Health

1. INSTITUTE OF HEALTH SCIENCES
SCHOOL OF MIDWIFERY AND NURSING
DEPARTMENT OF ADULT HEALTH NURSING
AND MIDWIFERY
PREPARED BY:- KIDANE DINKU.
UPPER GASTROINTESTINAL BLEEDING
Presentation
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2. Presentation outline
 Objectives
 Definition of upper gastrointestinal bleeding
 Etiology of UGIB
 Clinical manifestation of UGIB
 Diagnosis of UGIB
 Initial management of UGIB
 Summary
 References
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3. Objectives
At the end this session the students will able to:-
 Define of upper gastrointestinal bleeding
 Identify Etiology of UGIB
 distinguish pathophysiology of UGIB
 Discuss the initial management of UGIB
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4. Over of GI system
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5. Upper gastrointestinal bleeding
 Upper gastrointestinal bleeding is defined as bleeding derived
from a source proximal to the ligament of Treitz.
 It refers to bleeding that occurs anywhere in the esophagus,
the stomach, or the upper part of the small intestine.
 UGIB is a potentially life-threatening abdominal emergency
that remains a common cause of hospitalization
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6. Epidemiology
 The overall annual incidence of upper GI bleeding ranges
from 39 to 172 per 100,000 in Western countries.
 factors associated with increased morbidity and mortality:-
 socioeconomic conditions, and prescription patterns of ulcer
healing and ulcer-promoting medications.
 Increasing age, coexistent organ system disease, and recurrent
hemorrhage.
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8. Pathophysiology
 non-variceal bleeding
 Variceal bleeding
 non-variceal bleeding
 It associated with the following causes:-
 Peptic Ulcer Disease
 Erosive Gastritis And Esophagitis
 Mallory-weiss syndrome
 Dieulafoy Lesions and Other Causes
sources of UGIB
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9. Pathophysiology
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Acids, bile salts, aspirin, ischemia, H. pylori
Breakdown of gastric mucosal barrier
Acid back-diffusion into mucosa
Destruction of mucosal cells
 Acid & Pepsin release
Further mucosal erosion
Destruction of B/Vs
Bleeding
Histamine release
from damaged
mucosa
 Vasodilation
 Capillary
permeability
Loss of plasma
proteins into gastric
lumen
Mucosal edema
ULCERATION

10. Variceal Bleeding
 It associated with the esophageal and gastric varices due to
portal veins hypertension and cirrhosis.
 It is cause of upper gastrointestinal bleeding.
 A complex of longitudinal tortuous and extremely dilated sub-
mucosal veins at the lower end of the esophagus gastric
enlarged and swollen.
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Alcoho Abuse, Infection, Drugs, Bilary Obstruction
Destruction of Hepatocytes
Replacement of destroyed liver cells gradually by scar tissue
The amount of scar tissue exceeds that of the functioning liver tissue
Fibrosis/Scar
Impaired blood and lymph flow
ed pressure in the venous & sinusoidal channels
Fatty infiltration—fibrosis/scar
Portal Hypertension
PP
Hepatomegally
Splenomegaly
Jaundice
Ascites
BP
Esophageal varices
DHN

12. Clinical manifestation
 Hematemesis and Melena
 Stomach cramps
 Unusually pale skin
 Feeling faint, dizzy, or tired
 Weakness a rapid pulse
 Drop in blood pressure
 Little to no urination
 Unconsciousness
Pain, often in the upper abdomen
Nausea or Vomiting
Feeling full or bloated
Pain in the chest when swallowing
Difficulty swallowing
lack of appetite
Feeling full after eating little
 Persistent cough
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13. Diagnosis
 History
 History of bleeding
 Number of episodes
 Most recent episode
 Hematemesis
 Melaena
 Vomiting prior to hematemesis and Abdominal pain
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14. Physical Examination
 Visual inspection of the vomitus for a bloody, maroon, or
coffee ground appearance is the most reliable way to diagnose
upper GI bleeding in the ED.
 Cool, clammy skin is an obvious sign of shock.
 Spider angiomas,
palmar erythema, jaundice, and gynecomastia suggest liver
disease

