2. Acute Upper Gastrointestinal
Bleeding
Entesar El Sharqawy
MD
Hepatology, Gastroenterology
and Infectious Diseases.
Benha University
26/09/12

3. Objectives
 Discuss and provide background information of upper
GIT bleeding.
 Identify goals of history, physical finding and care in
UGIB.
 Discuss utility of NGT in the evaluation of UGIB.
 Identify key points to resussitation and work up of
UGIB.
 Discuss therapy of upper GIB.
 Outline key informations to have when calling GI
consultants.

4. Gastrointestinal Bleeding
 Introduction:
GI bleeding is a common disorder that
troubles all medical/surgical specialties
UGI bleeding>LGI bleeding
Prevalence: 170 cases/100.000 adults/yr
Cost estimate: $2.5B/yr (USA)
Mortality 5-12%
40% for recurrent bleeders
Severity: acute/chronic/intermittent/occult

5. Epidemiology:
 Upper: Lower GI bleeding = 5:1
 30% pts are older than 65 years.
 Incidence: 1-2% of all hospital admissions
Most common diagnosis of new ICU admits
 85% stop sponateously
Those with massive bleeding need urgent
intervention
Only 5-10% need operative intervention after
endoscopic interventions
Early therapeutic maneuvers decrease mortality rates

6. Gastrointestinal Bleeding
Presentation of bleeding:
Hematemesis-UGI source
Melena-UGI source usually but 5% can be from
LGI source
Hematochezia (BRBPR)-LGI source usually but
15% from UGI source
Occult-UGIB

7. Chain of events
1. Recognize severity
2. Establish access for resusitation
3. Resusitate
4. Identify source
5. Intervention

8. Gastrointestinal Bleeding
 UGI vs LGI location determined by the
Ligament of Treitz:
UGI – proximal to LT
*Esophagus, *stomach, *duodenal bulb, 2nd/3rd
portion of duodenum, Hepatic and Pancreatic
LGI – distal to LT
Small bowel, *colon

10. Etiology of Significant UGI
Bleeding in Adults
Varices
Peptic ulcer disease
Gastric erosions
Mallory-Weiss tear
Esophagitis
Duodenitis

11. Etiology of Significant UGI
Bleeding in Children
Esophagitis
Gastritis
Ulcer
Esophageal Vs
 Mallory-Weiss

12. Initial Assessment
 History and PE
 Vitals, ABC’s, and IVFs
 HR, BP, Orthostatics
 Signs of gross blood loss?
 Hematemesis, melena, hematochezia
 NG Tube
 Labs
 CBC, Kidney Profile, LFT, Electrolytes, Coags, Acid-Base
balance, type and cross
 Hct unreliable
 ECG
 Imaging: chest & abd. radiography, US, CT

13. Gastrointestinal Bleeding
 Determine the urgency of the clinical situation:
Is the patient in shock?
40% loss of circulating blood volume
Agitation, pallor, tachycardia, hypotension
Is the patient orthostatic?
20% loss of circulating blood volume
Postural hypotension
Never rely on initial H/H values to asses amount of blood
loss (hemoconcentration)

14. ATLS Classification of Shock
Assess Blood Loss
Category % loss HR BP Pulse Cap refill Neuro
Pressure
Stage 1 <15 % < 100 Normal Normal WNL WNL
Stage 2 15-30% > 100 Normal Decreased > 3 sec Alert
Stage 3 30-40% > 120 Decreased Decreased > 3 sec Lethargic
Stage 4 > 40% > 140 Decreased Decreased > 3 sec Obtunded
HR not useful if Tachycardic means If they are
patients are on they have lost about hypotensive, you
AV node blockers 1 liter of blood! are in trouble!
From Advanced Trauma Life Support Guidelines

15. General Approach
Upper GI Bleed
vs
Lower GI Bleed

16. Upper GI hemorrhage
 How do you know its upper?
85% of all GI hemorrhage is upper
Hematemesis diagnostic
Don’t forget about nasal bleeding as possible source
Melena
Degradation of hemoglobin to hematin by acid
Bowel bacteria and digestive enzymes also contribute
Hematochezia
10-15% of patients with very rapid UGI source

17. Gastrointestinal Bleeding
Nasogastric aspirate:
Determines the status of UGI bleeding
and gives indirect information in LGI
bleeding
Bright red/clots – active UGI bleed
Coffee-grounds – slow bleeding, oozing,
stopped
Clear – indeterminate (16% still bleeding)
Bilious – UGI bleeding has stopped

18. Diagnosis
 Questions to ask in history
 Any hematemesis, coffee-ground emesis, melena, or
hematochezia.
 Any vomiting and retching.
 Any history of viral infection.
 Any history of ASA, NSAID’s, steroids.
 Any ETOH abuse.
 Any history of iron or bismuth which can simulate melena and
beets which can simulate hematochezia.
 Any weight loss or changes in bowel habits.
 Any history aortic graft.

