Describes the symptoms and management of Upper GI bleed from a surgeon's perspective

1. Acute Gastrointestinal Bleeding
Upper GI tract
Dr. Niladri Banerjee
MBBS, MS, MRCS Ed
MCh (Trauma Surgery & Critical Care)
Assistant Professor, Surgery
AIIMS, Jodhpur

2. Content
• Introduction
• Causes of UGI bleed
• Presentation, diagnosis & principles of
management
• Specific Management

3. INTRODUCTION

4. GI Bleeding
Upper Lower
GI Bleed – Overt – Acute, Chronic
Occult – Chronic
Obscure – cause not identified
Ligament of Treitz

5. Upper GI Bleeding
• Upper GI Bleed – Hematemesis, Melena
• Hematemesis- Coffee ground vomitus
• Melena - Black tarry stool, a foul odour
Colour and smell - Acid Hematin
• 60 ml of blood loss - melena
• Melena may persist for 3 days

6. AIIMS Delhi Data: 5 years
• Total admission - 5174
• GI Bleed - 1460
(28%)
• Mortality - 13%

7. CAUSES OF UGI BLEED

8. Major Causes of UGI Bleed
Ulcer
EMD(erosive mucosal
disease
Varices
s

9. Uncommon causes
Ca.
stomach Hemobilia
AV malformation

10. Causes of UGIB
Non-variceal bleeding
• Gastric and duodenal ulcers (30%-40%)
• Gastritis and duodenitis (20%)
• Esophagitis (5%-10%)
• Mallory-Weiss tears (5%-10%)
• Arteriovenous malformations (2%)
• Tumors (5%)
• Other causes (Dielafoy lesions,GAVE,
Aortoenteric fistula, Hemobilia,
Hemosuccus pancreaticus)
Portal hypertensive bleeding
• Gastroesophageal varices (>90%)
• Hypertensive portal gastropathy
(<5%)
• Isolated gastric varices (rare)

11. EMD
7%
Peptic
ulcer
60%
Variceal
25%
Others
8%
West
Peptic
ulcer
24%
Variceal
55%
EMD
18%
Others
3%
India
Etiology of UGI Bleed: West vs India

12. Prevalence of variceal bleeding in UGI bleeding- In
Indian scenario

13. Prevalence of variceal bleeding in UGI bleeding- In
Indian scenario

14. PRESENTATION, DIAGNOSIS &
PRINCIPLES OF MANAGEMENT

15. Presentation
• May present in subtle way (unexplained
microcytic anemia, positive occult blood in
stool) in the OPD
• Or may present as massive GI hemorrhage in
the emergency

16. Obscure bleeding (OPD)
• Clinical recognition:
– History of dyspepsia
– NSAIDs intake
– History of jaundice
– Splenomegaly
– Ascites
– Collaterals
Peptic ulcer
Variceal bleed

17. Acute exsanguinating bleed
• Patient in shock
• Severe bouts of hematemesis and melena
• Ryle’s tube shows bright red blood/coffee
ground

18. Principles of management
Initial assessment and resuscitation
History and examination
Localise bleeding
Initiate therapy

19. Initial Assessment
• ABC assessment
• To assess magnitude of bleeding
– Degree of shock
– Haematocrit
– Elderly vs young
• Lab evaluation (ABG, Base deficit, lactate)
• Resuscitation
– Ringer’s Lactate, Massive transfusion protocol

20. Resuscitation
• Initial 1-2 litres of crystalloids (RL)
• Early administration of blood
• Massive transfusion protocol (1:1:1 ratio of pRBC,
FFP and platelets)
• Restrictive target Hb strategy (Target around
7gm/dL) *
* Villanueva et al N Engl J Med. 2013

21. History and Physical Exam
• Symptoms assessment
• Medications
• Previous Surgery
• Head to toe examination

22. Risk stratification
It includes
– BUN
– Hb
– SBP
– Pulse
– Presence of melena, syncope, hepatic or cardiac dysfunction
Glasgow Blatchford Bleeding score: screening tool to
assess the likelihood that a person with acute upper GI bleed
will need some medical intervention
>6 means >50 % chance of
intervention