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15. Cont…
 Vital signs may reveal obvious hypotension and tachycardia or
more subtle findings such as decreased pulse pressure or
tachypnea.
 Younger patients and those without comorbidities can tolerate
substantial volume loss with minimal or no changes in vital
signs.
 Paradoxical bradycardia may occur even in the face of
profound hypovolemia.
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16. LABORATORY TESTING
 In patients with significant bleeding, the single most important
laboratory test is to obtain blood for type and cross-match in
case transfusionis needed.
 A CBC is also important, although the initial hematocrit
level may not reflect the actual amount of acute blood loss.
 In addition, consider BUN, creatinine, electrolyte, glucose,
coagulation, and liver function studies.
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17. Cont…
 Upper GI hemorrhage will elevate BUN levels through
digestion and absorption of hemoglobin.
 A BUN :creatinine ratio ≥30 suggests an upper GI source of
bleeding.
 Coagulation studies, including INR, partial thromboplastin time,
and platelet count, are useful in patients taking anticoagulants
and those with underlying hepatic disease.
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18. Nasogastric Lavage
 Visual inspection of the aspirate for a bloody, maroon, or
coffee-ground appearance is the most reliable way to diagnose
upper GI bleeding in the ED.
 Intermittent bleeding, pyloric spasm, or edema preventing reflux of
duodenal blood can cause false-negative results.
 Ultimately, nasogastric aspiration yields a positive result in only
23% of patients without hematemesis who have occult upper GI
bleeding.
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19. Cont…
 Nasogastric intubation and aspiration are diagnostically
useful.
 In patients without a history of hematemesis, a positive
aspirate provides strong evidence for an upper GI source of
bleeding.
 High-risk lesions are more likely in patients with bloody
aspirates.
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20. Treatment
 Initial management based on the condition of the patient (ABC
approach).
 Early airway management, assess breathing and the circulation of
Patients in hemorrhagic shock require emergent resuscitation,
including two large-bore IVs, typed and cross-matched blood with
the consideration of massive transfusion protocols.
 Give iv fluids and transfuse blood, fresh frozen plasma or platelets.
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21. Cont…
 In patients with an upper GI bleed who are receiving anticoagulants.
 International consensus guidelines recommend reversal of
coagulopathy for upper GI bleed patients who have an elevated INR
or platelet counts<50,000/μL.
 Tranexamic acid, in a small systematic review study, has been
shown to reduce the risk of death in patients with upper GI
bleeding,
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22. Proton Pump Inhibitors
 Consensus guidelines continue to recommend proton pump inhibitors
for patients with nonvariceal bleeding from peptic ulcer disease.
 When proton pump inhibitors are given at high dose, the gastric pH
remains neutral.
 Administer a high-dose proton pump inhibitor such as omeprazole 80
milligrams IV bolus followed by infusion of 8 milligrams/hr, because
the cause of bleeding cannot be determined without endoscopy.
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23. Somatostatin Analogues/Octreotide
 Octreotide is a long-acting analogue of somatostatin that elicits
several actions in patients with upper GI bleeding.
 The dose is a 50-microgram bolus followed by a continuous
infusion of 25 to 50 micrograms/hr.
 Octreotide does not appear to provide a clear benefit on
mortality, but when combined with early endoscopy, it may
reduce bleeding.
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24. Cont…
 These medications cause selective vasoconstriction.
 Propranolol and nadolol , beta-blocking agents that decrease
portal pressure, have been shown to prevent bleeding from
esophageal varices.
 it is recommended that they be used only in combination with
other treatment modalities such as sclerotherapy, variceal
banding, or balloon tamponade.
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25. Antibiotic
 Patients with cirrhosis have an impaired immune system and
have an increased risk of gut bacterial translocation during an
acute bleeding episode.
 Prophylactic antibiotics (e.g., ciprofloxacin 400 milligrams IV
or ceftriaxone 1 gram IV) reduce infectious complications,
rebleeding, days of hospitalization, mortality from bacterial
infections, and all-cause mortality and should be started as
soon as possible.
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26. Promotility Agents
 Erythromycin and metoclopramide are examples of
promotility agents used to enhance endoscopic visualization.
 Consider administration if the patient is undergoing
endoscopy in the ED and the patient is suspected to have large
amounts of blood in the upper GI tract.
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27. Endoscopy
 It considered as the gold standard for diagnosis and intervention.
 Endoscopy is recommended within 24 hours of presentation for the
diagnosis and treatment of active UGI bleeding and for the prevention
of recurrent bleeding rather than waiting more than 24 hours.
 Early endoscopy within 6–24 hours of presentation for
unstable patients and 12–36 hours for stable patients is recommended
for most patients.
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28. Endoscopic Stigmata
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29. Cont…
 Endoscopic treatment options commonly used for variceal
bleeding include variceal ligation and sclerotherapy.
In unstable patients, consider using cardiovascular stable
agents such as etomidate or ketamine.
While providing sedation, consider that the most noxious part
of the procedure is when the scope is passed around the
tongue.
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30. Endoscopic variceal ligation
 It is modified endoscope loaded with an elastic rubber band is
passed through an over tube directly onto the varix to be banded.
After suctioning the bleeding varix into the tip of the endoscope, the
rubber band is slipped over the tissue, causing necrosis, ulceration, and
eventual sloughing of the varix.
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31. Endoscopic Sclerotherapy
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It is sclerosing agent is injected through a fiberop-tic endoscope into
the bleeding esophageal varices to promote thrombosis and eventual
sclerosis.

