This is a detailed approach to a patient with acute upper Gastrointestinal bleeding - including hematemesis

1. APPROACH TO PATIENT
WITH
Acute upper
gastrointestinal
haemorrhage / bleeding
By:-
Jwan Ali Ahmed AlSofi

2. Contents
 Introduction.
Definition and epidemiology
 Etiology
Risk factors
Assessment
Complications
Prognosis

3. Introduction
 Acute UGIB is a potentially life-threatening condition
 It associated with 10 % mortality rate
 UGIB is defined as bleeding derived from a source proximal to
the ligament of Treitz
 Can be divided into variceal and non-variceal.
– Variceal is a complication of end stage liver disease.
– While non variceal bleeding associated with peptic ulcer disease or other
causes of UGIB.
 UGIB is 4 times more common than bleeding from lower GIT,
with a higher incidence in male.

5. Definition of UGIB
Upper GI bleeding is a bleeding arising from a
source above ligament of Treitz.ie above third
part of duodenum

7. Definitions:-
1. Hematemesis: vomiting of blood ,could be: either
1. Digested blood in the stomach (coffee-ground ) emesis that indicate slower
rate of bleeding
2. Fresh/unaltered blood (gross blood and clots, indicates rapid bleeding)
2. Melena:
– stool containing of partially digested blood
– Criteria:- black tarry, semi-solid, shiny and has a distinctive odor
– when its present it indicates that blood has been present in the GI tract for at
least 14 h.
– The more proximal the bleeding site, the more likely melena will occur.
3. Hematochezia:-
– usually represents a lower GI source of bleeding
– an upper GI lesion may bleed so briskly that blood does not remain in the bowel
long enough for melena to develop.

8. Clinical scenario
 A 35 years old male patient presents with sudden
onset of vomiting of blood of few hours duration
 Approach to management of this patient entails a
knowledge of :
– The causes of UGIB
– Assessing the severity of UGIB
– The available diagnostic measures
– The available therapeutic measures

9. Causes

10.  Dieulafoy's lesion (a vascular malformation of the proximal
stomach).
 Angiodysplasia.
 Haemobilia (bleeding from the gallbladder or biliary tree).
 Pancreatic pseudocyst and pseudo-aneurysm.
 Aortoenteric fistula.
 Bleeding diathesis.
 Ehlers-Danlos syndrome.
 Pseudoxanthoma elasticum.
 Gastric antral vascular ectasia ( GAVE).
 Osler-Weber-Rendu syndrome.
Rare causes of Upper GI Bleeding:

11. Assessment
 History
 Examination
 Investigation
 Hospital admission
 Management

12. Approach to a patient in distress
 If the patient looks agitated, dizzy ,weak and pale,
– 1st check the vital sign before taking full history
– If hypotensive put an IV line and start IV fluid
– Take blood sample for lab ix e.g. CBC. ,B.urea, INR ,
fibrinogen level….etc
– Asses the Blatchford score:
 history of : melena, liver ds , HF, syncope
 Vital Sg,
 Hb,
 BU ,

13. Assessment: History:
1. Features of blood loss: wheather hematemesis ,
melena, hematochezia bright or clot of blood
2. Systemic manifestation of blood loss; shock
syncope, anemia
3. Clincal features of underlying cause: dyspepsia,
jaundice, weight loss
4. Ask about Other causes of black stool
5. History of epistaxis or hemoptysis: to rule out the GI
source of bleeding.

14.  Drug history: NSAIDs, Aspirin, corticosteroids,
anticoagulants, (SSRIs) particularly fluoxetine and
sertraline.* Iron preparation, Bismuth cause blck stool;
 Past medical :previous episodes of UGIB, DM;
coronary artery disease; chronic renal or liver disease; or
chronic obstructive pulmonary disease.
 Past surgical: previous abdominal surgery

16. Examination
 The main aim of examination is to:
 assess the amount of blood loss and
 look for signs of shock.
 A secondary aim is to look for
 signs of underlying disease and
 significant comorbid conditions , for example: liver ds
renal ds, COAD.

