This presentation deals with various forms of upper gi haemorrhage , diagnostic approach and management options

1. Acute GI Haemorrhage
Presented By : Dr Ankit Lalchandani
Moderated By : Dr Puneet K Agarwal

2. • Can be trivial to massive
• Can originate from any part of GI tract including
Liver, biliary tree and pancreas
• Upper GI bleed : proximal to ligament of Treitz
• Lower GI bleed : distal to ligament of treitz
• Obscure Bleeding : persists even after a
negative endoscopy
• Most stop spontaneously, 15% massive
haemorrhage requiring emergent resuscitation

3. Upper GI Bleed

4. Presentation
• Hemetemesis
• Bright red
• Coffee ground
• Melena : Foul smelling, black , tarry stools
• Hematochezia : Fresh blood per rectum ( massive bleeding)

5. Etiology
Others :
• Hemobilia
• Dieulafoy lesion
• Gastric Antral
Vascular Ectasia
(GAVE)
• Aortoenteric fistula

6. Goals:
• Initial assessment and Resuscitation
• Diagnosis and localization
• Risk stratification
• Specific management

7. Initial evaluation
• Presentation : Ongoing bleeding( Hemetemesis/Melena/Hematochezia)
Tachycardia, hypotension, cold peripheries
Obtundation, altered sensorium
Shock
• ABCs
• Send CBC, LFT, RFT, PT/INR, cross match
• Quantify haemorrhage
( Hematocrit not a good indicator as acute losses involve RBC and plasma
equally)

8. ATLS guidelines

9. • Resuscitation
• Advanced airway : if obtunded, altered sensorium, massive bleeding
• Supplemental oxygen
• Circulation : Fluid bolus upto 2 lit, Whole Blood/ PRBC (FFP +/-)
(target haematocrit > 30% in elderly, >20% in young otherwise healthy)
• Foleys catheter, NG tube

10. Localization
* GI Contrast studies are
contraindicated as they
interfere with endoscopy

11. • EGD
• Diagnostic and Therapeutic
• Most effective if done within 24 hrs ( but after
adequate resuscitation)
• Visualization poor in case of ongoing massive
haemorrhage
• Complications :
• Esophageal perforation
• Respiratory depression
• Aspiration

13. • RBC scan
• Uses Tc99 labelled RBCs
• Can detect Minute bleeding upto 0.1ml/min
• Sensitivity 90%
• Can only detect active bleeding
• Poor Spatial resolution as blood may move
retrograde in colon and distally in small
bowel
• Used to guide the utility of angiography

14. • Angiography
• Usually to localize lower GI bleed
• Reserved for patients unfit for surgery
• Selective angiography : SMA or IMA
• Can detect bleeding upto 0.5 – 1 ml/min
• Can identify vascular patterns of angiodysplasias
• Can be therapeutic ( Intra-arterial vasopressin injection/ embolization)
• Complications :
• Bowel ischemia, coronary , cerebral ischemia
• Pseudoaneurysm
• Rebleeding

15. Ileocolic artery

16. Risk Stratification
• To determine the
risk of rebleeding
and mortality
• To decide if the
patient required
ICU admission and
urgent endoscopy

17. • Factors associated with rebleeding :
• Hemodynamic instability (systolic blood pressure less than 100 mmHg, heart
rate greater than 100 beats per minute)
• Hemoglobin less than 10 g/L
• Active bleeding at the time of endoscopy
• Large ulcer size (greater than 1 to 3 cm in various studies)
• Ulcer location (posterior duodenal bulb or high lesser gastric curvature)

18. Specific Management

19. Peptic Ulcer Disease

21. • Medical Mx:
• Stop ulcerogenic meds : NSAIDs, SSRIs
• PPI : esmoprazole iv 80mg bolus f/b 40 mg iv BD
• HP kit : Amoxycillin, omeprazole, metronidazole x 2 weeks
• 50 -60% cases are H pylori positive
• Endoscopic Mx
• Injection
• Epinephrine ( large volume inj in 4 quadrants around the ulcer)
• Fibrin Glue
• Sclerosant ( STS, Ethanol)

22. • Coagulation
• Electrocautery
• Heater probe
• Argon Plasma coagulation
• Nd YAG laser
• Mechanical
• Hemostatic clips ( difficult to apply, effective in controlling spurters)
• Endoloop
• Combination of inj with electrocoagulation achieves hemostasis in 90% cases
• Angiographic Mx
• Superselective angiography f/b intraarterial vasopressin inj/ embolization

23. • Surgery :
• Required in 10 % cases
• Primary aim is to control haemorrhage
• Acid reducing surgeries not preferred with the availability of PPIs

24. • Duodenal ulcer :
• Bleeding gastroduodenal artery
• Longitudinal pyloroduodenotomy is made
• Sutures placed proximal and distal to
gastroduodenal artery
• Third suture to control transverse pancreatic
branch

