The document provides information on the management of massive gastrointestinal hemorrhage. It discusses that the majority of massive GI bleeds originate from the upper GI tract. The initial management of a patient with massive GI hemorrhage involves airway protection, intravenous fluid resuscitation, monitoring of vital signs, and blood transfusions if indicated. Early endoscopy within 4 hours is advocated for diagnostic and therapeutic purposes such as locating the bleeding site and achieving hemostasis. Additional procedures like angiography may be used if endoscopy is unsuccessful or for lower GI bleeds. Antibiotic prophylaxis is recommended for patients with cirrhosis to reduce infectious complications. Restrictive blood transfusion strategies with a hemoglobin threshold of 7-8 g

1. Management of Massive GI
Hemorrhage

2. CASE
• 50 yo female with massivehematemesis
• Hypotensive and tachycardic, drowsy
• Initial actions?

3. Facts
•Majority (>75%) of massiveGIbleed is from the
upper GI tract (Proximal to ligament of Treitz– D4)
•Majority of the LGIBleeding is self limiting
•More common in males and in the elderly (>60),
antiplatelet use/anticoagulants/co-morbidities.
•Mortality 5-10%

4. Etiology
Upper GI Bleed Lower GI bleed
Pepticulcerdisease-50%- H.pylori,NSAIDS,
smokers,ETOH,steroids
Colonic Bleeding – 95% (mainly
Diverticular disease)
Esophageal/GastricVarices–12%-25% Smallintestinal bleeding-5%
Esophagitis- 8%
Mallory-Weiss tear
Angiodysplasia
Boerhaave’s syndrome
Other : Stress
ulcers/AVM/Malignancy/Aortoenteric
fistula

5. Clinical features
• Upper abdominal pain
• Odynophagia, gastro-esophageal reflux, dysphagia
• Emesis, retching, or coughing prior to hematemesis
• Jaundice, abdominal distention (ascites)
• Dysphagia, early satiety, involuntary weight loss, cachexia
• Hematochezia, Melena, Occult GI bleed(anemic symptoms)

6. Physical Examination
• Resting tachycardia, orthostatic blood pressure changes
suggest moderate to severe blood loss;
• Hypotension suggests life-threatening blood loss(>40% of
body volume)
• Rectal examination is performed to assess stool color
(melena versus hematochezia)
• Significant abdominal tenderness accompanied by signs of
peritoneal irritation (eg, involuntary guarding) suggests
perforation

7. Rockall Score
Variable Score 0 Score 1 Score 2 Score 3
Age <60 60-79 >80
Blood pressure fall
(Shock)
No shock Pulse >100
BP >100 systolic
SBP <100
Co morbidity Nil Major CHF, IHD ESRD, Liver failure,
metastatic disease
Diagnosis Mallory Weiss All other Diagnosis GI malignancy
Evidence of bleeding None Blood, Adherent
clot, Spurting vessel
A score of less than 3 carries good prognosis, but a total score of more
than 8 carries high risk of mortality.

8. Initial Management
• Keep NPO24h,Pendingspecialistintervention
• Stabilization andmonitoring-
- A& B
• Airwayprotection–i/v/oaspiration.
• Almostalwaysneedendotrachealintubation,facilitatesendoscopyinpatients
withongoinghaematemesisandaltered resp.and mentalchanges
-C
• 2Largebore peripheral IVcannula’s(16Gor larger)
• Volume resuscitation (blood and fluid)
• CallBlood bank
• Invasivearterial blood pressuremonitor
• Comprehensive cardiopulmonarymonitoring
• Keepwarm –Warm fluids andblankets –avoidhypothermia /
hypoglycaemia

9. Fluid resuscitation
• Administer IVFs (Crystalloids) in well-defined boluses (eg,
500 to 1000 mL) that can be repeated until blood pressure
and tissue perfusion are acceptable. (Aiming for a perfusing
MAP>65)
• NGT and gastric lavage not useful in risk stratification, may
play role in improving visualization for endoscopy.

10. Investigations
• Bedside: ECG, VBG
• Initial investigations
-CBC with differential, platelet count,Hct
-Group and cross match
-Coags– INR:<2 (for endoscopy),D-dimer
-U&E; urea andcreatinine ratio - 30:1
-LFT- Toassessforcirrhosis
-Cardiac enzymes –Trop T/I – elderly pt toexclude
AMI in large bleed
-Imaging– CXR
-Consult- Gastroenterology / IR, Surgery if indicated

11. Blood Transfusions
• Hemodynamic instability despite crystalloid resuscitation
• Hemoglobin <9 g/dL (90 g/L) in high-risk patients (eg, elderly,
coronary artery disease0
• Hemoglobin <7 g/dL (70 g/L) in low-risk patients
• Give fresh frozen plasma for coagulopathy; give platelets for
thrombocytopenia (platelets <50,000) or platelet dysfunction (eg,
chronic aspirin therapy)
• 1 FFP should generally be transfused every 4 pRBC transfusions.
• Transfusing pt with Hb levels <7-8 (Restrictive BT) –
-Decreases rebleeding
-Reduces complications
-Increases survival
• Hbideally >9-10g/dL for unstable CAD/Elderly

