This document summarizes the management of upper GI hemorrhage. It outlines the steps to take which include obtaining a complete history and physical exam, performing laboratory tests, considering radiological scans, stabilizing the patient, identifying the source of bleeding through endoscopy, and various pharmacological and endoscopic interventions depending on the underlying cause of bleeding such as PPIs, octreotide, angiography, embolization, surgery, or TIPS procedure. Refractory cases may require repeat endoscopy, angiography, embolization or surgery.

1. Management of upper GI Hemorrhage ABDWAHID M SALIS, M.D

3. Management Upper GIT Bleeding Complete history: alcohol use, cirrhosis, heart burn, reflux, and medications. Exam : signs of cirrhosis including spider angiomata, palmer erythema, prominent abdominal veins, caput medusa, and ascites. mucous membranes for melanin spots associated with Puetz-Jeghers syndrome.

4. Physical Exam Vital signs: instability, respiratory distress, beware of beta blockade signs of anemia, dehydration Abdominal exam : Rectal exam : Look for perianal causes of bleeding . check for occult blood in the stool.

5. Laboratory studies: Type and Cross CBC: anemia? hepatic dysfunction and renal compromise Coags: coagulopathy ABG: probe for acidosis

6. Radionuclide scanning Uses technetium-99m labeled RBC

8. Interventions to consider ABC’s Ensure adequate airway protection and adequate respirations:massive bleeding considered for intubation Start 2 large bore IV’s . Fluid bolus either NS or LR 3-for-1 rule: Replace each milliliter of blood loss with 3 mL of crystalloid fluid.

9. Pharmacotherapy Proton pump inhibitors (PPIs), orally or intravenously as an infusion Octreotide is a somatostatin analog: shunt blood away from the splanchnic circulation. variceal and non-variceal upper GI hage. vasopressin analog most commonly for variceal upper GI hage. Anti-fibrinolytic drugs such as tranexamic acid Factor VII for variceal hemorrhage If Helicobacter pylori : antibiotics and a PPI

10. Tubes Foley Catheter NG with gastric lavage : If the stomach contains bile but no blood, UGIB is less likely Iced saline lavage STAT Upper endoscopy

11. Early Endoscopy Both As A Diagnostic And Therapeutic: Injection of adrenaline or sclerotherapy Electrocautery: thermal Endoscopic clipping Banding of varices Argon plasma coagulation . Cryotherapy ablation is another possibility

13. Stigmata of high risk Active bleeding Oozing Visible vessels Red Spots

14. Visible vessels oozing bleeding Active bleeding Red Spots

15. Contraindications to endoscopy Uncooperative severe cardiac decompensation, acute myocardial infarction perforated viscus ( eg, esophagus, stomach, intestine ).

16. Refractory cases Repeat esophagogastroduodenoscopy Angiography Embolization the feeder vessel Balloon tamponade Surgery , to oversew or remove

17. PU bleeding TREATMENT Medical Anti-ulcer medication H. pylori treatment Stop NSAIDs Follow up EGD for gastric ulcer in 6 weeks

18. PU TREATMENT Endoscopic interventions Thermal coagulation Injected agents Success rate 95% initailly 80% will not rebleed

19. PU TREATMENT Surgical intervention Only 10% of patients Indications Failure of endoscopy Significant rebleeding after 1 st endoscopy Ongoing transfusion requirement Need for >6 units over 24 hours Earlier for elderly, multiple co-morbidities

20. PU Surgical intervention Doudenal ulcer Expose ulcer with duodenotomy or duodenopyloromyotomy Direct suture ligation, The gastroduodenal artery may be ligated if necessary the pyloric channel is closed vertically resulting in a Heineke-Mikulicz pyloroplasty Anti-secretory procedure Truncal, parietal cell vagotomy can use meds

22. PU Surgical intervention Gastric ulcer 10% are maliganant 30% will rebleed with simple ligation Resection Distal gastrectomy Bilroth I or II Subtotal gastrectomy

24. Angiographic obliteration of the bleeding vessel is considered in patients with poor prognoses

25. Gastritis Treatment Vasopressin Iced saline lavage Sucralfate, h2 blockers, and proton pump inhibitors. Bleeds refractory to these treatments : Electrocautery Vagotomy and antrectomy Even total gastrectomy.

26. Mallory-WeissTreatment 90% resolves spontaneously no further therapy. Bleeding persists : Endoscopic inj of vasoconstrictive agents, Iv vasopressin Balloon tamponade: sengstaken-blakemoore tube Gastrotomy with oversewing

27. Dieulafoy’s treatment Endoscopic Injection. Wedge resection after endoscopic marking

28. Treatments for GAVE Endoscope: Argon plasma coagulation and electrocautery. "Endoscopy with thermal ablation" is favored medical treatment Cryotherapy ablation is another possibility

29. Varices management Sclerotherapy, Ligation Vasopressin. If unsuccessful: shunting transplant .

30. Somatostatin or vasopressin w/wo NTG

32. TIPS

34. Sugiura procedure

35. Shunt procedures

36. الحمد لله