1) Acute gastrointestinal bleeding can originate from the upper GI tract and has many potential causes, including peptic ulcers, esophageal and gastric varices, erosive mucosal disease, and tumors. 2) Initial management involves resuscitation, localization of the bleeding site, and initiation of pharmacotherapy or endoscopic therapy to stop active bleeding. 3) Specific treatments depend on the underlying cause, with peptic ulcers commonly treated with proton pump inhibitors, endoscopic therapy, and surgery if bleeding persists, while variceal bleeding is managed with vasoactive drugs, balloon tamponade, endoscopic band ligation or sclerotherapy, and TIPS procedure.

1. Acute Gastrointestinal Bleeding
Upper GI tract
Dr. Niladri Banerjee
MBBS, MS, MRCS Ed
MCh (Trauma Surgery & Critical Care)
Assistant Professor, Surgery
AIIMS, Jodhpur

2. Content
• Introduction
• Causes of UGI bleed
• Presentation, diagnosis & principles of
management
• Specific Management

3. INTRODUCTION

4. GI Bleeding
Upper Lower
GI Bleed – Overt – Acute, Chronic
Occult – Chronic
Obscure – cause not identified
Ligament of Treitz

5. Upper GI Bleeding
• Upper GI Bleed – Hematemesis, Melena
• Hematemesis- Coffee ground vomitus
• Melena - Black tarry stool, a foul odour
Colour and smell - Acid Hematin
• 60 ml of blood loss - melena
• Melena may persist for 3 days

6. AIIMS Delhi Data: 5 years
• Total admission - 5174
• GI Bleed - 1460
(28%)
• Mortality - 13%

7. CAUSES OF UGI BLEED

8. Major Causes of UGI Bleed
Ulcer
EMD(erosive mucosal
disease
Varices
s

9. Uncommon causes
Ca.
stomach Hemobilia
AV malformation

10. Causes of UGIB
Non-variceal bleeding
• Gastric and duodenal ulcers (30%-40%)
• Gastritis and duodenitis (20%)
• Esophagitis (5%-10%)
• Mallory-Weiss tears (5%-10%)
• Arteriovenous malformations (2%)
• Tumors (5%)
• Other causes (Dielafoy lesions,GAVE,
Aortoenteric fistula, Hemobilia,
Hemosuccus pancreaticus)
Portal hypertensive bleeding
• Gastroesophageal varices (>90%)
• Hypertensive portal gastropathy
(<5%)
• Isolated gastric varices (rare)

11. EMD
7%
Peptic
ulcer
60%
Variceal
25%
Others
8%
West
Peptic
ulcer
24%
Variceal
55%
EMD
18%
Others
3%
India
Etiology of UGI Bleed: West vs India

12. Prevalence of variceal bleeding in UGI bleeding- In
Indian scenario

13. Prevalence of variceal bleeding in UGI bleeding- In
Indian scenario

14. PRESENTATION, DIAGNOSIS &
PRINCIPLES OF MANAGEMENT

15. Presentation
• May present in subtle way (unexplained
microcytic anemia, positive occult blood in
stool) in the OPD
• Or may present as massive GI hemorrhage in
the emergency

16. Obscure bleeding (OPD)
• Clinical recognition:
– History of dyspepsia
– NSAIDs intake
– History of jaundice
– Splenomegaly
– Ascites
– Collaterals
Peptic ulcer
Variceal bleed

17. Acute exsanguinating bleed
• Patient in shock
• Severe bouts of hematemesis and melena
• Ryle’s tube shows bright red blood/coffee
ground

18. Principles of management
Initial assessment and resuscitation
History and examination
Localise bleeding
Initiate therapy

19. Initial Assessment
• ABC assessment
• To assess magnitude of bleeding
– Degree of shock
– Haematocrit
– Elderly vs young
• Lab evaluation (ABG, Base deficit, lactate)
• Resuscitation
– Ringer’s Lactate, Massive transfusion protocol

20. Resuscitation
• Initial 1-2 litres of crystalloids (RL)
• Early administration of blood
• Massive transfusion protocol (1:1:1 ratio of pRBC,
FFP and platelets)
• Restrictive target Hb strategy (Target around
7gm/dL) *
* Villanueva et al N Engl J Med. 2013

