The document provides tips for using a PowerPoint presentation on the management of upper gastrointestinal hemorrhage. It recommends that users can freely edit and modify the slides. It also suggests showing blank slides first to elicit what students already know before presenting content on subsequent slides. This active learning approach should be repeated through three revisions for maximum learning. The presentation is also useful for self-study.

1. Tips on using my ppt.
1. You can freely download, edit, modify and put your
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2. Don’t be concerned about number of slides. Half the
slides are blanks except for the title.
3. First show the blank slides (eg. Aetiology ) > Ask
students what they already know about ethology of
today's topic. > Then show next slide which enumerates
aetiologies.
4. At the end rerun the show – show blank> ask questions >
show next slide.
5. This will be an ACTIVE LEARNING SESSION x
three revisions.
6. Good for self study also.
7. See notes for bibliography.

2. MANAGEMENT OF UPPER
GASTROINTESTINAL
HAEMORRHAGE

3. INTRODUCTION
.

4. INTRODUCTION
• The part above the Ligament of Treitz is the
upper GI
11/25/2022 4
Definition:
Any bleeding from GI tract proximal to
Ligament of Treitz.
It is a common cause of emergency hospital admission
and accounts for 5-10% mortality which increase in the
elderly.

5. INTRODUCTION
• modes of presentation
– Hematemesis- 40-50%
– Melena-70-80%
– Hematochezia- 15-20%
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6. PRINCINPLES OF MANAGEMENT

7. PRINCINPLES OF MANAGEMENT
• INITIAL ASSESSMENT
• RESUSCITATION
• DETERMINATION OF BLEEDING SITE
• TREATMENT/INTERVENTION
• PREVENTION OF RECURRENCE
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8. HISTORY

9. HISTORY
• COMMON CAUSES
• Duodenal ulcer
• Gastric ulcer
• Stress ulcer
• Oesophageal varices
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10. ASSESSING SEVERITY
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eeding
Bleeding severity Vital Signs Blood loss (%)
Minor Normal < 10 %
Moderate Postural
(Orthostatic hypotension)
10 – 20 %
Massive Shock
(Resting hypotension)
20 – 25 %

11. RESUSCITATION

12. RESUSCITATION
• Ensure a patent airway and breathing.
• Elevate foot of bed to about 15⁰
• Secure IV access, take samples; PCV, U/Ecr, GXM, Platelet
count, LFT.
• IV crystalloid, N/S R/L 1L over 30-45min
• Pass urethral catheter, empty the bladder then monitor urine
output. (0.5-1ml/kg/min)
• Reassess PR,BP,CVP, urine output, to determine the rate of
infusion
• Supplemental Oxygen---enhances oxygen carrying capacity
of blood
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13. RESUSCITATION
• Pass N-G tube-
– Decompression, prevent aspiration
– Cold saline lavage
• Transfuse;
– significant blood loss or pcv <30
– on going bleeding,
– inadequate response to fluid resuscitation,
– elderly and
– presence of cardiopulmonary disease
• Sedation
– Phenobarb to quieten patient.
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14. HISTORY

15. HISTORY
• History to find the cause, co-morbidity and
character(onset, volume and frequency) of
bleeding. Careful history and physical
examination may yield no definitive cause in
50%.
– HX of PUD
– Alcohol ingestion
– NSAID
– Dysphagia
11/25/2022 15

16. HISTORY
• COMMON CAUSES
• Duodenal ulcer
• Gastric ulcer
• Stress ulcer
• Oesophageal varices
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17. HISTORY
• COMMON CAUSES
• Duodenal ulcer
• Gastric ulcer
• Stress ulcer
• Oesophageal varices
11/25/2022 17

18. HISTORY
• LESS COMMON CAUSES
• Oesophagitis
• Mallory- Weiss syndrome
• Malignant gastric tumours
• Benign gastric tumours
• Oesophageal ulcers or tumour
• Para-oesophageal hiatal hernia
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19. EXAMINATION
11/25/2022 19

20. EXAMINATION
– Pallor
– Sweating
– Cold extremities
– Nostrils/ pharynx
– Epigastric tenderness
11/25/2022 20

21. EXAMINATION
• Collapse subcutaneous veins
• Tachycardia
• Hypotension
• Restlessness
• Features of CLD, gastric ca, abdominal
masses,
11/25/2022 21

22. DETERMINATION OF BLEEDING
SITE

23. DETERMINATION OF BLEEDING
SITE
• NG-tube aspiration
• Endoscopy
• Barium studies
• Angiography
• Tagged rbc scan
11/25/2022 23

24. LOCALIZATION
11/25/2022 24

25. TREATMENT

26. TREATMENT
• Non-operative
• Operative
11/25/2022 26

27. NON OPERATIVE

28. NON OPERATIVE
Peptic ulcer disease
• Endoscopic
• PPI
• Elimination of H. pylori
• Endoscopic therapy:
– Injection of adrenaline at the base of the vessel/
Sclerotherapy
– Bipolar electro- / thermal probe coagulation
– Argon plasma / laser photocoagulation
– Hemostatic materials, including biologic glue
11/25/2022 28

29. NON-OPERATIVE
• If bleeding controlled:
• PPI- proton pump inhibitor
– omeprazole/pantoprazole, 80 mg bolus
then 8 mg/hr infusion x 24 hrs.
then 40 mg IV OD/BD
then transition to oral PPIs for 6-8 wks.
• Helicobacter pylori treatment, if present
triple drug regimen x 2-3 wks.
recurrent colonization 70-90% within few month to years.
• Repeat endoscopy < 6-8 wks.
11/25/2022 29