23. Sabiston textbook of surgery 21st ed

24. Initiation of therapy
• Obtain immediate consultation with gastroenterologist,
surgery and interventional radiology
• Pharmacotherapy (Ulcer)
– Pantoprazole/Esomeprazole 80 mg iv stat and start infusion at 8
mg/hour
• Pharmacotherapy (Variceal bleed)
– somatostatin or an analogue (eg, octreotide 50 mcg IV bolus followed
by 50 mcg/hour continuous IV infusion)
– IV antibiotic (eg, ceftriaxone or fluoroquinolone)

26. SPECIFIC MANAGEMENT

27. Peptic Ulcer Bleeding
• Peptic Ulcer: DU, GU, Stomal ulcer
• 15-20% of all ulcer bleed
• 50% of bleeds associated with NSAID use
• Presentation – Hematemesis + melena
- Melena alone

28. Peptic ulcer bleeding: Natural History
• 70% - bleeding stops spontaneously
• Rebleeding - 25%
• Mortality - 10%
- unchanged over the years

29. • Prognostic factors
- age >60 years
- co-morbid illness
- shock at presentation
- Hematemesis/red blood in NG lavage
- Endoscopy - active bleed, visible vessel
• High risk vs. low risk
Peptic ulcer bleeding: Prognostication

30. Age
<60 yr
60–79 yr
>80 yr
Shock
Heart rate >100 beats/min
Systolic blood pressure <100
Coexisting illness
CAD, CHF
Renal or Liver failure, Cancer
Endoscopic diagnosis
No lesion observed, M-W tear
Any other diagnosis
Cancer of upper GI tract
Endoscopic stigmata of recent hemorrhage
2C, 3
1, 2A, 2B
0
1
2
1
2
2
3
0
1
2
0
2
Score <2 low risk
Rockall Score for Prognosis

31. Management: Fundamental principles
• Determine the source of bleeding
• Stop active bleeding
• Treat the underlying abnormality
• Prevent recurrent bleeding
• Most important: Immediate assessment and
stabilization of the hemodynamic status

32. Peptic ulcer bleeding: Management
• Resuscitation: 2 lines, iv fluids
• BT if HB <8 gm/dl
• Pharmacotherapy
• Endoscopic Rx
• Surgery
• Prevention of long term re-bleeding

33. Blood transfusion: Target
• In elderly - 10 gm/dl
• In younger, healthy patients – 8 gm/dl
• In Portal hypertension : 7-8 gm/dl
• Hematocrit better guide after volume resuscitation
• Packed red blood cells are preferred
• FFP should be given if blood requirement more
than 10 units or if coagulopathy

34. Ulcer Bleeding: Pharmacotherapy
• Acid Suppression: clot stabilization
- H2 blockers no benefit
- Proton pump inhibitors useful
• Tranexamic acid: ? Benefit
• Anti H. pylori treatment

35. Ulcer Bleeding: Role of PPIs
• Omeprazole alone, No endoscopic Rx
- reduce re-bleeding, need for surgery
(Khuroo et al, 1997)
• Omeprazole + endoscopic Rx
Re-bleed day 3 - 0 vs 8%
day 14 - 2 vs 12%
• Pantoprazole – IV infusion similar efficacy
(Lin et al,1999)

36. Ulcer Bleeding: Anti-H. pylori Rx
Anti-HP Omeprazole
(n=29) (n=22)
Ulcer recurrence 3/29 9/22
Re-bleeding 0/29 6/22
(Jaspersen et al, 1995)
Re-bleeding 0/16* 5/15*
(Rokkas et al,1995)

37. Ulcer Bleeding : Endoscopic Therapy
Timing of endoscopy
• Emergency diagnostic endoscopy – no role
• Endoscopy in emergency - if therapeutic intent
• Endoscopic signs - Stigmata of Recent
Hemorrhage (SRH)