17. • SIGNS of shock:
Cold extremeties, Tachycardia, Hypotension
Chest pain, Confusion, Delirium, Oliguria, and
Vital Sign (VS):
Pulse = Thready pulse
BP = Orthostatic Hypotension
• postural hypotension may be detected and usually
indicates a blood loss of 20% or more.
Approach Cont.
Examination :

18. • Skin changes:
Cirrhosis – Palmer erythema, spider nevi
Bleeding disorders – Purpura /Echymosis
Sign of Coagulation disorders – Haemarthrosis, Muscle
hematoma.
• Signs of dehydration (dry mucosa, sunken eyes, skin turgor
reduced).
• Signs of a tumour may be present (nodular liver, abdominal
mass, lymphadenopathy, and etc.
• Subcutaneous emphysema and vomiting suggests
Boerhaave's syndrome.
• DRE : fresh blood, occult blood, bloody diarrhea
• Respiratory, CVS, CNS  For comorbid diseases

20. Investigations
Laboratory
- CBC
- Cross matching.
- Coagulation profile
- LFT
- RFT & electrolyte.
- Gastrin level.
Imaging
- CXR
- Abdominal X-ray
- CT scan & US
- Nuclear medicine
- Angiography

21. • complete blood count (CBC):-
• amount of blood loss.
• CBC should be checked frequently(q4-6h) during the first day.
• Hemoglobin Value, Type and Cross match Blood
– Hb < 10gm is an indication for blood or packed RBC transfusion
– The patient should be cross matched for 2-6 units, based on the rate of
active bleeding.
– The hemoglobin level should be monitored serially in order to follow the
trend.
– An unstable Hb level may signify ongoing hemorrhage requiring further
intervention.
– normal Hb level at presentation doesn't exclude severe bleeding, up to 48 hr
may take for complete hemodilution to occurs
Lab Diagnosis :

22. Lab.Investigations
 The BUN-to- Creatinin ratio increases in (UGIB).
– A ratio of greater than 36 in a patient without renal
 The prothrombin time (PT), International Normalized Ratio
(INR) and activated partial thromboplastin time( APTT),
should be checked to document the presence of a
coagulopathy
• Prolongation of the PT based on an INR of more than 1.5 may
indicate moderate liver impairment.
• A fibrinogen level of less than 100 mg/dL also
indicates advanced liver disease with extremely poor
synthetic function

23. • Liver FT- to detect underlying liver disease
• Renal FT- to detect underlying renal disease
• Calcium level- to detect hyperparathyroidism and
monitoring calcium in patients receiving multiple
transfusions of citrated blood
• Gastrin level
• Cardiac enzymes and ECG- An electrocardiogram
(ECG) should be ordered to exclude arrhythmia
and cardiac disease, especially acute myocardial
infarction due to hypotension

24. Investigations Endoscopy :
Endoscopy is the primary diagnostic investigation in
patients with acute UGIB.
 Endoscopy should be undertaken immediately
after resuscitation and stabilization of the hemodynamic
status Preferably within 24 hours of admission
 endotracheal intubation (may be needed), and
adequate monitoring in an intensive care unit (ICU)
setting have been achieved.

25. Aetiology
 Common causes:
Peptic ulceration

26. • Computed tomography (CT) and ultrasonography
may be indicated for the evaluation of
• liver disease with cirrhosis,
• cholecystitis with hemorrhage,
• pancreatitis with pseudocyst and hemorrhage,
• aortoenteric fistula, and
• other unusual causes of upper GI hemorrhage.
• Nuclear medicine scans may be useful in
determining the source of active hemorrhage when
the cause of bleeding is obscure
Cont, Investigations of UGIB

27. Angiography :
 Angiography may be useful if bleeding persists and
endoscopy fails to identify a bleeding site. Angiography
along with transcatheter arterial embolization (TAE) should be
considered for pt
– with a known source of arterial UGIB that does not respond to
endoscopic management,
– with active bleeding and a negative endoscopy.
 In cases of aortoenteric fistula, angiography requires
active bleeding (1 mL/min) to be diagnostic.

