Upper gastrointestinal bleeding occurs proximal to the ligament of Treitz and may present as hematemesis, melena, or other symptoms. The annual incidence in the U.S. is 0.1% with a mortality rate of 5-10%, and risk factors are assessed using scoring systems like the Rockall score. Treatment varies significantly based on the specific cause identified during endoscopy, with options including endoscopic therapy, intravenous PPI, and management of underlying conditions.

1. UPPER GASTROINTESTINAL
BLEEDING
• Bleeding which occurs proximal to
ligament of Treitz
• Commonly Presents as either
hematemesis or melena
• May also present as hematochezia, occult
GI bleeding or anaemia
• In the US, it has an annual incidence of
0.1% and mortality rate of 5-10%

2. Upper GI bleeding cont..
• May be due to variceal or non-variceal
causes

3. Causes
• Ulcers – gastric, duodenal, NSAID induced
• Varices – gastric or esophageal
• Mallory-weiss tears
• Gastroduodenal erosions
• Erosive esophagitis
• Neoplasms
• Vascular ectasias
• Others

4. Risk factors and risk
stratification
• Developed only for nonvariceal bleeding to
identify patients at greater risk for mortality
and rebleeding
• Scoring systems are classified as either
pre-endoscopic or post-endoscopic
• Pre-endoscopic systems include
Blatchford, clinical Rockall Score and
artificial neural network score
• Complete Rockall Score

5. Risk stratification cont..
• Rockall Scoring:
• Score zero if; age < 60yrs, pulse < 100
bpm, Normal systolic Bp, no comorbidity,
mallory-weiss tear or no lesion on
endoscopy and no stigmata or dark spot
on ulcer base
• Score one if; age 60-79yrs, pulse > 100,
Bp >100, no comorbidity, endoscopic
diagnosis other than mallory-weiss tear
and no stigmata of recent hemorrhage

6. Risk statification cont…
• Score two if; age> 80yrs, pulse >100bpm
Bp< 100, presence of comorbidities,
malignant lesions on endoscopy, blood in
the upper GIT, adherent clot, visible or
active bleeding blood vessel
• Score three if; there is renal failure,
hepatic failure or metastatic cancer in
addition to two above
• Scores of zero to two are at lower risk for
poor outcome

7. Approach to the patient
• Resuscitative measures should be carried
out with initial evaluation
• Heart rate, blood pressure and postural
hypotension are most important rather
than hemoglobin in the initial evaluation
• ABC of resuscitation should be followed
• When patient is stable, brief history and
physical examination- for possible cause
• Upper GI endoscopy

8. Treatment
• This depend largely on cause found during
upper GI endoscopy
• Causes due to esophageal varices should
be treated with band ligation or
sclerotherapy + octreotide
• Causes due to mallory-weiss tear are
usually self limiting except if actively
bleeding in which case endoscopic
therapy such as thermal coagulation or
sclerosant injection should be used

9. Treatment cont..
• Causes due to ulcer are managed based
on endoscopic stigmata of rebleeding;
Actively bleeding or visible vessel or
adherent clot should be treated with high
dose intravenous PPI and endoscopic
therapy
Ulcer with pigmented spot may not require
PPI or endoscopic therapy while clean
base ulcer may not require admission

10. Treatment cont..
• High dose PPI enhances platelet
aggregation and clot formation
• Except where there is compelling
indication NSAIDS should be stopped
• Recurrent variceal bleeding may require
more invasive procedure- TIPS