1. Gastrointestinal bleeding is a common presenting problem in the emergency room, with upper GI bleeding having an annual incidence of approximately 47 per 100,000 people. 2. The main causes of upper GI bleeding include peptic ulcers, esophageal varices, gastritis, and esophagitis. 3. The initial priorities in management are resuscitation through fluid resuscitation and blood transfusion if needed, followed by endoscopy to determine the source of bleeding and provide endoscopic therapy if active bleeding is detected.

1. Dr.Sunil Kumar
MEM Resident
Dr.Mehta Hospital Pvt Ltd
Chennai

2. • Introduction.
• Definition.
• Pathophysiology / Cause.
• Diagnosis.
• Diagnostic study.
• Treatment.
• Clinical Presentation in ER.
• Approach to the patient.
• First priority in ER.
• Principle of Management in ER.
OBJECTIVE

3. • Gastrointestinal(GI)bleed is a common
presenting problem in the ER.
Upper GI bleed
Lower GI bleed
• Acute Upper GI bleeding in adult has
an over all annual incidence of approximately
47 per 1 lac.
• Male >female.
• Mortality rate 10% (Approx.).
INTRODUCTION

4. Anatomy

5. • Upper GI Bleed is defined as bleeding from
mouth to suspensory ligament of duodenum
( ligament of treitz ) at duodenojejunal.
.juction.
Definition

6. “PAGE ME”
• 1.Peptic ulcer ( 50% )-Including oesophageal gastric, duodenal
( due to H.Pylori/NSAID)
• 2.Atrioenteric fistulas.
• 3.Gastrits(13%)–Haemorrhagic and
erosive (due to NSAID,alcohol,stress)
• 4.Esophagitis(2-5%).
• 5.Mallory- Weiss Syndrome–Mucosal tear in the cardio-
oesophageal region ( repeated vomiting followed by bright
red hematemesis)-due to coughing or seizures.
• 6.Esophageal and Gastric Varices -due to Portal hypertension
(most common in case of cirrhosis)
Pathophysiology / cause / DD

7. • Stress ulcer
• Malignancy- oesophageal cancer,
Gastric cancer.
• Alcohol and Smoking
• Drugs : salicylates, and non-steroidal anti-inflammatory agents
( NSAID)
Other cause

8. DIAGNOSIS
1.Clinical presentation/medical history
2.Physical Examination
3.Laboratory Data

9. (Source of bleeding)
A.Hematemesis-Vomiting of fresh or old blood
Bright red blood --significant bleeding
Coffee ground –----no active bleeding.
(don’t confuse with Hemoptysis (bleed from pharynx)
B. Melena-Passage of black & foul smelling usually
upper source –may right colon.
C.Sign of hypovalemia-active bleeding, blood in stool, pain
abdomen,confusion and BP,HR,RR,Urine output.
D.Hematochezia (bright red blood per rectum (BRBPR).
1.Clinical presentation/Medical history

10. Assessing the severity of Bleeding
Blood loss Vital signs Bleeding
Severity
<750 ml Normal
HR-<100/min
RR-14-20/min
BP-120/80mmhg
Urine -30ml/hr
Minor
750-1500ml Postural
HR->100/min
RR-20-30/min
BP-Low
Urine-20-30 ml/hr
Moderate
>2000ml Shock
HR->140/min
RR->35/min
BP-low
Urine-nil
Severe

11. • General Inspection
• Anaemia,
• Dehydration, Cool & clammy skin ( sign of shock)
• SKIN Changes:
 Spider angiomata(Central arteriole)
 palmer erythema(Exagereted red
flushing of palms Fades on pressure)
jaundice(liver disease)
 Petechiae and puroura (cogulopathy)
• Ear nose and throat exa ( occult bleeding)
• Rectal exa ( indicated to detect presence)
2.Physical Examination

12. • Abdomen examination
A.Inspection-Distension ,Dilated vein,Scar.
B.Palpation-Tenderness,Mass/Organomegaly
C.Percussion-Shifting dullness
D.Auscultation-Hyperactive bowel sound
Systemic examination

13. • Complete blood count.
• Blood grouping and typing
( most important lab test).
• Blood urea nitrogen ( BUN) :Creatinine >30-severe bleed
• Glucose.
• Cogulation studies.
• Liver function test ( LFT )
• Stool ocult blood test ,HIV,HCV,HBsAg.
3.Laboratry Data

14. • Chest x-rays/ABG :
To Rule out aspiration /
/ Pulmonary diseases.
• Serial ECG
• Barium contrast studies
limited diagnostic value
in an emergency setting.
continue..

