22.02.2017

2. • 80% of all GI bleeding is upper GI bleeding.
• Out of all upper GI bleeding, 80% is due to non-
variceal causes.
• Non-variceal bleeding can also occur in patients
who are at high risk of developing variceal bleeding.
• Even with the advent of many modern techniques in
treatment, the mortality rates remain unchanged.

3. 1. Peptic ulcer disease : 30-50%
- Gastric ulcer
- Duodenal ulcer
2. Mallory-Weiss tears : 15-20%
3. Gastritis and Duodenitis : 10-15%
4. Oesophagitis or Oesophageal ulcer : 5-10%
5. Tumors : 2%
- Gastric
- Oesophageal
- Stromal

4. 6. Vascular anomalies : 5%
- Angiodysplasia
- Dieulafoy’s lesion
- Arteriovenous malformations
- Gastric antral vascular ectasia (GAVE)
7. Others : 5%
- Hemophilia
- Hemobilia
- Purpura
- Hemosuccus pancreaticus
- Iatrogenic

5. AN OVERVIEW OF MANAGEMENT OF
GASTROINTESTINAL BLEEDING
INITIALASSESSMENT AND
RESUSCITATION
-Assessment of airway, breathing,
circulation
-Determine severity and volume of
blood loss
- Laboratory tests-
CBC,electrolytes,group and type
HISTORYAND EXAMINATION
FINDINGS
-risk factors for bleeding
-previous surgical procedures
-relevant medications
LOCALISATION OF THE
SOURCE OF BLEEDING
-Aspiration of nasogastric tube
-EGD or colonoscopy
-Other studies eg,small bowel
investigations
TREATMENT OPTIONS
-pharmacologic
-therapeutic endoscopy
-angiography and embolization
-surgery

6. - Most frequent cause of upper GI bleeding
(30-50% of all cases of GI haemorrhage)
- Approximately 10-15% of patients with PUD
develop bleeding at some point in the course of
their disease.
-Bleeding develops as a consequence of peptic
acid erosion of mucosal surface
- Significant bleeding results when there is
involvement of a vessel.

7. - Causes - Helicobacter pylori : 40-50%
-NSAIDs : 40-50%
-Others

8. RISK FACTORS FOR MORTALITY
AND MORBIDITY IN ACUTE GI
HAEMORRHAGE
1. Age >60 years
2. Comorbid disesae
-Renal failure
-Liver diseses
-Respiratory insufficiency
-Cardiac diseases
3. Magnitude of haemorrhage
4. Persistent or recurrent haemorrhage
5. Onset of haemorrhage during hospitalization
6. Need for surgery

9. RISK STRATIFICATION
-Predicts mortality and rebleeding
BLEED study identified ongoing Bleeding.
•Low blood pressure( SBP < 100 mm Hg),
•Elevated prothrombin time(>1.2 times control),
•Erratic mental status, and
•Unstable comorbid disease
As there is no uniform scoring system,these should be
applied with appropriate clinical judgement

10. AIMS OF MANAGEMENT
- Immediate assessment and resuscitation
- Need of blood transfusion
- Determine the source of bleeding
- Stop active bleeding
- Treat the underlying abnormality
- Prevent recurrent bleeding

11. Algorithm for
management of peptic
ulcer bleeding

12. MANAGEMENT OF PEPTIC
ULCER DISEASE
1. Initial or Non specific management
2. Specific management
- Medical
-Endoscopic
- Surgical

13. INITIAL MANAGEMENT
1. Immediate evaluation
2. Resuscitation
3. Blood is sent for typing and cross matching,
hematocrit, platelet count, coagulation profile,
routine biochemical analysis and LFT
4. Foley’s catheterisation for assessment of end organ
perfusion
5. Oxygen supplementation

14. 6. Nasogastric lavage
- 15-20% of upper GI bleeding have negative
aspirate
7. Blood transfusion, if required.
- Patient may need 10 units of blood transfusion in
massive bleeding
- He/she will also need to maintain adequate platelet
count and calcium amount

15. MEDICAL MANAGEMENT
1. IV Proton pump inhibitors used as a bolus
followed by an hourly continuous drip for 72
hours to reduce acidity.
2. Eradication of Helicobacter pylori by using two
antibiotics with PPIs. The most common
antibiotics used are clarithromycin,
amoxycillin and metronidazole.
3. Stop ulcerogenic medications such as NSAIDs,
SSRIs, etc.
4. Follow up oesophagogastroduodenoscopy for
gastric ulcers.

