BASIC TO HIGHER

1. Presented By
Dr.(Maj) Ajay Kandpal MD DNB

2. An Axe and 2 Men

3. Basis Of Presentation
 Sleisenger and Fordtran’s GI & Liver Diseases 10th
Edition
 Yamada’s Textbook of Gastroenterology 6th Edition
 Harrison textbook of Medicine 19th Edition
 Strength of recommendation from ACG guidelines
2012
 Some other Articles

4. Outline Of Presentation
 Definitions
 Introduction
 Approach considerations
 Risk stratification and Management of UGI bleed

5. Definitions
 Upper GI Bleeding : always proximal to ligament of
Treitz
 Hematemesis : Vomiting of red blood or coffee ground
vomitus, indicative of bleeding from the esophagus,
stomach or duodenum.
 Malena: Black tarry stools resulting from degradation of
blood to hematin or other hemochromes by intestinal
bacteria.
 Hematochezia : Bright red blood per rectum and
suggests active UGI or small bowel bleeding or distal
colonic or anorectal bleeding

6. Severe GI Bleeding?
 Hematemesis ,melena, hematochezia or positive
nasogastric lavage
 Accompanied by shock
 Orthostatic hypotension
 Decrease in the haematocrit value by atleast 6%
 Decrease in Hb of atleast 2 grams/dl or transfusion of
two units of packed red blood cells.

7. Some Facts
 Approximately 50% of admissions for GI bleeding are
for upper GI (UGI) bleeding (from the esophagus,
stomach, and duodenum).
 Self limiting in 80%.
 Remaining 20% have a mortality of 30-40%.
 5-10% mortality despite advances

8. Causes
COMMON CAUSES
 Duodenal ulceration
 Gastric ulceration
 Esophagitis, gastritis,
duodenitis
 Varices
 Mallory Weiss tear
LESS COMMON CAUSES
 Gastro oesophageal
cancer
 Leiomyoma
 PHG
 Dieulafoy lesion

9. Causes

10. Approach Considerations
 Clinical suspicion
 Arriving at a confirmed diagnosis
 Management of UGI bleed

11. Clinical Suspicion
 Overt bleed
 History points
 Examination findings
 PR findings

12. History
Suspected source /cause History
Esophagus erosion GERD/heartburn/alcohol/odynophagia
/ pill ingestion/NG tube placement
Peptic ulcer Epigastric discomfort/asprin/NSAID
use/ history of PUD
Mallory weiss tear Alcohol binge
Retching/vomiting
Cameron lesion Large hiatal hernia
Gastric angiodysplasia CKD
Variceal bleed CLD/cirrhosis/heavy alcohol use
Malignancies Dysphagia/wt loss/early satitation
Nasopharynx Radiation/recurrent epistaxis/
malignancy
Lungs Hemoptysis

13. Physical Examination
SEVERE BLEED (SR)
 Tachycardia
 Systolic blood pressure of less than 90 mm Hg
 Cool extremities
 Syncope
 Ongoing brisk hematemesis or the occurrence of
maroon or bright-red stools, which requires rapid
blood transfusion.

14. Review Article
Upper Gastrointestinal Bleeding – A Review of the Literature
(Part 1)
Author(s): Bashir S, Roy P
Vol. 5, No. 2 (2008-05 - 2008-06)

15. HEPATOLOGICAL SIGNS

16. SKIN AND MUCOSAL SIGNS
 Skin,lips,buccal mucosa
suggestive of HHT or osler
weber rendu disease
 Pigmented skin lesions
HSP
 Pigmented lip lesions
Peutz Jeghers syndrome
 New onset acanthosis
nigricans

17. RHEUMATOLOGICAL SIGNS
Secondary to NSAIDS
HEMATOLOGICAL SIGNS
• Petechial hemorrhages
• Bruising
• Suggests bleeding diathesis
• Drug induced aplastic anemia