25. • Gastric Ulcer :
• Erodes into Left Gastric artery
• 10% incidence of malignancy
• Resection of ulcer
recommended
• Gastric resection indicated for
recurrent /intractable ulcers

26. • Type 1 ulcer can be oversewn or wedge resection
can be performed
• Type 2 and 3 are amenable to distal gastrectomy
• Type 4 requires Pouchets procedure

27. Variceal bleeding
• Mostly associated with Portal
hypertension
• Dilated , friable submucosal veins in
esophagus and stomach
• Can also present as Portal Hypertensive
Gastropathy
• Increased risk of rebleeding and
requirement of transfusion
• Treatment focussed on arresting
bleeding and preventing rebleeding

29. • Medical Mx :
• Octreotide/ Somatostatin/Vasopressin : reduce splanchnic circulation
• Non selective b blockers/ Nitrates : Reduce Portal blood pressure
• Endoscopic Mx:
• Mainstay of treatment
• Most effective if done within 12 hrs
• Band ligation
• Strangulates the varices causing thrombosis
• Cant be used for gastric varices

30. • Sclerotherapy
• Only if visualization is poor for banding
• Intravariceal/paravariceal inj of Ethanolamine oleate/Sodium
Monorrhuate
• Best results achieved with pharmacotherapy along with
banding
• Balloon Tamponade
• Uses Sengstaken Blakemore balloon
• If endoscopic therapy fails or massive bleeding
• Achieves temporary hemostasis (>90%)
• Recurrence rate >50%
• Complications : Esophageal perforation,
Aspiration

31. • TIPS
• When Endoscopy and pharmacotherapy fail
• Achieves Control in upto 100 %
• Creation of side to side portocaval shunt
• Uses PTFE shunts
• Complications : Encephalopathy, Shunt Thrombosis
• High mortality (>60%) in decompensated patients
• Ideal therapy for short term portal decompression for patients awaiting
transplant

32. • Surgery
• Most effective in preventing rebleeding
• Diverts portal blood flow and reduces portal pressures
• Complications :
• Hepatic encephalopathy
• Accelerated liver failure
• Shunt thrombosis

34. Mallory Weiss tears
• Mucosal and Submucosal tears at the GE
junction
• Follows intense retching and vomiting after
binge drinking
• Mechanism : Forceful contraction of abdominal
wall against closed cardia
• Most occur along lesser curvature
• Diagnosed with endoscopy : retroflexion
manoeuvre
• Mx : Conservative  Endoscopic coagulation 
Angiographic embolization  Surgery

35. Dieulafoy lesion
• Vascular malformations found primarily
along the lesser curve of the stomach
• Within 6 cm of the gastroesophageal
junction
• Rupture of unusually large vessels (1 to 3
mm) found in the gastric submucosa
• Can cause massive bleeding
• Mx : Endoscopic sclerotherapy effective
in 80 – 100%)  Angiographic
embolization  Surgery

36. Gastric Antral Vascular Ectasia
• Also known as watermelon stomach
• Collection of dilated venules appearing as linear
red streaks converging on the antrum in
longitudinal fashion
• Acute severe hemorrhage is rare
• Most patients present with persistent, iron
deficiency anemia from continued occult blood
loss
• Persistent, transfusion dependent disease can
be managed successfully with Endoscopic APC

37. Lower GI Bleed

38. • Incidence of Lower GI bleed is half compared to upper GI bleed
• Incidence increases with age, and the cause is often age related
• Mortality rate is similar to that of upper GI bleeding at around 3%
• This rate increases with age to more than 5% in those 85 years or
older
• The source of hemorrhage is the colon in >95% cases
• May present with severe hemorrhage in diverticular disease/vascular
lesions to a minor inconvenience secondary to anal fissure or
hemorrhoids

39. Etiology

41. Diverticular disease
• Mostly seen in pt >40 yrs
• Significant Bleeding occurs in 3-15%
• Bleeding generally occurs at the neck of
the diverticulum
• Secondary to bleeding from the vasa recti
as they penetrate through the submucosa
• Bleeding stops spontaneously in 75%
• Diagnosis : Colonoscopy
• Mx : Endoscopic Mx  Angiographic
embolization(superselective)  Surgery

42. Angiodysplasia
• Submucosal AV malformations
• Degenerative lesions secondary to progressive
dilation of normal blood vessels
• Seen in patients aged > 50 yrs
• Frequently associated with aortic stenosis and
renal failure
• Mostly arises from Ascending colon ( MC
Caecum)
• Presents with massive bleeding in 15 %

43. • Diagnosis :
• Colonoscopy : red stellate lesions with a
surrounding rim of pale mucosa
• Angiography : dilated, slowly emptying
veins and sometimes early venous filling.
• Mx : Endoscopic  Angiographic
emobolization  Surgery

44. THANK YOU