28. • CHEST X-RAY-Chest radiographs should be
ordered to exclude aspiration pneumonia, effusion,
and esophageal perforation.
• Abdominal X-RAY- erect and supine films should
be ordered to exclude perforated viscous and ileus.
Imaging :

29. Nasogastric Lavage
 A nasogastric tube is an important diagnostic tool.
1. Give crude estimation of rapidity of bleeding
2. Better visualization during endoscopy
3. Prevent the development of Porto systemic encephalopathy in
cirrhosis
4. Increases PH of stomach, and hence, decreases clot desolation
due to gastric acid dilution
5. Tube placement can reduce the patient's need to vomit
– During gastric lavage use saline and not use large volume of
water to avoid water intoxication.
– Gastric lavage should be done in alert and cooperative patient to
avoid bronco-pulmonary aspiration

30. Steps of Management
1. Resuscitation to Stabilize the patient
hemodynamic stutus by restoring the circulation.
2. Assess the Blatchford score severity of the UGIB
3. Identify the source of bleeding.
4. Definitive treatment of the cause.

31. Resuscitation and initial management
 Protect airway: position the patient on side
 IV access: use 1-2 large bore cannula
 Restore the circulation:
– Either colloid or crystalloid solutions may be used to achieve volume restoration
prior to administering blood products;
if pts haemodynamically stable give 5%G.W. infusion,
if not give colloid 500ml/1hr and then crystalloid and continue until blood is
available.
 Assess Blatchford score : this need knowledge of the following:
– Hb, B.urea, BP. PR, presence of melena or syncope, sg&sx of heart
failure or liver disease

32. Hospital admission
Consider for admission and early endoscopy (and
calculation of full Rockall score) if:
 aged ≥60 years (all patients who are aged >70 years
should be admitted); or
 witnessed haematemesis or haematochezia (suspected
continued bleeding); or
 haemodynamic disturbance (systolic blood pressure
<100 mm Hg, pulse ≥100 bpm); or
 liver disease or known varices.

33. Risk assessment
Use the following formal risk assessment
scores for all patients with acute upper
gastrointestinal bleeding:
– the Blatchford score at first assessment, and
– the full Rockall score after endoscopy.

34. Interpretation of Blatchford score
 A score of 0 is the cut-off with any patient scoring >0 being at risk of
requiring an intervention e.g. endoscopy or blood transfusion.
 Score >6 were ass.w >50% risk of needing an intervention
 Score 0 indicate low risk, pt suitable for out patient management. If:
 Hb>12.9g/dl (men )or >11.9gm/dl (women) ,Systolic BP>109mm Hg, PR<100 bpm,
BUN<18.2mg/dl, no melena or syncope, no past or present liver or heart disease

35. Risk assessment
The full Rockall score
 This is determined after endoscopy
 used to assess the risk of re- bleeding
 Attempts to identify patient of adverse outcome and predict mortality
 A convenient mnemonic is ABCDDE- i.e. Age, BP fall (shock),Co-morbidity,
Diagnosis, and Evidence of bleeding

National Institute for Health and Clinical Excellence
(NICE)

36. Blood and blood product transfusion:
 Decisions on blood transfusion should be based on the
full clinical picture
 red cell transfusion should be considered after loss of
30% of the circulating volume
 Prothrombin complex concentrate should be used
for patients who are taking warfarin and actively
bleeding.
 Recombinant factor Vlla should not be used except
when all other methods have failed.

37.  Platelet transfusions should be offered to patients
who are actively bleeding and have a platelet count
of less than 50 x 109/litre.
 Fresh frozen plasma should be used for who are
actively bleeding and have either
 a prothrombin time (INR) or activated partial
thromboplastin time (APTT) greater than 1.5 times
normal.
 a. a fibrinogen level of less than 1 g/litre,  If a
patient's fibrinogen level remains less than 1.5 g/litre
despite fresh frozen plasma use, offer cryoprecipitate
as well.