12. Pharmacologic therapy
1.ProtonPumpInhibitors–Inhibitiongastric
H+/K+ATPase/neutralizationofgastricacid/Pepsin
• Current empiricin acute UGIB
Hasbeenthe mainstay early treatment/Adjunct toendoscopy
• Proposedreduction in haemorrhageduring endoscopy,noimmediate
impact.
• Given mainly to prevent rebleeding.
• Esomeprazole 40mg IV BD after initial 80 mg bolus.
2. Prokinetics- The goal of using a prokinetic agent is to improve
gastric visualization at the time of endoscopy by
clearing the stomach of blood, clots, and foodresidue.
eg- erythromycin or metoclopramide (A dose of
3 mg/kg intravenously over 20 to 30 minutes)

13. Cont.
3. Vasoactive medications-
-Reduction of portal HTN via splanchnic and systemic
vasoconstriction
-In patients with suspected variceal bleeding, octreotide is given as an
intravenous bolus of 20 to 50 mcg, followed by a continuous infusion
at a rate of 25 to 50 mcg per hour
4. Antibiotics for patients with cirrhosis- May reduce
risk of recurrence bleeding in variceal bleeding/Prior or after
endoscopy – 23% infection prevention.

14. Endoscopy
• Diagnosticandtherapeutic modality ofchoice
• Accurateat locating bleedingsite (78-95%)andpredicting
mortality +risk stratification aboutre-bleeding and also achieve
acute hemostasis.
• Banding,clipping,sclerosentinjection +/-Adren
• Earlyendoscopywithin 4hadvocated
• CorrectINRifapplicable.
• Risks: Aspiration,perforation, increased bleeding, sclerosing
agent dissemination.

15. Additional Procedural Therapies
• Angiography- Nonvariceal/FailedEndoscopy
Detect bleedsof 0.5ml/min with100%sensitivity
• Radionuclideimaging-Technecium-99m labelledRBCscintigraphy,
diagnosticvalue.
• Wireless capsuleendoscopy- Imagingcannotbecontrolledfrom
outside,onlydiagnosticvalue,
• Provoked bleeding trial

16. Colonoscopy
• Full length colonoscopy is the most important
investigation in a patient with suspected Lower GI
bleed. It helps in visualizing from rectum to the last 10-
15 cms of terminal ileum
•Therapeutic uses are
1-Electro-cauterization of bleeding points
2-Polypectomy
• Diagnostic uses are
1- Imaging
2- Biopsy of thelesion

17. Approach to apatient withLGIBleeding

18. Disposition
• ICU – Hct<30%, syst BP<100, Hx cirrhosis/ascites, vomiting
frank red blood, Hematochezia.
• Manage complications.
• Early involvement of sub specialities
• Risk Stratification – Rockall / Modified Blatchford/ AIMS65

19. Some Interesting studies
• In a meta-analysis of five randomized trials with a total of 1965 patients with acute upper
gastrointestinal bleeding, patients assigned to a restrictive transfusion strategy were at lower
risk than those assigned to a liberal transfusion strategy for mortality (absolute risk reduction
[ARR] 2.2 percent, relative risk [RR] 0.65, 95% CI 0.44-0.97) and rebleeding (ARR 4.4 percent,
RR 0.58, 0.40-0.84).
• A meta-analysis examined five trials with 316 patients who were assigned to erythromycin,
metoclopramide and placebo. The analysis found that the use of a prokinetic agent decreased
the need for second-look endoscopy, but did not affect the number of units of blood transfused,
length of hospital stay, or need for surgery. In subgroup analyses, erythromycin continued to
show a benefit with regard to the need for second-look endoscopy, but metoclopramide did not.
• Multiple trials evaluating the effectiveness of prophylactic antibiotics in cirrhotic patients
hospitalized for GI bleeding suggest an overall reduction in infectious complications and
possibly decreased mortality. Antibiotics may also reduce the risk of recurrent bleeding in
hospitalized patients who bled from esophageal varices. A reasonable conclusion from these
data is that patients with cirrhosis who present with acute upper GI bleeding (from varices or
other causes) should be given prophylactic antibiotics, preferably before endoscopy
• A total of 225 patients assigned to the restrictive strategy (51%), as compared with 61 assigned
to the liberal strategy (14%), did not receive transfusions (P<0.001) [corrected].The probability
of survival at 6 weeks was higher in the restrictive-strategy group than in the liberal-strategy
group (95% vs. 91%; hazard ratio for death with restrictive strategy, 0.55; 95% confidence
interval [CI], 0.33 to 0.92; P=0.02).

20. Questions?
• References-
- Barkun A, Bardou M, Marshall JK, Nonvariceal Upper GI Bleeding Consensus Conference Group. Consensus
recommendations for managing patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med 2003;
139:843.
• Hwang JH, Fisher DA, Ben-Menachem T, et al. The role of endoscopy in the management of acute non-variceal upper GI
bleeding. Gastrointest Endosc 2012; 75:1132.
- Gralnek IM, Dumonceau JM, Kuipers EJ, et al. Diagnosis and management of nonvariceal upper gastrointestinal
hemorrhage: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2015; 47:a1.
- LongstrethGF.Epidemiologyof hospitalization for acuteuppergastrointestinal hemorrhage:apopulation-basedstudy.AmJ
Gastroenterol 1995; 90:206.