Upper Gastrointestinal Bleeding

1. UPPER GI BLEEDING
PRESENTER: DR. VISHNU THEJA. POSA
MODERATOR: PROF. KARAM ROMEO SINGH

2. INTRODUCTION
• Gastrointestinal (GI) bleeding is a common and potentially life-threatening
problem.
• Mortality rate of upper GI bleeding (6% to 10%) has remained unchanged
over the years.
• Manifestastion of UGIB is Malena and
Haematemesis.

3. HAEMATEMESIS:
• Gastric acid may alter the colour of the vomited blood.
• If vomiting occurs shortly after the onset of bleeding, the vomitus appears red.
• Precipitated blood clots and acid-degraded blood produce a characteristic
‘coffeeground’ appearance of the vomitus.
MELAENA:
• Melaena is black, tarry, foul-smelling stool due to acid haematin (hb degredation
product)
• 60 mL of blood can cause single melaenic stool.
• Melaena may persist a week.

4. CAUSES

5. Initial Assessment
• A,B,C Assessment
• Blood loss of <500 mL is rarely associated with systemic signs.

6. Resuscitation

7. Diagnostic Evaluation
• Stigmata of liver cell failure with painless UGI bleed may indicate Variceal Bleed
• History of NSAID intake, pain epigastrium may indicate Peptic Ulcer Bleed
• A history of retching and vomiting prior to haematemesis may indicate Mallory-
Weiss syndrome
• History of aortic graft can have Aortoenteric Fistula
• History of radiation therapy may indicate Radiation Enteritis
• History of shock before bleeding may indicate Ischemic Enteritis

8. Poor Prognostic Indicator

9. Acute Variceal Hemorrhage
• Oesophageal varices, Gastric varices can bleed.
• IV terlipressin 1 mg every 4 to 6 hourly or octreotide 50 to 100 µg bolus,
followed by infusion at 50 µg/hour.
• Sengstaken Blakemore tube with oesophageal and gastric balloon inflated with
250ml air for mechanical haemostasis.

10. EVL
• Involves the placement of rubber bands around a portion of the varix causing
ischaemic necrosis of the mucosa and submucosa.
• Application of the bands is started at the gastroesophageal junction and progresses
cephalad in a helical fashion.
• Heals in 14 to 21 days.
• EVL sessions are repeated at approximately 2-week intervals until varices are
obliterated, usually requiring 2 to 4 ligation sessions.

12. OTHER MODALITIES
1. Transjugular Intrahepatic Porto-systemic Shunt (TIPSS)
2. Gastroesophageal Devascularisation
3. Balloon-occluded Retrograde Transvenous Obliteration (B-RTO)
Indications for TIPS
• Multiple episodes of variceal bleeding
• Refractory variceal hemorrhage despite adequate endoscopic treatment
• Bleeding portal hypertensive gastropathy
• Bleeding gastric varices

13. Prophylaxis of Variceal Bleeding
• After control of initial haemorrhage, prevention of variceal rebleeding is an
important aspect of the management of portal hypertension. Non-selective
beta-blockers reduce cardiac output and cause splanchnic vasoconstriction,
reducing portal venous pressure

14. Primary Prophylaxis In Esophageal Varices
Ligation is more effective than beta-blocker therapy in reducing first bleeding. @GH
Secondary Prophylaxis In Esophageal Varices
Combined endoscopic and drug therapy is more effective than either therapy alone. @GH
Carvedilol Versus Propranolol For Secondary Prophylaxis Of Variceal Hemorrhage
In Patients With Liver Cirrhosis
Carvedilol was equally efficacious and may be preferred over propranolol due to lower
rate of rebleeding. @ARGH

15. • All patients with cirrhosis should be endoscoped at the time of diagnosis (level
1a).
• If at the time of first endoscopy no varices are seen, endoscopy should be at 2–
3-year intervals (level 2a).
• Grade I varices» should be endoscoped at yearly intervals (level 2a).
• Varices with red signs or grade 2–3 varices primary prophylaxis is must (level
1a).

16. PEPTIC ULCER
• Duodenal > Gastric.
• Up to 80% of duodenal ulcers and 50% of gastric ulcers are caused by H pylori.
• Bleeding stops spontaneously in 80% cases.
• Proton pump inhibitors (PPI) are the mainstay of pharmacological treatment.
• High dose intravenous (IV) omeprazole or pantoprazole (80 mg IV bolus
followed by 8 mg per hour for 72 hours).
• Patients with ongoing bleed, haemodynamic compromise, and high transfusion
requirements need urgent endoscopic therapy

17. • The most popular endoscopic therapy is injection therapy using epinephrine
(1:10,000).
• Newer techniques include application of metal clips, band ligation, argon plasma
coagulation and endoloops.
• Presence of hypotension at admission and an ulcer size larger than 2 cm are
independent predictors of failure of endoscopic therapy
• Eradication of H. pylori and stopping NSAIDS are two factors shown to prevent
recurrent bleeding.

18. Erosive Gastropathy
• Erosive gastropathy refers to endoscopically visualised subepithelial
haemorrhages and erosions.
• Antacids, H2 receptor blockers, proton pump inhibitors and sucralfate decrease
bleeding from gastric erosions.
• Endoscopic argon plasma coagulation

19. Mallory-Weiss Syndrome
• Recurrent vomiting or retching can lead to mucosal tears at the gastro-
oesophageal junction causing haematemesis
• Bleeding is usually not massive and stops spontaneously
• Haemoclips

20. Dieulafoy’s Lesion
• Dieulafoy’s lesions are prominent submucosal vessels.
• These lesions are difficult to identify if they are not bleeding actively during
endoscopy.
• Argon plasma coagulation

21. GAVE
• AKA watermelon stomach.
• It is associated with cirrhosis and scleroderma.
• Endoscopic hemostasis with thermal heat modalities such as laser and argon
plasma coagulation

22. Aortoenteric Fistula
• Communication between the abdominal aorta and duodenum.
• Infected abdominal aortic surgical graft can cause AE fistula
• Diagnostic suspetion history of an abdominal aortic aneurysm or by palpation of a
pulsatile abdominal mass
• Patients with an acute UGIB and a history of an aortic aneurysm repair should
undergo urgent CT with IV contrast or MR angiography.
• Surgical treatment is required to remove the infected graft

25. REFERENCES
• HARRISON PRINCIPLES OF INTERNAL MEDICINE
• THE WASHINGTON MANUAL OF CRITICAL CARE
• API TEXT BOOK OF MEDICINE
• SLEISENGER AND FORDTRAN’S GASTROINTESTINAL AND LIVER
DISEASES
• JOURNAL OF HEPATOLOGY

26. THANK YOU