38. Proton pump inhibitors
 Do not offer acid-suppression drugs (proton
pump inhibitors or H2-receptor antagonists)
before endoscopy to patients with suspected
non-variceal upper gastrointestinal bleeding.
 Offer proton pump inhibitors to patients with
non-variceal upper gastrointestinal bleeding
and stigmata of recent haemorrhage shown at
endoscopy.

39. IV PPI
 LOADING
 MAINTENACE

40. Management of non- variceal bleeding
Endoscopic treatment
one of the following interventions should be used:
1. A mechanical method (eg: clips) with or without
adrenaline (epinephrine).
2. Thermal coagulation with adrenaline (epinephrine).
3. Fibrin or thrombin with adrenaline (epinephrine).
*** Do not use adrenaline as monotherapy for the
endoscopic treatment of non-variceal upper GI bleeding.

41. Treatment after first or failed
endoscopic treatment:-
 Indications for a repeat endoscopy:-
1. for all patients at high risk of re-bleeding,
2. if there is doubt about adequate haemostasis at the first
endoscopy.
3. patients who re-bleed with a view to further endoscopic
treatment or emergency surgery.
 Offer interventional radiology to unstable patients
who re-bleed after endoscopic treatment.
 Refer urgently for surgery if interventional radiology
is not promptly available.

42. Argon plasma coagulation (APC)
42

43. 43

44. Surgical intervention
in UGIB
Age over 60 years:
• Transfusion >4 units
in 24 hours.
• One re-bleeds.
• Continued bleeding.
Age under 60 years:
• Transfusion >8 units
in 24 hours.
• Two re-bleeds.
• Continued bleeding.

45. Managment of variceal bleeding
 Vasopressin is a potent splanchic vasoconstrictor agent
continuous IV infusion of 0.2-0.4 IU/min, (should not be given via a central IV
line,)
 Vasopressin always sb accomp. By IV nitroglycerin at a dose of 40mcg/min
not to excced 400 mcg/min to maintain systolic BP greater than 90mmHg
 Terlipressin is a synthetic analogue to Vasopressin have
longer biologic activity and fewer SE than vasoprissin.
 Treatment should be stopped after definitive haemostasis has been
achieved, or after five days, unless there is another indication for
its use.
 Octeriotide a synthetic analogue of somatostatin is DOC
in acute variceal bleeding is usually adminstered at a dose of 50mcg/hour
(i.e 1 vial of 0.1mg in 2 hours -12 vial for 24hours)

46.  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
Cont.

47. Complications could be:
-gastric and oesophageal ulceration.
-pneumonia.
-oesophageal perforation.
Balloon tamponade

48. Band ligation

49. Stent insertion
Oesophageal stent insertion is generally a very safe procedure,but
there are some risks:
1- Occasionally a little bleeding can occur during the procedure.
2- Some people get heartburn and acid reflux afterwards.
3- Rarely the stent may slip out of the position.
4- Very rarely, the placement of a stent may cause a tear in the
oesophagus.

50. Transjugular intrahepatic portosystemic shunts
(TIPS)
*Transjugular intrahepatic portosystemic shunting is an effective
salvage procedure for stopping acute variceal haemorrhage,
controlling bleeding from gastric varices, and congestive
gastropathy after failure of medical and endoscopic treatment.

51. Gastric varices
1. Endoscopic injection of Nbutyl-2cyanoacrylate.
2. Transjugular intrahepatic portosystemic shunts
Gastric varices are difficult to be banded

52. Control of bleeding and prevention
of re-bleeding in patients on
NSAIDs, aspirin or clopidogrel
 Continue low-dose aspirin for secondary prevention of
vascular events in patients with upper gastrointestinal
bleeding in whom haemostasis has been achieved.
 Stop other non-steroidal anti-inflammatory drugs
(including cyclooxygenase-2 [COX-2] inhibitors) during
the acute phase in patients presenting with upper
gastrointestinal bleeding.
 Discuss the risks and benefits of continuing
clopidogrel (or any other thienopyridine antiplatelet
agents) in patients with upper gastrointestinal bleeding
with the appropriate specialist (for example, a cardiologist
or a stroke specialist) and with the patient.

53. Questions