MANAGEMENT OF UPPER GASTROINTESTINAL BLEEDING

1. DR. TALHA-SAMI-UL-HAQUE
BATCH- IM 7-D
BIRDEM General Hospital

2. • Careful history and physical examinations.
• Gain IV access with large bore cannula
• Full blood count & cross matching
• Monitoring Blood pressure, pulse, urine output
• IV colloids or crystalloid
• Blood transfusion
• ENDOSCOPY for diagnosis & treatment
• PUD- IV PPI
• Bleeding recurs: surgery

3.  When the patient is first seen, a
quick examination must be
made to answer the three
following critical questions :
a) Is there evidence of airway
obstruction ?
b) Is there evidence of active
bleeding ?
c) Is there evidence of
hypovolemia ?

4.  Measure pulse and blood pressure
 If hemodynamically stable
• Obtain full history
• Carry out full examination
• Proceed with investigation

5.  If hemodynamically unstable
• Resuscitate
• If rapid responsive, then proceed as for
stable patient
• If transient or non-responsive  prompt
investigation to locate the source of
bleeding and to established ideal
treatment

6. Management:
• Intravenous access
– at least 1 large bore cannula
• Initial clinical assessment
– Circulatory status
– Evidence of liver disease
– Identify comorbidity

7. Continued…..
• Basic investigations
– Full blood count
– Blood Urea & electrolyte
– Liver function test
– Prothrombin time
– Cross-matching

8. • Fluid replacement
Crystalloid fluid
Colloid fluid
– Blood transfusion
• Monitor CVP

9. • Can start with 500 ml NaCl 0.9% over the first 15
min, followed by 500 ml colloid (eg. Gelatin) over the
next 15 min
• If BP fails to come up or falls  infusion rate must be
increased accordingly
• If patient becomes stable ( BP > 100 mmHg, pulse <
100/min ) rapid infusion must be stopped, and
maintenance fluids only given.

10. Indication for blood transfusion
 Shock (Pallor, cold sweaty
skin, systolic BP
<100mmHg)
 Hb <10 gm% in patients
with recent or active
bleeding.
 Patient with coagulopathy,
low platelet count should be
transfused with fresh frozen
plasma and platelets
respectively.

11. • Oxygen therapy
– Should be given to all patients in shock.
• IV PPI: Omeprazole

12. ENDOSCOPY
• Ideally, endoscopy should be performed
within 24 hours.
• Endoscopy can be used both in diagnosis and
therapy.

13. Indications of endoscopic
therapy
• Actively bleeding lesion
• Non-bleeding visible vessels
• Ulcers with adherent clot

15. • Bleeding can be 2 type
– 1. non- variceal bleeding
– 2. variceal bleeding

17. Endoscopic therapy
• Adrenaline(1:10,000) or sclerosant injection
• Heat probes
• application of metallic clips
• Bipolar diathermy
• Laser photocoagulation using the Nd-YAG
laser

18. • Constant probe pressure
tamponade
• Argon plasma
coagulator
• Rubber band ligation
The preference is for dual
therapy, e.g. injection of
adrenaline with thermal
coagulation.

19. Repeated endoscopy
• endoscopy and endo-therapy should be
repeated within 24 hours when initial
endoscopic treatment was considered sub-
optimal (because of difficult access, poor
visualisation,technical difficulties) or in
patients in whom rebleeding is likely to be life
threatening.

20. Medication
• Injectable proton pump inhibitor / Ranitidine
• oral PPI in high doses.
• NSAIDs should be stooped and future use
should be restricted.