15. • UGI endoscopy: Most accurate Diagnostic study for identify upperGI bleeding site
• Nasogastric (NG) Intubation :may have both diagnostic and therapeutic
benefits.
>Use under topical anaesthesia.
>Assess the Aspiration –
Red Blood-current bleeding.
Coffee ground-Recent bleeding,
Continuous aspiration-Severe active bleeding,
No blood-Bleeding stop.
>Strong evidence of UGI bleed in case.
of without H/O hematemesis.
>In Varices patient –NG tube passage may cause
bleeding.
• Angiography -Localization of bleeding vessel
whom endoscopy does not identify
the bleeding point.
Diagnostic Studies

16. PRIMARY
• Immediate resuscitation measures take priority.
• Airway-Require definitive airway management-
in profuse UGI bleeding for prevent aspiration.
Endotracheal tube Administer oxygen.
Breathing-Support respiratory function.
Circulation-Expend circulatory volume, maintain the BP
• cardiac monitoring.
• Provide volume replacement with crystalloids.
• Blood transfusion.
Treatment

17. • Active Bleeding.
• Failure to improve perfusion and vital signs after 2 L of
crystalloid.
1.Systolic BP < 110 mmHg
2.Postural hypotension
3.Pulse > 110/min
• Haemoglobin <8g/dl.
• Angina or cardiovascular disease with a Haemoglobin <10g/dl.
• Coagulation factors should be replaced as ,needed.
Blood Transfusion-indication

18. • ENDOSCOPY
• DRUG THERAPY
• BALLON TAMPONADE
SECONDARY

19. • Used to detect the site of bleeding ,It is single diagnostic
tool –success around 90% , done in ICU.
• May also be used in a therapeutic capacity (active bleeding
from the ulcer, the presence of a visible vessel, adherent
clot overlying the ulcer).
• Injection Therapy( including epinephrine,thrombin,ethnol
etc).
• endoscopic clips and band ligation is used commonly in
Esophageal varices.
• Endoscopic coaptive therapies include heater probe
thermocogulation.
Endoscopy

20. Antisecretory Agents
• PPI (Proton pump inhibitors )-Reduce the rebleeding and
best used as an adjunct to endoscopic therapy
o Pantoprazole –80 mg bolus and
8 mg/h infusion continues.
o Lansoprazole -60 mg bolus and
6 mg/h infusion continues.
• H2-receptor antagonists -less effective
• An acidic environment impairs platelet function and
haemostasis
Drug therapy

21. Splanchnic blood pressure modifiers
• Somatostatin -infusion have been used in UGI bleeding
when uncontrolled bleeding/endoscopy
unsuccessful/contraindicated /unavailable endoscopy.
• Octreotide -25 to 50 microgram IV bolus and 25-
50 microgram/h infusion.
• Vasopressin –Used to control GI bleed (most common
from Varices) - However reaction are more
common(HTN,Myocardial ischemia,Decreased CO /
increase the portal HTN and gangrene).
Continue..

22. • Antifibrinolytic Agents-Tranexamic acid .Antibiotics(e.g.
quinolone, 3G ceph). Vit K and clotting factors
• H. pylori irradication-reduces the recurrence of peptic ulcer
and rebleeding
Triple regimen – proton pump inhibitor + 2 antibiotics
given for 1 week (elimination rate > 90%)
e.g. Omeprazole + metronidazole/amoxycillin + clarithromycin
Combination of endoscopic and pharmacologic therapy offers the best
therapy for ulcer bleeding patients.
Continue…

23. • BALLOON TAMPONADE :A NOW RARELY USED IN UGI BLEEDING
BECAUSE OF ADVERSE REACTIONS.
• SURGERY : Depend upon medical and endoscopic therapy.
 GU – remove ulcer, gastrin secreting zone.
– Billroth I gastrectomy.
 DU – Polya or Billroth II gastrectomy.
– Vagotomy.
Balloon Tamponade and Surgery

24. • Acute blood vomiting.
• Chronic black tarry stools.
• Signs of hypovolemia ( HR ,BP ,RR ,Urine output ,
Syncope )
• Melena.
• Hematochezia.
• Abdomen Pain.
Clinical Presentation in ER

25. • Vital Information can be gained from the view
at the door
• Airway
• Breathing
• Circulation
Altered Level of consciousness is a very early sign
of impending circulatory collapse
Initial Apporach in ER

26. • Needs a team approach
• IV access
• Organise fluids
• Apply monitoring
• Oxygen
• Contact blood bank
• Contact endoscopists
• Specific therapies
First priority in ER ?

27. • 1.Fluid resuscitation.
• 2.Replacement of Hb/cloting factor if there is
significant blood loss
• 3.Monitoring fluid & blood resuscitation & periodic re-
evaluation
• 4.Determine the etiology & treat the cause .
Principles of management

28. Patient with a score of zero
BUN<18,Hb>13(men)12(womem)
Systolic BP>110,
pulse,100/min
No Syncope,No malena
are AT VERY LOW RISK FOR
A ADVERSE CLINICAL OUTCOMES
Glasgow-Blatchford Bleeding Score

29. • Acute Upper GI bleeding
• Ulcer Esophageal varices Mallory-wiess tear
• Active bleeding Adherent clot Pigment clean Ligation + IV Vasoactive drug Active B No Active B
• IV PPI+endoscopy IV PPI No IV PPI No IV PPI ICU for 2-3 Days Endoscopy No endoscopy
therapy endoscopy+/- & Endo & Endo therapy therapy
• ICU admission Ward adm Ward adm D/S Ward adm D/S
Further reading HARRISON’S 18th edition
Algorithm of upper GI bleeding