21. History and Physical Exam
• Symptoms assessment
• Medications
• Previous Surgery
• Head to toe examination

22. Risk stratification
It includes
– BUN
– Hb
– SBP
– Pulse
– Presence of melena, syncope, hepatic or cardiac dysfunction
Glasgow Blatchford Bleeding score: screening tool to
assess the likelihood that a person with acute upper GI bleed
will need some medical intervention
>6 means >50 % chance of
intervention

23. Sabiston textbook of surgery 21st ed

24. Initiation of therapy
• Obtain immediate consultation with gastroenterologist,
surgery and interventional radiology
• Pharmacotherapy (Ulcer)
– Pantoprazole/Esomeprazole 80 mg iv stat and start infusion at 8
mg/hour
• Pharmacotherapy (Variceal bleed)
– somatostatin or an analogue (eg, octreotide 50 mcg IV bolus followed
by 50 mcg/hour continuous IV infusion)
– IV antibiotic (eg, ceftriaxone or fluoroquinolone)

26. SPECIFIC MANAGEMENT

27. Peptic Ulcer Bleeding
• Peptic Ulcer: DU, GU, Stomal ulcer
• 15-20% of all ulcer bleed
• 50% of bleeds associated with NSAID use
• Presentation – Hematemesis + melena
- Melena alone

28. Peptic ulcer bleeding: Natural History
• 70% - bleeding stops spontaneously
• Rebleeding - 25%
• Mortality - 10%
- unchanged over the years

29. • Prognostic factors
- age >60 years
- co-morbid illness
- shock at presentation
- Hematemesis/red blood in NG lavage
- Endoscopy - active bleed, visible vessel
• High risk vs. low risk
Peptic ulcer bleeding: Prognostication

30. Age
<60 yr
60–79 yr
>80 yr
Shock
Heart rate >100 beats/min
Systolic blood pressure <100
Coexisting illness
CAD, CHF
Renal or Liver failure, Cancer
Endoscopic diagnosis
No lesion observed, M-W tear
Any other diagnosis
Cancer of upper GI tract
Endoscopic stigmata of recent hemorrhage
2C, 3
1, 2A, 2B
0
1
2
1
2
2
3
0
1
2
0
2
Score <2 low risk
Rockall Score for Prognosis

31. Management: Fundamental principles
• Determine the source of bleeding
• Stop active bleeding
• Treat the underlying abnormality
• Prevent recurrent bleeding
• Most important: Immediate assessment and
stabilization of the hemodynamic status

32. Peptic ulcer bleeding: Management
• Resuscitation: 2 lines, iv fluids
• BT if HB <8 gm/dl
• Pharmacotherapy
• Endoscopic Rx
• Surgery
• Prevention of long term re-bleeding

33. Blood transfusion: Target
• In elderly - 10 gm/dl
• In younger, healthy patients – 8 gm/dl
• In Portal hypertension : 7-8 gm/dl
• Hematocrit better guide after volume resuscitation
• Packed red blood cells are preferred
• FFP should be given if blood requirement more
than 10 units or if coagulopathy

34. Ulcer Bleeding: Pharmacotherapy
• Acid Suppression: clot stabilization
- H2 blockers no benefit
- Proton pump inhibitors useful
• Tranexamic acid: ? Benefit
• Anti H. pylori treatment

35. Ulcer Bleeding: Role of PPIs
• Omeprazole alone, No endoscopic Rx
- reduce re-bleeding, need for surgery
(Khuroo et al, 1997)
• Omeprazole + endoscopic Rx
Re-bleed day 3 - 0 vs 8%
day 14 - 2 vs 12%
• Pantoprazole – IV infusion similar efficacy
(Lin et al,1999)

36. Ulcer Bleeding: Anti-H. pylori Rx
Anti-HP Omeprazole
(n=29) (n=22)
Ulcer recurrence 3/29 9/22
Re-bleeding 0/29 6/22
(Jaspersen et al, 1995)
Re-bleeding 0/16* 5/15*
(Rokkas et al,1995)