18. Variceal Non variceal
History
CLD, Jaundice,decompesation
Alcohol consumption
Drugs,pain abdomen
,heartburn,retrosternal discomfort
NCPF recurrent bacterial
infection,umbilical sepsis
Examination
Jaundice,abd.distention.signs of liver
cell failue
No such signs .look for
rheumatological,petechial signs
Epigastric tenderness
Painless bleeding Painful bleeding
Large amount ,FRESH BLEED Mild to moderate, COFFEE
GROUND
Decompensates rapidly

19. Clues From Initial Investigation
Parameter Implications
Hb /HCT 24-72hrs
Need of transfusuion
MCV Less than 80
Less than 80 with negative SOB
Platelets CLD
Hematological disorder
PT/INR Coagulopathy
Disproportionate rise of
BUN

20. Points To Decide Line Of
Management
 Severe or non severe
 Overt/ hidden
 Etiology
 Co-morbid conditions
 Availability of resources

21. Where To Manage
 Severe UGI bleed in ICU. (SR)
 Acute GI bleed with hemodynamic stability in ward.
 Mild Acute GI bleed with hemodynamic stability and
routine investigations normal, on OPD basis.(CR)
 SBP>110, pulse<100
 Hb13/12. BUN <18.2
 No malena, syncope, cardiac failure , liver disease
 Chronic bleed OPD basis.

22. How to Manage
 Resuscitation
 Initial medical therapy
 Endoscopy
 Endoscopic hemosatasis
 Post endoscopic considerations
 Imaging and surgery

23. RESUSCITATION (SR)
 IV access (14/16G ).
 Volume replacement (target SBP- 100. PR < 100).
 IVF (crystalloid) normal saline or ringer lactate.
 Vasopressors if hypotension present.
 Transfusion: (CR)
 PRBC (Hb target 7)
 FFP (PT < 15)
 Platelets <50,000

24.  Monitoring
 Vitals
 Hct levels 4-6 hrly till stablise
 Urinary catheter
 ET intubation
 MI evaluation

25. Initial Medical Therapy
 Depends on cause
 PUD – high dose PPI(CR)
 Reduce endoscopic stigmata of bleed
 Reduced need of endoscopy
 No improvement in transfusion reqmt/ rebleed
rate/surgery/survival
 Portal htn/variceal bleed
 Octreotide infusion

26. Endoscopy
 Requirement
 Stable hemodynamic condition
 Intubation if required
 Correction of coagulopathy and thromboctopenia
 Gastric lavage (CR)
 IV erthromycin/metoclopramide 30-90 min before (CR)
 Timing
 Cirrohosis/aorto enteric fistula /rebleed in hosp---6hrs
(CR)
 Stable with no ongong bleed – 12 hrs (CR)

27. Pre-Endoscopic Risk Stratification
 Clinical condition
 Co morbidities
 Scoring systems for non- varicel bleed

28. Pre- Endoscopy Scoring System
 Blatchford Score : BP, heart rate, syncope,melena,
liver disease,heart failure, Hb%, BUN.
Assess need of intervention to control bleed (score>6)
 Clinical Rockall score : SBP, heart rate, age,
comorbidities.
 AIMS 65 score : Albumin <3gm/dl, INR >1.5,
Impaired mental status, SBP<90mmHg, age>65 yrs.
Score less than 2 is low mortality, short stay.less
hopitalization

30. Endoscopic Risk Stratification
 Visual scales
 Scoring systems

31. Post Endoscopy Scoring System
(SR)
 Complete Rockall score : Clinical Rockall score +
endoscopic stigmata of recent bleeding and
endoscopic diagnosis.
• Score 0-2: very less risk of rebleeding
• Score 9 and above: high risk of rebleeding and mortality.
• Correlates well with mortality but not as well with
rebleeding.

33. FORREST Classification for Peptic
Ulcers
CLASSIFICATION ENDOSCOPIC PIC RISK OF REBLEEDING
FORREST IA ACTIVE SPURTING
AND BLEEDING
85 TO 100%
FORREST IB OOZING BLEEDING 10- 25%
FORREST 2A PIGMENTED
PROTRUBERANCE OR
NBVV
50%
FORRSET 2B ADHERENT CLOT 30 -35%
FORRSET 2C FLAT PIGMENTED
SPOT
<8%
FORRSET 3 CLEAN BASED ULCER <3%

34. Risk For Bleed
 The most important predictor of hemorrhage is the
size of varices, with the highest risk of first
hemorrhage (15% per year) occurring in patients with
large varices.
 Other predictors of hemorrhage are decompensated
cirrhosis (Child B ,C).
 The endoscopic presence of red wale marks.