30. NON-OPERATIVE
• VARICES
• Balloon tamponade
• Pharmacological
• Endoscopic
• Transjugular intrahepatic portosystemic stent-shunt (TIPSS)
– Balloon tamponade:
– Initially temporizing measure in all pts, now < 10%
temporary hemostasis in 85%, near 100% re-bleed on
removal
– 20% complication rate
Esophageal rupture, Tracheal rupture, Duodenal
rupture, Respiratory tract obstruction, Aspiration,
Tracheoesophageal fistula, Esophageal necrosis / ulcer
11/25/2022 30

31. Pharmacologic treatment

32. Pharmacologic treatment
• :
• Vasopressin splanchnic vasoconstriction; 20IU in
250ml of 5% DW over 30min, 4hrly. It improves
hemostasis. Terlipressin (pro-drug) better
hemostasis and survival benefits. And longer
duration of action.
– Side effects
• Pallor
• Hypertension
• Abdominal colic
• Cerebral and coronary ischemia
• purgation
– Nitroglycerine 40 mcg/min may be given
simultaneously to prevent coronary ischemia.
11/25/2022 32

33. • Nitroglycerine systemic hypotension and venous
pooling, counteract cardiac effects of vasopressin;
titrate to SBP 90-100.
• Glypressin; contains both nitroglycerin and
vasopressin
• Beta-Blockers: Propranolol 40 mg bd; lowers portal
pressure. Daily oral dose after bleeding has stopped
is found to stop re-bleeding in about 80%.
• Octreotide: 250 mcg bolus, 250 mcg/hr infusion;
Decreases gastric acid, pepsin, gastric blood flow
11/25/2022 33

34. • Band Ligation; is efficacious and is now
preferred to Sclerotherapy
• Endoscopic surveillance;
– 3 monthly for 1year then
– 6monthly for 1year then
– Annually
11/25/2022 34

35. • TIPSS;
– In refractory bleeding after sclerotherapy or
band ligation.
– A shunt is established between the portal vein
and the right or middle hepatic vein
11/25/2022 35

36. OPERATIVE

37. OPERATIVE
• Indications;
– Massive bleeding
– Severe haemorrhage continues or recurs/not
responsive to resuscitative efforts
– Associated perforation
– Blood not readily available
– Failure of medical therapy and endoscopic
hemostasis with persistent / recurrent bleeding
– A second hospitalization for peptic ulcer
hemorrhage
11/25/2022 37

38. OPERATIVE
• Factors predicting further bleeding from a
peptic ulcer and possible need for surgery
– Age > 60years
– Hb <8g/dl
– Shock on admission
– Visible spurting vessel on endoscopy
– Giant ulcer >2cm
– Ulcer on the posterior lesser curvature or posterior
inferior wall of the duodenal bulb
11/25/2022 38

39. OPERATIVE
• AIMS;
– To stop the bleeding
– To prevent a recurrence
– To cure underlying cause
11/25/2022 39

40. Anterior longitudinal duodenotomy
11/25/2022 40

41. DEFINITIVE PROCEDURES

42. DEFINITIVE PROCEDURES
• Peptic ulcer disease
– Laparotomy
– Upper mid-line incision
– Duodenal ulcer: most common, posterior
bleed;
• longitudinal anterior duodenotomy
• Under-run the vessel (i.e. gastroduodenal artery)
using non-absorbable suture preferable prolene 4-
O.
• Quickest and safest operation
11/25/2022 42

43. Gastric ulcer:

44. Gastric ulcer:
1.wedge excision gastric ulcer – (always
send for frozen to r/o cancer)
• Under-running the vessel
• Followed by post-OP PPI, H.P. therapy, follow-up
endoscopy
• Effective and quicker
2.Billroth 1 partial gastrectomy
3 truncal vagotomy and pyloroplasty with
excision of the ulcer
11/25/2022 44

45. VARICES

46. VARICES
• Surgical Shunts:
• Goal: decompression of the high-
pressure portal venous system into
a low-pressure systemic venous
system and devascularization of the
distal esophagus and proximal
stomach
• Portacaval shunt (end-to-side,
side
to side, interposition graft)
• Mesocaval shunt (Large- or small
diameter interposition graft)
• Distal splenorenal (Warren) shunt
• Esophagogastric
devascularization,
• Esophageal transsection, &
reanastomosis
• Orthotopic liver transplantation
• Splenectomy (for splenic vein
thrombosis)
11/25/2022 46

47. • Stress ulcers
– Numerous ulcers- vagotomy + hemi-gastrectomy
– Few - oversewn
• Mallory-Weiss syndrome
– Mucosal laceration is sutured
• Aorto-enteric fistula
– Fistula disconnected and closed
– Aorta grafted with antibiotic primed graft and
covered with omentum
– Antibiotic cover
11/25/2022 47

48. NEGATIVE LAPAROTOMY

49. NEGATIVE LAPAROTOMY
• No lesion may be found in the eosophagus,
stomach or duodenum
• The small and larged intestined are
carefully examined for possible source of
bleeding
• If negative, the abdomen is closed
11/25/2022 49

50. COMPLICATION OF UPPER GI BLEEDING

51. COMPLICATION OF UPPER GI BLEEDING
• Anaemia
• Sepsis
• DIC
• MODS
11/25/2022 51

52. CONCLUSION

53. CONCLUSION
• Even though 70-80% stops spontaneously,
• Bleeding frighten the patient it requires
expeditious work-up ,prompt diagnosis and
treatment.
• Accurate patient evaluation and early
resuscitation before
esophagogastroduodenoscopy (EGD) is critical
to decrease the morbidity and mortality.
11/25/2022 53

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