38. Forrest Class 1b
Forrest Class IIa

39. Forrest Class IIb
Forrest Class IIc
Forrest Class III

40. Ulcer Bleeding : Endoscopic Therapy
• Who requires EndoRx ?
Forrest class Re-bleeding EndoRx
Ia spurting bleeding 50-65% 
Ib active ooze 30-40% 
IIa visible vessel (NBVV) 40-50% 
IIb adherent clot 20% ?
IIc ulcer with hematin spot 10% x
III clean base ulcer 5% x

41. Endoscopic therapy:Modalities
• Injection - adrenaline,
saline, alcohol,
fibrin,
cyanoacrylate glue
• Thermal contact – EC,
Heater Probe
• Thermal non contact –
Laser, APC
• Mechanical – Hemoclip,
banding

42. Ulcer Bleeding : Endoscopic Therapy
• Injection:
– ? Tamponade, vasoconstriction
– 1:10,000 adrenaline around the ulcer
• Thermal:
– Heater probe, Electrocoagulation
– Principle – coaptive coagulation
– Seal the vessel up to 2 mm by pressure and heat
• Mechanical – clip the vessel

43. EndoRx: Meta-analysis
Further bleed Surgery Mortality
• Thermal 0.3 0.3 0.6
• Laser 0.5 0.6 0.5
• Injection 0.2 0.2 0.5
• All Rx 0.4 0.3 0.5
(0.4-0.7)
(Cook et al, 1992, Gastro, 30 trials, 2136 patients)

44. Ulcer Bleeding : Surgery
• Indications
- Continued Bleeding,
- Failure of Endo. Rx
- Re-bleeding in the hospital
- Blood Transfusion > 4 units

45. Re-bleeding: Long Term Prevention
• Anti H. pylori Rx
• Long term H2 blockers
• No/safer NSAIDs,
• Long term NSAID user: PPIs

46. Erosive Mucosal Disease
• Risk Factors - Acute stress, NSAIDs
• Bleeding usually mild, may be massive
• Re-bleeding uncommon
• Prevention:
-Acute stress - Ranitidine vs Sucralfate
• Treatment - supportive,
- pantoprazole/ ranitidine infusion

47. Portal Hypertension & UGI Bleeding
• 30-60% of cirrhotics have
varices
• One third of varices bleed
• High Mortality – 30% die
• 70% rebleed within next 6
weeks
• Important factors : Child Pugh
score and variceal grade

48. Variceal Bleeding: Aims of treatment
• Prevent First Bleeding
• Control Acute Bleeding
• Prevent Re-bleeding

49. Varices: Prevent First Bleeding
• Primary Prophylaxis –
- β-blockers – Propranolol, nadolol
clinical guide – heart rate <60/min.
Problems – contraindications to β-blockers
- 1/3rd patients do not respond
- Variceal Band ligation - promising

50. Varices: Control Acute Bleeding
• Pharmacotherapy –
– Somatostatin, Terlipressin, Octreotide
– Somatostatin
• 250 ugm stat, 250 ugm hourly infusion
• Duration 3-5 days
• As sole therapy - 80-85% efficacy
• Adjunct to Endo. Rx – early re-bleeding
• Cost is high

51. Varices: Control Acute Bleeding
• Mechanical :
– Balloon tamponade (SB tube), 80% effective
– Use if no Endoscopy available or fails

52. Varices: Control Acute Bleeding
• Endoscopic Rx - Variceal Sclerotherapy,
- Variceal Band ligation
- Efficacy – 90%, best modality
- Problems – early re-bleed, complications
• Fundal varices – glue injection

53. Endo clipping
Band ligation
Sclerotherapy

54. Varices: Prevent Re-bleeding
• Endoscopic therapy :
- Sclerotherapy, EVL – for variceal eradication
- EVL – faster variceal eradication, less
complications, but early recurrence
- Surveillance endoscopy after eradication
• Pharmacotherapy – may be useful