16. ENDOSCOPIC INTERVENTIONS
USES : 1)Diagnostic
2)Therapeutic
3)Prognostic

17. ENDOSCOPY IN TREATMENT
OF NON-VARICEAL BLEEDING
1) Laser coagulation
- Nd: YAG laser has been used more
commonly
- Success rate is around 80%
2) Sclerotherapy
- Epinephrine (1: 10000) arrests bleeding by
vasoconstriction
- Success rate is around 80-90%
3) Haemoclip application
4) Bipolar electrocoagulogram

18. HAEMOCLIP APPLICATION

19. ENDOSCOPY IN DIAGNOSIS AND
PROGNOSIS OF PEPTIC ULCER
DISEASE
Should be done on an emergency basis within 6 to
36 hours of admission.
Endoscopy can determine the risk of rebleeding in
PUD and thus determines prognosis.

21. Forrest Classification for Endoscopic Findings and
Rebleeding Risks in Peptic Ulcer Disease
GRADE DESCRIPTION RE- BLEEDING
RISK
Ia Active,pulsatile bleeding High
Ib Active,non-pulsatile bleeding High
II a Non-bleeding visible vessel High
II b Adherent clot Intermediate
II c Ulcer with black spot Low
III Clean, non-bleeding ulcer bed Low

22. SURGICAL MANAGEMENT
INDICATIONS:
•Hemodynamic instability despite vigorous
resuscitation (>6 U transfusion).
•Failure of endoscopic techniques to arrest
hemorrhage.
•Recurrent hemorrhage after initial stabilization (with
up to two attempts at obtaining endoscopic
hemostasis).
•Shock associated with recurrent hemorrhage.
•Continued slow bleeding with a transfusion
requirement
>3 U/day

23. SURGICAL MANAGEMENT OF
PEPTIC ULCER BLEEDING
- Exposure of the bleeding site
- Longitudinal duodenotomy or duodenopyloromyotomy
- Hemorrhage is controlled initially with pressure, then
direct suture ligation with non-absorbable suture
- Anterior ulcers- four quadrant suture ligation.
-Posterior ulcer eroding into pancreaticoduodenal or
gastroduodenal artery- requires suture ligation of vessel
proximal and distal to the ulcer as well as placement of a
U stitch
- Once bleeding is controlled, a definitive acid
reducing operation should be considered.

24. OPERATIVE PROCEDURES FOR
PEPTIC ULCERS
BILROTH II
GASTRECTOMY :

25. ROUX-EN-Y GASTROJEJUNOSTOMY :

26. TRUNCAL VAGOTOMY AND PYLOROPLASTY :
Division of the anterior vagus, mobilisation of
oesophagus, division of posterior vagus
Advantage : Good drainage
TRUNCAL VAGOTOMY AND ANTRECTOMY :
-In addition to truncal vagotomy, the antrum of the
stomach is removed and the gastric remnant is joined to
the duodenum
Advantage : recurrence rates are exceedingly low

27. HIGHLY
SELECTIVE
VAGOTOMY :
-The anterior and
posterior vagus nerves
are preserved but all
branches to the fundus
and body of the
stomach are divided

28. - Longitudinal tear at gastro-oesophageal junction
- Cause of hemorrhage : repetitive and strenous vomiting
- Presentation : repeated retching , vomiting or coughing followed
by hematemesis
- Diagnosis : endoscopy
- Treatment : stomach is opened by longitudinal gastrotomy ,
longitudinal mucosal tear is sutured

29. -GI tumors may present as
ulcerative lesions that
bleed persistently
- Persistent bleeding is
more characteristic of GI
stromal tumors (GISTs)
but may occur with other
lesions like leiomyomas
and lymphomas.

30. -Vascular malformations found primarily along the
lesser curvature of stomach within 6 cm of
gastroesophageal junction
-Treatment : application of thermal or sclerosant therapy
is effective in 80-100% cases
-If fails, Angiographic coil embolization is done
-If fails, surgical intervention is needed.

32. Also known as watermelon stomach
Features of GAVE are as follows :
-Women in their 50s are commonly affected
- Antrum is commonly involved
- Ectasia of antral vessels gives rise to UGI bleeding
- Endoscopy is the investigation of choice
- Red parallel stripes on mucosal fold are characteristic

33. -Mucosal fibromuscular hyperplasia and
hyalinisation are present
-Liver disease in 25% patients – cirrhotic men
- No control of bleeding – antrectomy may be
required

34. IATROGENIC : UGI bleeding may follow a
therapeutic or diagnostic procedure, for example –
bleeding in endoscopic sphincterotomy, percutaneous
endoscopic gastrostomy placement, etc.
HEMOBILIA :
-Is usually associated with
• intraductal neoplasm,
• trauma, or
• iatrogenic injury such as percutaneous liver biopsy and
cystic artery pseudoaneurysm.

35. -Angiographic therapy is the treatment of choice
Hemobilia

36.  Non variceal upper GI bleeding still
constitutes the major bulk of GI bleeding.
 Evaluation should be prompt.
 Upper GI endoscopy is the investigation of
choice.
 Treatment is mostly non surgical.