37. Ulcer Bleeding : Endoscopic Therapy
Timing of endoscopy
• Emergency diagnostic endoscopy – no role
• Endoscopy in emergency - if therapeutic intent
• Endoscopic signs - Stigmata of Recent
Hemorrhage (SRH)

38. Forrest Class 1b
Forrest Class IIa

39. Forrest Class IIb
Forrest Class IIc
Forrest Class III

40. Ulcer Bleeding : Endoscopic Therapy
• Who requires EndoRx ?
Forrest class Re-bleeding EndoRx
Ia spurting bleeding 50-65% 
Ib active ooze 30-40% 
IIa visible vessel (NBVV) 40-50% 
IIb adherent clot 20% ?
IIc ulcer with hematin spot 10% x
III clean base ulcer 5% x

41. Endoscopic therapy:Modalities
• Injection - adrenaline,
saline, alcohol,
fibrin,
cyanoacrylate glue
• Thermal contact – EC,
Heater Probe
• Thermal non contact –
Laser, APC
• Mechanical – Hemoclip,
banding

42. Ulcer Bleeding : Endoscopic Therapy
• Injection:
– ? Tamponade, vasoconstriction
– 1:10,000 adrenaline around the ulcer
• Thermal:
– Heater probe, Electrocoagulation
– Principle – coaptive coagulation
– Seal the vessel up to 2 mm by pressure and heat
• Mechanical – clip the vessel

43. EndoRx: Meta-analysis
Further bleed Surgery Mortality
• Thermal 0.3 0.3 0.6
• Laser 0.5 0.6 0.5
• Injection 0.2 0.2 0.5
• All Rx 0.4 0.3 0.5
(0.4-0.7)
(Cook et al, 1992, Gastro, 30 trials, 2136 patients)

44. Ulcer Bleeding : Surgery
• Indications
- Continued Bleeding,
- Failure of Endo. Rx
- Re-bleeding in the hospital
- Blood Transfusion > 4 units

45. Re-bleeding: Long Term Prevention
• Anti H. pylori Rx
• Long term H2 blockers
• No/safer NSAIDs,
• Long term NSAID user: PPIs

46. Erosive Mucosal Disease
• Risk Factors - Acute stress, NSAIDs
• Bleeding usually mild, may be massive
• Re-bleeding uncommon
• Prevention:
-Acute stress - Ranitidine vs Sucralfate
• Treatment - supportive,
- pantoprazole/ ranitidine infusion

47. Portal Hypertension & UGI Bleeding
• 30-60% of cirrhotics have
varices
• One third of varices bleed
• High Mortality – 30% die
• 70% rebleed within next 6
weeks
• Important factors : Child Pugh
score and variceal grade

48. Variceal Bleeding: Aims of treatment
• Prevent First Bleeding
• Control Acute Bleeding
• Prevent Re-bleeding

49. Varices: Prevent First Bleeding
• Primary Prophylaxis –
- β-blockers – Propranolol, nadolol
clinical guide – heart rate <60/min.
Problems – contraindications to β-blockers
- 1/3rd patients do not respond
- Variceal Band ligation - promising

50. Varices: Control Acute Bleeding
• Pharmacotherapy –
– Somatostatin, Terlipressin, Octreotide
– Somatostatin
• 250 ugm stat, 250 ugm hourly infusion
• Duration 3-5 days
• As sole therapy - 80-85% efficacy
• Adjunct to Endo. Rx – early re-bleeding
• Cost is high

51. Varices: Control Acute Bleeding
• Mechanical :
– Balloon tamponade (SB tube), 80% effective
– Use if no Endoscopy available or fails

52. Varices: Control Acute Bleeding
• Endoscopic Rx - Variceal Sclerotherapy,
- Variceal Band ligation
- Efficacy – 90%, best modality
- Problems – early re-bleed, complications
• Fundal varices – glue injection

