 rule as a guide; 1 ml of estimated blood loss :3 ml of crystalloids
• Supplemental oxygen
22. History andexamination
• Possible site and cause of bleeding
• Severity, timing, duration and volume of the
bleeding
• Risk factors and co-morbidities
• Previous surgery or previous history of UGIT
bleeding
• Medications
23. Probable source of GIbleeding with thegut
Clinical indicator Probability of upper GIT source Probability of lower GIT
source
Hematemes
is
Almost
certain
rar
e
Melen
a
probabl
e
possibl
e
Hematochezi
a
possibl
e
probabl
e
Blood streaked
stool
rar
e
Almost
certain
Occult blood in
stool
possibl
e
possibl
e
24. history
• history of dyspepsia suggestive of PUD
• liver disease or alcohol abuse may be suggestive of bleeding oesophageal
varices
• Prolonged vomiting or retching after a bout of alcohol is typical of MW tear
• Massive bleeding preceded by hematemesis and /melena and abdominal or back pain
is suggestive of aorta-enteric fistula in 50% of cases in a patient with previous aortic
surgery
• Weight loss raises spectre of malignant disease
• History of ingestion of salicylates, NSAIDS, SSRI, anticoagulants particularly in
elderly
25. Examination
• Signs pointing to extent of bleeding
Pallor, sweating, cold extremities, collapsed veins, tachycardia, hypotension,
restlessness and coma
• Signs pointing to cause
Epigastric tenderness =PUDx
Hepatosplenomegally spider naevi, ascites =oesophageal varices
Epigatric mass = ca stomach
Telangiectasia of mouth and lips= hereditary telangiectasia
Pulsatile expansile mass suggestive of aorto-enteric fistula
DRE must be performed to exclude rectal ca or haemorrhoids
Oropharynx and nose should be examined
26. Localisation of bleeding
• NG tube and gastric lavage to examine aspirate and remove
particulate matter and clots to enhance endoscopy
• unreliable in localising the bleeding site
• But still important in diagnosis, prognosis, visualisation and has therapeutic
effect
• May show
Coffee ground = recent bleeding
Active bleeding= red blood in aspirate that doesn’t clear
No blood/clear=active bleeding not likely, but doesn’t exclude UGIT
lesion(15- 18%)
Bilious aspirate= almost definitely not UGIT bleeding
27. ENDOSCOPY
• After haemodynamic stability
• It is the diagnostic modality of choice with high
sensitivity and specificity for localising the site of
ongoing bleeding
• It is used therapeutically and for biopsy
• Usually within first 24hrs
28. Endoscopyctd
• Urgent or emergent endoscopy is associated with:
Decreased accuracy o/a poor visualisation
Increased risk of complications .e.g. aspiration, respiratory depression, GI
perforation
• For patients with cirrhosis or on warfarin endoscopy is done if INR <2.5
29. Other diagnostictest
• RBC Scintigrapy: highly sensitive and detects bleeding rates of 0.05-
0.1ml/min. But has prolonged imaging time and therefore not ideal for
unstable patients. It has a poor spatial resolution and cannot precisely
localise active bleeding
• Video capsule endoscopy: currently not considered a substitute for
endoscopy but beneficial in evaluation of obscure gastrointestinal
bleeding.
• Barium meal : currently contraindicated
• Angiography excellent in localization of bleeding site and estimation
• Can detect
30. Angiography generally is diagnostic of extravasation into
the intestinal lumen only when the arterial bleeding rate is
at least 0.5 mL/min.
The sensitivity of mesenteric angiography is 30% to 50%
(with higher sensitivity rates for active GI bleeding than for
recurrent acute or chronic occult bleeding), and the
specificity is 100%
31. Riskstratification
• Not all patients require in patient management
• Several risk assessment models permit identification of
persons with low risk of recurrent or life threatening
haemorrhage
• Such patients with low risk are suitable for early
discharge or OPD care
• Stratifying results in decreased resource utilisation
• Scoring systems are used to predict the need
for ICU care or emergent endoscopic
evaluation
32. Riskstratification
The most important predictors of rebleeding are:
• Age > 60yrs
• Hb < 8g/dl
• Endoscopic stigmata of significant hemorrhage
(SSH)
• Co-morbidities
• Ulcer size >2cm
* These are combined in the risk stratification score
33. Riskscores
• Glasgow Blatchford Score or modified GBS
• Rockall score( RS )
• Aims 65
• GBS;doesn’t take endoscopic data unlikeR
S
• GBS Out performed RS and AIMS in predicting need for clinical
intervention, rebleeding and mortality. (Stanley,2017)
34.
35. Specific management
• Initially conservative for all
• Stress ulcers
Treatment of underlying condition
Antacids and iv PPIs
Bleeding usually resolves after 24-48hrs
MW syndrome ; 90% will resolve spontaneously by 72hrs
Supportive therapy
In rare cases of severe ongoing bleeding ,local endoscopic therapy with
injection and electrocoagulation is effective
Angiographic embolization with absorbable material like gelatin sponge
have been successfully employed in cases of failed endoscopic
management
36. Specific managementctd’
• Peptic ulcer disease
Iv PPI started whiles preparing for endoscopy.
increase in PH above 6.0 enhances blood coagulability, inactivates pepsin which
promotes platelet aggregation and inhibit fibrinolysis
Current( ICG )guideline: iv PPI 80mg bolus, followed by a continuous infusion of
8mg/hr for 72hrs, reduces rebleeding and mortality
This is followed by twice daily oral PPI for 14 days, and then once daily PPI
therapy
37. Peptic ulcerdisease
surgical options
• Endoscopic therapy indicated for FORREST I-IIa
Injection of 10-16mls of 1:10000 adrenalin +ethanol
Thermal treatment :bipolar diathermy, laser photocoagulation, heat
probes
Fibrin glue or thrombin injection
heamoclips
70% would not bleeding at re endoscopy
NEW TRENDS
Heamostatic sprays
Doppler endoscopic
38.
39. Prophylactic antibiotic therapy should be
offered at presentation to all patients with
suspected or confirmed variceal bleeding.
Balloon tamponade should be considered as a
temporary salvage treatment for uncontrolled variceal
haemorrhage
Management of Variceal bleeding
43. Specificmanagementctd
Dieulafoy’s lesion
• its treated endoscopically by placement of heamoclips,
electrocoagulation and photocoagulation
• Effective in 80 -100 %of cases.
• In failure of the above angiographic coil embolization can be done
44. Prognosis
• Overall mortality of UGIT bleeding is 10-15%
• Mortality increases with age ,>33% in patients over 70
• With conservative treatment alone 20% rebleed in 5-10yrs
• Only 4.5% rebleed after surgical treatment
• Predictors of mortality are age ,shock ,co morbidity, delay in diagnosis and
rebleeding
45. conclusion
• Upper GIT bleeding is a common clinical problem with diverse presentation
• Management is multidisciplinary
• The surgeons role in management cannot be overemphasised
• Determination of site of bleeding is relevant to direct intervention without
delay but this should not override appropriate resuscitative measure
• Risk assessment helps in resource utilization
• Distinction between variceal and nonvariceal causes guides initial and
definitive management