21. Endoscopic hemostasis vs medical therapy
SIGNS
RISK OF RECURRENT
BLEEDING WITH MEDICAL
THERAPY ALONE
RISK OF RECURRENT
BLEEDING WITH
ENDOSCOPIC
HEMOSTASIS
Active arterial bleeding
(spurting)
85%–95% 10%–20%
Nonbleeding visible vessel 50% 5%–−10%
Nonbleeding adherent clot 35% < 5%
Ulcer oozing 10%–25% < 5%
Flat spots 7% Not indicated
Clean-based ulcer 3% Not indicated

22. Surgical Treatment of Acute Peptic Ulcer
Disease ( PUD )
Indications for Surgery
• Perforation
• Pyloric obstruction
• Continued bleeding that fails to
respond to endoscopic measures
• Recurrent bleeding
• Patients > 60 years
• Cardiovascular disease with predictive
poor response to hypotension

23. • Aim of surgery :
- Stops bleeding
- Prevent recurrent bleeding

24. Choice of operation for duodenal
ulcer
– Billroth II gastrectomy
– Truncal vagotomy and
pyloroplasty with suture ligation
of the bleeding ulcer
• Selective vagotomy
• Highly selective vagotomy
– Truncal vagotomy and
antrectomy with resection or
suture ligation of the bleeding
ulcer

25. Choice of operation for gastric ulcer
– Billroth I gastrectomy
– Billroth II gastrectomy
– Truncal vagotomy and pyloroplasty with a
wedge resection of the ulcer,

26. All patients should be given H. pylori
eradication therapy post operatively

27. Complications
• The complications of UGIB are self-evident. Other
complications can arise from treatments
administered. For example:
• Endoscopy:
– Aspiration pneumonia
– Perforation
– ventricular arrhythmias during endoscopy
– Complications from coagulation, laser treatments
• Surgery:
– Ileus
– Sepsis
– Wound problems

28. Prognosis
• A score of less than 3 using the Rockall system above is associated
with an excellent prognosis
• whereas a score of 8 or above is associated with high mortality
• Mortality is about 7%.
Rockall risk scoring system

29. Prognosis is worse with the following:
• Increasing age
• Co-morbidity
• Liver disease
• Shock at presentation
• Continued bleeding after presentation
• Haematemesis
• Haematochezia
• Elevated blood urea

30. Prevention
• The most important factor to consider is
treatment for H. pylori infection. This
should be completed as an outpatient.

32. • The mortality of a variceal bleed is
approximately 50%
• 70% patients will have a rebleed
• Survival is dependent on the degree of
hepatic impairment

33. Variceal bleeding
• Treatment options are:
– Endoscopic ligation
– Sclerotherapy
– Transjugular intrahepatic porto-systemic
shunting (TIPSS)
– Surgical shunting

34. BALOON TAMPONADE
• Temporary tamponade can be achieved with
Sengstaken-Blackmore tube
– Should be considered as a salvage
procedure
– Unfortunately 50% patients rebleed within
24 hours of removal of tamponade

35. BAND LIGATION & SCLEROTHERAPY
• Emergency endoscopic therapy includes:
– Endoscopic banding of varices
– Intravariceal or paravariceal sclerotherapy
– Sclerosants include ethanolamine and
sodium tetradecyl sulphate

36. Transjugular intrahepatic porto-systemic
shunting (TIPSS)
• If endoscopic methods fail.
• Recommended as the treatment of choice for
uncontrolled variceal haemorrhage.
• Reduces risk of rebleeding but increases risk of
encephalopathy
• Mortality of the procedure ~1%

37. Porto-systemic shunt operation
• Only done if
– Unsuccessful endoscopic treatment
– Good liver function
• Can lead to:
– Post operative liver failure
– Hepatic encephalopathy
• Emergency shunting associated with 20% operative
mortality.

38. PROGNOSIS
• Recurrence within 2 year
– 7% for small varies
– 30% for large varies
• Poor liver function – 45%
• Mortality – 15%

39. PREVENTION
Primary prevention
Bleeding from varices more likely if poor hepatic
function or large varices
• Primary prevention of bleeding is possible
with β blockers
– Reduces risk of haemorrhage by 40-50%
• Band ligation may also be considered
Sclerotherapy or shunting is ineffective

40. Secondary prevention
• 70% of patients with an variceal
haemorrhage will rebleed
• The following have been shown to be
effective in the prevention of rebleeding
– Beta-blockers possibly combined with
isosorbide mononitrate
– Endoscopic ligation
– Sclerotherapy
– TIPSS
– Surgical shunting