32. Balloon Tamponade
 Balloon tamponade is an effective short-term solution for life-
threatening variceal bleeding.
 Today, it is generally reserved for temporary stabilization of
patients for transfer to an appropriate institution or until
endoscopy can be done.
 The Sengstaken-Blakemore tube and the Minnesota are
examples of balloons that have been used.
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33. Cont…
 Balloon tamponade is an effective short-term solution for life-
threatening variceal bleeding.
 The tube has four openings, each with a specific pur-pose:
gastric aspiration, esophageal aspiration, inflation of the
gastric balloon, and inflation of the esophageal balloon.
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34. Sengstaken-Blakemore tube
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35. Surgery
 Patients who do not respond to both pharmacologic and
endoscopic treatments may require emergent surgery.
 In patients with variceal bleeding, there are two basic types of
operations:
(1) Shunt operations
(2) Non shunt operations.
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36. shunt operations
 Transjugular intrahepatic portosystemic shunt is a procedure to
create new connections between two blood vessels in the liver
 It is a procedure that involves inserting a stent (tube) to connect
the portal veins to adjacent blood vessels that have lower
pressure.
 This relieves the pressure of blood flowing through the diseased
liver and can help stop bleeding and fluid back.
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38. Non shunt Operations
 Esophagogastric devascularization procedures are performed
to control bleeding from varices in the esophagogastric region.
 They are not intended as treatment of the underlying disease,
and they do not control bleeding from ectopic varices.
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39. In non variceal bleeding
 percutaneous embolization or subtotal or total gastrectomy
can be performed.
 Emergent surgical consultation is considered prudent in case
of uncontrolled bleeding.
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40. Summary
 UGIB is a relatively common, potentially life-threatening
condition that requires rapid assessment of clinical
presentation, rapid resuscitative measures, and appropriate
medical and surgical management.
 Administration of PPIs is an important adjunctive measure for
NVUGIB.
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42. References
1. Tintinalli’s Emergency Medicine
2. Transjugular intrahepatic portosystemic shunt (TIPS)
https://www.mountsinai.org
3. Brunner & Suddarth’s Medical-surgical Nursing 14TH
EDITION,2018.
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43. Thanks for your
time &attention
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