55. TIPS
• Transjugular intrahepatic
porto systemic shunt
• Between Hepatic vein and
Portal vein
• Stent is made up of PTFE
• Complications:
– Capsule rupture with
intraperitoneal hemorrhage
– Encephalopathy, shunt
thrombosis- within 1 month
– Shunt stenosis- within 1 year
– Ascitis gets resolved

56. Non-selective shunts
• End to side poto caval
• Side to side porto caval
• Interposition graft
• TIPS
• Linton shunt
Selective shunts
• Warrens shunt
• Inokuchi shunt
Surgical shunts
Variceal Bleeding : Surgery

57. Devascularisation operations
Variceal Bleeding : Surgery
Sugiura operation
• Ligation of veins near
esophagus
• Vagotomy
• Pyloroplasty
• Esophageal transection
and anastomosis
• Splenectomy

58. Last resort: Liver Transplantation
Variceal Bleeding : Surgery

59. Upper GI Bleeding: uncommon causes
• Vascular Lesions
– Dieulafoy’s lesion (ectatic abnormal vessel)
– A-V malformation
– GAVE (Watermelon stomach)
• Uncommon, bleeding usually massive
• Treatment: - Endoscopic
- Surgery

60. Dieulafoy lesion
• Vascular malformation within
6 cm of GEJ
• 1-3 mm vessels- at sub-
mucosa
• T/t: endoscopic t/t if fails
angiographic coil
embolisation
• Last resort: partial
gastrectomy

61. GAVE
• Watermelon stomach d/t
multiple dilated venules
• Antrum
• Continued occult bleed
• TOC: APC
• Last resort: antrectomy

62. Mallory-Weiss tears
• Binge drinking
• Mucosal and sub-mucosal
tears
• UGIE
• Most: self limiting within 72
hours
• Local endoscopic t/t,
angiographic embolisation,
gelatin sponge

63. Esophagitis
• GERD
• Usually superficial
mucosal ulceration
• Occult bleeding
• R/o medications, radiation,
Crohn’s
• T/t: acid suppressive
therapy

64. Malignancy
• C/f: chronic anemia or
hemoccult-positive stool
• GIST
• Endoscopic t/t good to
control bleed but
rebleeding chances are
higher
• Surgical resection or
palliative resection

65. Aortoenteric fistula
• Post graft-enteric erosion: 1% of aortic graft
• Median interval is 3 years
• Pseudoaneurysm with fistulisation
• Sentinel bleed massive and fatal
bleed
• D3 or D4
• Therapy: ligation of graft proximal to the
graft, removal of infected prosthesis, and
extra-anatomic bypass
• Duodenum-primarily repaired

66. Hemobilia
• Post trauma, iatrogenic, hepatic neoplasm
• Triad: hemorrhage, right upper quadrant pain
and jaundice
• UGIE: blood at the ampulla
• CT angio and embolization

67. Hemosuccus pancreaticus
• Bleeding from the pancreatic duct
• Splenic artery erosion: pancreatic pseudocyst
• Abdominal pain, hematochezia
• Treatment of choice: Distal pancreatectomy

68. Iatrogenic bleeding
• Endoscopic sphincterotomy
• Percutaneous trans-hepatic procedures
• Percutaneous endoscopic gastrostomy

69. UGI Bleeding: Summary
Upper GI Bleeding
Resuscitation
Clinical evaluation
Endoscopy – Emergency – if therapeutic
Otherwise Elective
Pharmacotherapy Endo. Rx Surgery
Prevent Re-bleeding

70. UGI Bleed: Summary
• UGI bleed: major cause of morbidity & mortality
• Varices and ulcers common causes
• Resuscitation, do not over transfuse
• UGI Bleed: Pharmacotherapy effective
– Ulcer bleed: intravenous PPI infusion
– Variceal bleed: somatostatin infusion
• Ulcer and variceal bleed: Endotherapy
• Surgery: minority of patients

71. Thank You