19. Diagnosis
Physical exam
 Vital signs may show hypotension and
tachycardia.
 Cool, clammy skin then in shock.
 Spider angiomata, palmer erythema, jaundice,
and gynecomastia seen in liver disease.
 Petechiae and purpura seen in coagulopathy.
 Careful ENT exam to rule out causes that
can mimic upper GI bleeds.
 Proper abdominal exam and rectal exam.

20. Upper GI hemorrhage
Upper endoscopy indications
Hematemesis
Melena or hematochezia with hypotension
NGT with guiac positive fluid
Should be completed in 24hrs for stable
patients

21. Gastrointestinal Bleeding
 Role of endoscopy in triage of UGI
bleeders:
Accurate identification of the urgency of the clinical
situation: hemodynamic compromise/signs of on-
going bleeding/coagulopathy.
Who should be hospitalized?
Where to admit?
Diagnosing the cause
Risk stratification

22. Gastrointestinal Bleeding
 Risk stratification in UGI bleeding:
Very low risk endoscopic findings:
Clean-bsed ulcer
Clean based Mallory-Weiss tear
Gastritis/duodenitis/esophagitis
Portal hypertensive gastropathy
Disposition: Discharge if stable

23. Gastrointestinal Bleeding
 Risk stratification in UGI bleeding
Medium risk endoscopic findings:
AVM’s
Ulcer with stigmata of recent hemorrhage
Mallory-Weiss with stigmata of recent hemorrhage
Varices with recent bleeding
Cancer
Hemostasis and medical ward/intermediate care unit

24. Gastrointestinal Bleeding
 Risk stratification in UGI bleeding:
High risk endoscopic findings:
Active variceal bleeding
Active ulcer bleeding
Active bleeding Dieulafoy’s lesion
Hemostasis and ICU admission

25. Resuscitation
Place in ICU and Surgery consultation
Airway protection
Maintain intravascular volume, O2
Give NS until PRBC and FFP available
Follow vitals, orthostatics, and urine
output

26. Acute U.G.I.
Bleeding )
**Shock management: ( ABC
• Airway: endotracheal tube, oropharyngeal airway. *Give oxygen
• Breathing: support respiratory function
* Monitor: resp. rate, bld gases, chest radiograph
 Circulation: expand circulating volume: blood, colloids,
crystalloids support CVS function:
1- 1 unit PRBC increases Hgb by 1 gm/dl and increase Hct by 3%
2- FFP for INR greater than 1.5
3-Platelets for platelet count less than 50.000
* Monitor: skin color, peripheral temp., urine
flow, BP, ECG

27. Rockall risk stratification score
Variable 0 1 2
Age (yrs) < 60 60-80 >80
Shock SBP>100mmHg SPB>100mmHg SPB<100mmHg
HR<100 bpm HR>100bpm
Co-morbidity No major co- Heart failure, IHD.
morbidity Renal Failure. Liver
disease.
Disseminated
malignancy.
Any co-morbidity
Endoscopic Mallory-Weiss tear. Peptic ulcer Malignancy of upper
Diagnosis No lesion identified. Erosive disease GIT
No SSH Esophagitis
Major SSH None/Clean base. Adherent clot. Visible
Dark spot sign on vessel (non
ulcer base bleeding). Oozing
bleeding, spurting
arterial vessel

28. Blatchford risk stratification score (23)
Variable 1 2 3 4 6
SBP (mmHg) 100-109 90-99 > 90
Blood urea 18-22 22-28 28-69 < 70
(mg / dl)
Hamoglobin (M) 12-12.9 10- > 10
(g / dl) 11.9
Hamoglobin (F) 10-11.9 > 10
(g / dl)
Other variables HR>100bpm Syncope
Melena Heart failure
Hepatic
Disease

30. INDICATIONS FOR
ADMISSION & REFERRAL
Admit pts with h/o recent brisk bleeding &
orthostatic changes
Admit pts with less severe blood loss who have
comorbid conditions aggravated by anemia
Profound anemia with no evidence of blood loss
Refer pts who are candidate for endoscopy when
source of bleeding is elusive

