Upper gastrointestinal bleeding is a common medical condition that requires prompt assessment and treatment. Key steps in evaluation include determining hemodynamic stability, performing nasogastric aspiration to identify the source and activity of bleeding, and endoscopy within 24 hours of presentation to identify the cause and risk stratify patients. Resuscitation focuses on restoring circulating volume through blood transfusions and intravenous fluids while controlling active bleeding endoscopically. Risk stratification scores like Rockall and Blatchford are used to determine patient disposition and guide management.

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