53. Endo clipping
Band ligation
Sclerotherapy

54. Varices: Prevent Re-bleeding
• Endoscopic therapy :
- Sclerotherapy, EVL – for variceal eradication
- EVL – faster variceal eradication, less
complications, but early recurrence
- Surveillance endoscopy after eradication
• Pharmacotherapy – may be useful

55. TIPS
• Transjugular intrahepatic
porto systemic shunt
• Between Hepatic vein and
Portal vein
• Stent is made up of PTFE
• Complications:
– Capsule rupture with
intraperitoneal hemorrhage
– Encephalopathy, shunt
thrombosis- within 1 month
– Shunt stenosis- within 1 year
– Ascitis gets resolved

56. Non-selective shunts
• End to side poto caval
• Side to side porto caval
• Interposition graft
• TIPS
• Linton shunt
Selective shunts
• Warrens shunt
• Inokuchi shunt
Surgical shunts
Variceal Bleeding : Surgery

57. Devascularisation operations
Variceal Bleeding : Surgery
Sugiura operation
• Ligation of veins near
esophagus
• Vagotomy
• Pyloroplasty
• Esophageal transection
and anastomosis
• Splenectomy

58. Last resort: Liver Transplantation
Variceal Bleeding : Surgery

59. Upper GI Bleeding: uncommon causes
• Vascular Lesions
– Dieulafoy’s lesion (ectatic abnormal vessel)
– A-V malformation
– GAVE (Watermelon stomach)
• Uncommon, bleeding usually massive
• Treatment: - Endoscopic
- Surgery

60. Dieulafoy lesion
• Vascular malformation within
6 cm of GEJ
• 1-3 mm vessels- at sub-
mucosa
• T/t: endoscopic t/t if fails
angiographic coil
embolisation
• Last resort: partial
gastrectomy

61. GAVE
• Watermelon stomach d/t
multiple dilated venules
• Antrum
• Continued occult bleed
• TOC: APC
• Last resort: antrectomy

62. Mallory-Weiss tears
• Binge drinking
• Mucosal and sub-mucosal
tears
• UGIE
• Most: self limiting within 72
hours
• Local endoscopic t/t,
angiographic embolisation,
gelatin sponge

63. Esophagitis
• GERD
• Usually superficial
mucosal ulceration
• Occult bleeding
• R/o medications, radiation,
Crohn’s
• T/t: acid suppressive
therapy

64. Malignancy
• C/f: chronic anemia or
hemoccult-positive stool
• GIST
• Endoscopic t/t good to
control bleed but
rebleeding chances are
higher
• Surgical resection or
palliative resection

65. Aortoenteric fistula
• Post graft-enteric erosion: 1% of aortic graft
• Median interval is 3 years
• Pseudoaneurysm with fistulisation
• Sentinel bleed massive and fatal
bleed
• D3 or D4
• Therapy: ligation of graft proximal to the
graft, removal of infected prosthesis, and
extra-anatomic bypass
• Duodenum-primarily repaired

66. Hemobilia
• Post trauma, iatrogenic, hepatic neoplasm
• Triad: hemorrhage, right upper quadrant pain
and jaundice
• UGIE: blood at the ampulla
• CT angio and embolization

67. Hemosuccus pancreaticus
• Bleeding from the pancreatic duct
• Splenic artery erosion: pancreatic pseudocyst
• Abdominal pain, hematochezia
• Treatment of choice: Distal pancreatectomy

68. Iatrogenic bleeding
• Endoscopic sphincterotomy
• Percutaneous trans-hepatic procedures
• Percutaneous endoscopic gastrostomy

69. UGI Bleeding: Summary
Upper GI Bleeding
Resuscitation
Clinical evaluation
Endoscopy – Emergency – if therapeutic
Otherwise Elective
Pharmacotherapy Endo. Rx Surgery
Prevent Re-bleeding

70. UGI Bleed: Summary
• UGI bleed: major cause of morbidity & mortality
• Varices and ulcers common causes
• Resuscitation, do not over transfuse
• UGI Bleed: Pharmacotherapy effective
– Ulcer bleed: intravenous PPI infusion
– Variceal bleed: somatostatin infusion
• Ulcer and variceal bleed: Endotherapy
• Surgery: minority of patients

71. Thank You