31. Causes of Upper GI Bleed
 Erosive Esophagitis
Normal GEJ Grade 1 EE Grade 2 EE
Grade 3 EE Grade 4 EE

32. Causes
 Upper GI Bleed
4. Esophageal or Gastric VaricesEsophageal Varices
Normal Esophagus
Normal Fundus
Gastric Varices

33. Gastric varices
Bleeding ulcers
Dieulafoy’s lesion
Esophageal
Varices

34. Causes of Upper GI Bleed
 Dieulafoy’s Lesion
Dieulafoy’s Lesion Actively Bleeding

35. Causes - Peptic ulcer disease
Gastric Ulcer
Gastric Ulcer
Pyloric Channel
Ulcer Duodenal
Ulcer

36. Watermelon stomach
Gastritis
Mallory-weiss

37. Causes - Upper GI Bleed
Gastritis
Erosive Gastritis Diffuse Gastritis

38. Causes of Upper GI Bleed
 Esophageal, Gastric, or Duodenal CA
Gastric Cancer

39. Ulcer with red
spot Aortoduodenal Fistula
Aorta
Duodenum
Fistula
Graft

40. Gastrointestinal Bleeding
 Prognostic factors in UGI bleeding:
Severity of initial bleed.
SHock/hemodynamic instability
Age of patient < 65
Comorbid disease
Anticoagulants/ coagulopathy
Hb < 8g/dl
APACHE II < 11
Presence of high-risk lesion, as varices/giant ulcer
Endoscopic stigmata of significant hemorrhage (SSH)
Need for emergency surgery

41. Modified Forrest Classification for Upper GI
bleeding
Prognosis of endoscopic UGI bleeding finding:
Class Endoscopic findings Re- Mortality
bleeding rate (%)
rate (%)
1a Spurting arterial vessel < 90 11
1b Oozing hemorrhage 80 11
2a Non-bleeding visible 40 - 60 11
vessel
2b Adherent clot 20-30 7
2c Ulcer base with black spot 10 3
sign
3 Clean base 5 2

42. Gastrointestinal Bleeding
 Special considerations in TTT UGI bleeding :
Keep Nsaid’s in mind in all patients (the cause of non-
healing until proven otherwise)
Evaluate and treat Helicobacter pylori infections in the
peptic disorder
Stress related mucosal disease (SRMD) in hospitalized
patients with non-bleeding illnesses
Suppress gastric acid secretion
Correct coagulopathy in most cases
Must get early consultation with gastroenterologist and
general surgeon for significant GI bleeds.

43. Therapy
 Supportive care : begin promptly
 IV fluids, blood products, pressors
 Class I + II hemorrhage replace with crystalloid.
 Class III + IV hemorrhage replace with crystalloid and blood.
 Specific care
 Barrier agents (sucralfate)
 H2 receptor antagonists (ranitidine)
 Proton pump inhibitors (omeprazole, lansoprazole)
 Vasoconstrictors (somatostatin analogue, terlipressin)
 Endoscopic therapy : stabilize and prepare patient first
 Variceal injection or band ligation
 Coagulation (injection, cautery, heater probe, laser)

44. Gastrointestinal Bleeding
 UGI bleeding in portal hypertension: Varices
High mortality on first bleed, 70% rebleed rate in next
12 months
Start IV octreotide in all suspected PHT bleeds
Antibiotic prophylaxis
Endoscopic ligation is procedure of choice (prophylactic
banding is standard of care, surveillance for variceal
recanalization q 6mos-12mos)
TIPS for endoscopy failures
Minnesota tube/Blakemoore tube
Surgical (shunts, transection)

45. Treatment
Endoscopic intervention
Banding
Sclerotherapy
Thermocoagulation
Electrocoagulation
Argon Plasma Coagulation

46. Treatment
 Treatment
 Submucosal injection of Epinepherine
Duodenal Ulcer Injection Therapy

47. Treatment
 Thermocoagulation
Duodenal Ulcer Heater Probe Therapy

48. Treatment
 Argon Plasma Coagulation (APC)

49. Treatment
 Banding Ligation

50. Further treatment
 ICU care
 Treatment of complications
- sepsis
- DIC
- MODS

53. TIPS
IVC Coronary Vein
Splenic Vein
Portal Vein

54. General Approach to GI
Bleeding
Stablize
Locate
Treat