35. Red Wale Signs Of A Varix In
Endoscopy
 Suggests recent haemorrhage
 Longitudinal streak located on
esophageal varix
 Cherry red spot (circular and
red)

36. Endoscopic Hemostasis
 Thermal probe
 multipolar electrocoagulation probe(MPEC)
 Non contact argon plasma coagulation
 Injection therapy
 Epinephrine 1:10000, submucosal
 N-butyl-2-cyanoacrylate, which is recommended as a first-
line endoscopic therapy
 Sclerosant like Ethanolamine or alcohol
 Hemoclips
 Band ligation
 Hemostatic spray

37. Endoscopic Therapy Rec.
 Oozing /spurting or NBVV (SR)
 Adherent clot with comorbidities increasing risk of
bleed (CR)
 Not to clean base ulcer or flat pigmented spot (SR)
 Epinephrine should not be used alone, if used then in
combination of other therapy(SR)
 Use of IV PPI after hemostasis in ulcer with Oozing
/spurting or NBVV (SR)
 Oral PPI clean base ulcer or flat pigmented spot (SR)

38.  Relook endoscopy for rebleed or high stigmata of
rebleed in initial endoscopy (SR)

39. Post Endoscopy

40. Post Endoscopy Considerations
 PUD
 PPI
 H Pylori eradication (SR)
 Iron replacement
 Aspirin (CR)
 Primary prevention : avoid
 Secondary prevention : start in 1-3 days
 NSAID (SR)
 Not if possible
 Cox2 inhibitors plus PPI

41.  VARICEAL BLEED
 Octreotide /Terlipressin
 NSBB
 TIPSS

42. Second Look Endoscopy
 Routine second look endoscopy is not
recommended for most patients with peptic ulcer
bleeding, except in those in whom the initial
endoscopic examination was suboptimal.

43. Rebleeding After Endoscopic
Treatment
 An urgent repeat endoscopy should be performed
within 6 hrs of rebleeding.
 75% of patients achieve endoscopic hemostasis &
donot require surgery.
 High dose PPI for more than 72 hrs should be
considered.
 Factors predicting failure of endoscopic retreatment
include ulcer >2cm & hypotension on initial
presentation.

44. ACTIVELY BLEEDING VARICES
TIPS OR SURGERY(PC SHUNT OR
ESO.TRANSECTION)
REPEAT BAND LIGATION OR
SCLEROSIS
BLEEDING CONTINUES
PERIPHERAL VENOUS VASOPRESSIN
ENDOSCOPIC BAND LIGATION OR
SCLEROSIS
BALLOON TAMPONADE
TIPS
BLEEDING CONTINUES
BLEEDING
CONTROLLED
CHRONIC
MANAGEMENT
OF VARICES
THAT HAVE BLED
CONSIDER:COURSE
OF ENDOSCOPIC
BAND LIGATION OR
INJECTION
SCLEROSIS OR
PORTOCAVAL
SHUNT SURGERY
(or)
and /or
or

45. Imaging
 Role only if both endoscopy and colonoscopy fails
 Mesentric arteriography 0.5ml/min
 Radionuclide scaning 0.04ml/min

46. Surgery
 Indicated only for massive continuous hemorrhage
with failed endoscopy and colonoscopy

47. Prevention
 Risk factors
 NSAID
 Binge drinking
 CLD
 Primary prophylaxis
 Secondary prophylaxis

48. Case Scenario
 43 year old male with hematemesis , HE
 History: alcohol consumption, liver
OPD visits, risk factors alcohol and no
prophylaxis for bleed
 Examination: CLD features, low BP,
tachycardia, cool extremities
 Inv : initial raised Hct, raised BUN
 Mgt: Octreotide infusion and late
endoscopy
 Complete resuscitation