non surgical management of non variceal upper gastrointestinal bleeding

2.  Acute gastrointestinal (GI) bleeding is a
potentially life-threatening abdominal
emergency that remains a common cause of
hospitalization.
 The underlying mechanisms of non-variceal
bleeding involve either:
 (high pressure) arterial hemorrhage, such
as in ulcer disease and mucosal deep tears.
 or (low-pressure) venous hemorrhage, as
in telangectasias.

3.  Peptic ulcer disease (PUD) remains the most
common cause of UGIB (27-40%)
 With precipitating factors:
 H Pylori infection
 NSAID`S
 Other causes
 Acute stress gastritis
 Erosive esophagitis
 Angiodysplasia

4.  80% of patients with UGIB from PU stops
spontaneously, (Gastroenterol Clin North Am. 2000 Mar. 29(1):189-222)
 However, still life threatening emergency with
risk of mortality and incidence of re bleeding
(10-30%)
 Most of deaths were not caused by bleeding,
almost result from other causes like
cardiopulmonary deaths and multi-organs
failure.

5.  The following risk factors are associated with
an increased mortality, recurrent bleeding:
 Age older than 60 years
 Severe comorbidity
 Shock upon admission
 Active bleeding (e.g. witnessed hematemesis, red
blood per nasogastric tube, fresh blood per rectum)
 Red blood cell transfusion greater than or equal to 6
units
 Severe coagulopathy

6.  The American Society for Gastrointestinal
Endoscopy (ASGE) grouped patients with
UGIB according to age and correlated age
category to the risk of mortality.
 3.3% for patients aged 21-31 years
 10.1% for those aged 41-50 years
 14.4% for those aged 71-80 years.
Patients who present in hemorrhagic shock have a
mortality rate of up to 30% and re bleeding up to 48%.

7. History
symptoms
Physical
examination
NSAIDs use
H Pylori eradication therapy
Melena (70-80%)
Hematemesis (40-50%)
Epigastric Pain (40%)
Evaluation of shock and blood loss

8.  Assessing patient for hemodynamic instability.
 Recommended:
 Check pulse and BP in supine and upright positions,
significant change in vital signs (↓ 10 BP,↑ 20 Pulse) blood
loss up to 20% of volume.
Worried clinical signs:
Pulse ˃ 100/min
Systolic BP ˂ 90
HB ˂ 8 gm/dl
Syncope
Cold Extremities
•ICU admission
•Cross Matching
(2-6 units packed RBCs)
•Rapid blood transfusion

9. 1st.
• Stabilization
+ Medications
2nd.
• Diagnosis
3rd.
• Therapeutic procedures
4th.
• Follow up

10.  ABC
 Elective intubation for shocked and confused patients
 Bilateral IV access
 Crystalloid (3 for 1 rule)
 Correct coagulation abnormalities
 Medications
 PPI : reduce rate of high risk stigmata identified on
endoscope
 Prokinetic Drug: decrease need for a repeat endoscopy
to determine site and cause of bleeding
stabilization
Patient respond to resuscitation by:
•Oxygen saturation
•Urine output

11.  Endoscopy
 Is the mainstay for diagnosis and treatment of acute
UGIB. It should be performed within 24 hours of
presentation by skilled operators in adequately equipped
settings.
 Several randomized clinical trials supported the idea
that early endoscopic therapy significantly reduces the
rates of recurrent bleeding, the need for emergent
surgery, and mortality.
Diagnosis & Treatment

13.  Endoscopic therapy is indicated for patients
found to have actively bleeding or spurting
arterial vessels and for those with a non-
bleeding visible vessel in an ulcer.
 Ulcers with an overlying clot should be
irrigated to evaluate and potentially treat
the underlying lesion

14.  ENDOSCOPIC TREATMENT MODALITIES FOR UGIB:
 Injection
 Saline
 Diluted epinephrine
 Cautery
 Heater probe
 Bipolar electrode
 Laser
 Mechanical
 Endoclips
 Banding device
ASGE; combination therapy with epinephrine injection in
conjunction with a second endoscopic treatment modality,
such as cautery or clips, is superior to epinephrine alone for
treating lesions with high-risk stigmata

15.  Endoscopic outcome:
 85-90% respond to endoscopic therapy
 Despite adequate initial endoscopic therapy,
recurrent UGIB can occur in up to 24% of high-risk
patients.
 The use of PPI therapy in addition to combination
endoscopic therapy reduces the rate of recurrent
bleeding to approximately 10%.

16.  Patients with recurrent bleeding generally
respond favorably to repeat endoscopic
therapy.
 In cases where the initial endoscopy failed to
identify the source or if there are concerns
that inadequate therapy was delivered, repeat
endoscopy may be appropriate.

18.  Angiography
 According to the (American College of Radiology
guidelines-2010), angiography along with (TAE)
should be considered for all patients with a known
source of arterial UGIB that does not respond to
endoscopic management or with active bleeding
and a negative endoscopy.

19.  Surgery
The indications for surgery in patients with
bleeding peptic ulcers are as follows:
 Life-threatening hemorrhage not responsive to
resuscitation.
 Failure of medical therapy and endoscopic hemostasis
with persistent recurrent bleeding (2 attempts)
 A coexisting reason for surgery, such as perforation,
obstruction, or malignancy
 Prolonged bleeding, with loss of 50% or more of the
patient's blood volume

20.  Operations performed:
DU GU
Truncal vagotomy and
pyloroplasty with suture
ligation of the bleeding ulcer
Truncal vagotomy and
antrectomy with resection or
suture ligation of the bleeding
ulcer
Proximal (highly selective)
gastric vagotomy with
duodenostomy and suture
ligation of the bleeding ulcer
Wedge resection of the ulcer
only.
Distal gastrectomy to include
the ulcer, with or without
truncal vagotomy
Truncal vagotomy and
pyloroplasty with a wedge
resection of the ulcer
Antrectomy with wedge
excision of the proximal ulcer

21. 1) https://emedicine.medscape.com/article/
187857-overview_Updated: Mar 21, 2016
2) American Society of Gastrointestinal
endoscopy ASGE- guidelines, 2012
3) Surgery casebook (2nd edition), 2016