management of upper GI bleed

1. Upper GI Bleed
Dr. Ankur kajal

2. Definitions
• Upper GI hemorrhage occurs from proximal to the ligament of Treitz
(more than 80% of acute bleeding)
• Obscure bleeding: Hemorrhage persisting or recurring after negative
endoscopy is termed
• Occult bleeding: where there are no signs of overt bleeding but only
symptoms of chronic blood loss anemia.

3. Stepwise
approach
to a
patient of
upper GI
bleed

4. Initial Assessment
• Principles of A (airway), B (breathing), and C (circulation).
• Hemodynamic resuscitation is of the highest priority
• History and examination to assess the amount of blood lost and the extent of
ongoing bleeding
• All patients will not demonstrate a tachycardic response to bleeding, particularly
in the elderly or those on β-blockers and sometimes severe blood loss may
cause vagal mediated bradycardia.
• Importantly a normal haematocrit in the early stage may be falsely normal, as
the haematocrit will only decrease following dilution of the blood volume with
resuscitation.

5. Resuscitation
• The most important contributor to morbidity and mortality in acute GI
bleeding is fulminant multiorgan failure from inadequate
resuscitation.
• Large-bore venous access is crucial
• Crystalloid solution infusion should be started earliest
• Adequacy of resuscitation should be continuously assessed.

6. Transfusion
• The most important factor to decide transfusion are the presence and
extent of ongoing bleeding and the response of the patient to fluid
resuscitation.
• Other factors are the age and presence of cardiopulmonary comorbidities
that might compromise tissue perfusion
• Suspected likelihood of rebleeding should also be taken into account; like,
a transfusion is more likely to be required for esophageal varices, which
have a high propensity for profuse rebleeding.

7. Risk Stratification
To facilitates-
• prediction of mortality
• risk of rebleeding
• triage for admission
• timing of investigations

8. • Specific scoring systems-
• Rockall score, requires endoscopic findings
• Blatchford score, do not require endoscopic data and can be
used during initial assessment.
• Non specific- APACHE II

9. Specific scoring systems
Rockall score Blatchford score
• Age
• Comorbid diseases
• Magnitude of haemorrhage
• Requirement of transfusion
• Endoscopic findings
• Stigmata of recent bleed
• Blood urea nitrogen
• Haemoglobin
• Systolic blood pressure
• Pulse
• Presence of melena, syncope,
cardiac or hepatic dysfunction

10. HISTORY AND EXAMINATION
• A thorough History and examination assist in-
• Diagnosing the cause of bleeding
• Identify comorbidities likely to influence outcome.
• Time of onset, volume, and frequency of bleeding are key aspects of the
history in determining amount of blood loss
• The character of bleeding is extremely important-
• Hematemesis
• Melena

11. • History should include
• antecedent vomiting suggesting a Mallory–Weiss tear
• recent weight loss or loss of appetite (suggesting malignancy)
• recent epigastric pain possibility of peptic ulceration
• alcohol intake or liver disease (likelihood of variceal bleeding).
• NSAIDs, salicylates and selective serotonin-reuptake inhibitors
(SSRIs)

12. PHYSICAL EXAMINATION
• Bleeding from the nasopharynx and oropharynx may occasionally
present as GI bleeding, so these sites should be routinely examined
• The abdomen examination to identify any masses or
hepatosplenomegaly.
• A tender epigastrium may suggest peptic ulcer disease.
• The neck and groins should be examined for lymphadenopathy
suggestive of malignancy
• Any stigmata of liver disease.

13. IDENTIFYING THE SOURCE
OF BLEEDING

14. • A nasogastric tube lavage is an important diagnostic maneuver to
• localize GI bleeding (aspirate positive for either fresh
blood or coffee grounds confirms upper GI bleeding)
• aids in assessing the rate of bleeding
• allows removal of blood to facilitate endoscopic
evaluation
• NOTE: A nonbilious, non-bloody aspirate of the stomach does not
rule out bleeding from the duodenum, as a competent pylorus will
prevent reflux of bile or blood into the stomach

15. Endoscopy in Upper GI Bleeding
• Gold standard investigation for the diagnosis and management of upper GI
bleeding
• Endoscopy within 24 hours of presentation has benefits in terms of aiding risk
assessment and reduced length of hospital stay
• Endoscopy facilitates
• identification of the source of bleeding
• determining the underlying etiology
• achieving hemostasis
• and providing prognostic information for risk stratification

16. • Note;
• the sensitivity of EGD reduced in the presence of active
bleeding, as mucosal visibility is impaired.
• endoscopic complications such as perforation and aspiration
increase in the emergency setting
• As per literature early endoscopy (within 12 hours) offered no
additional benefit
• Resuscitative measures should not be delayed or paused for the
endoscopic procedure.

17. THERAPEUTIC OPTIONS
Pharmacologic
Management
Endoscopic
Treatment
Interventional
Angiography
Surgery

18. Pharmacologic Management
• Not to halt active bleeding
• It aimed at preventing recurrent bleeding.
• Proton pump inhibitors reduce recurrent bleeding from gastric ulcers,
because clot formation is stabilized in the absence of gastric acid.
• Octreotide is useful in variceal bleeding and have an adjunctive role
in other upper GI bleeds

19. Endoscopic Treatment
• Remains the mainstay of investigation and therapy for most causes of upper GI
bleed
• Techniques used for controlling hemorrhage are-
• thermal coagulation
• injection therapy
• mechanical devices such as metallic clips and band ligation.
• Argon plasma coagulation (non-contact coagulation with an
almost nonexistent risk of perforation)

20. Interventional Angiography
• Initial attempts of embolization led to high rates of bowel infarction
• Embolization materials include
• Microcoils
• Gelfoam
• polyvinyl alcohol particles

21. Causes of Upper GI Haemorrhage
NONVARICEAL
BLEEDING
• 80% PORTAL
HYPERTENSIVE
BLEEDING
• 20%
• Gastric and duodenal ulcers
• Gastritis and duodenitis
• Esophagitis
• Malory Weiss tears
• Arteriovenous malformations
• Tumors
• others
• 30-40%
• 20%
• 5-10%
• 5-10%
• 5%
• 2%
• 5%
• Varices
• Portal gastropathy
• Isolated gastric varices
• >90%
• <5%
• rare

22. Peptic Ulcer Disease and Bleeding
• 40% of all non-variceal upper GI bleeding
• The endoscopic appearance of a bleeding ulcer can also be used to stratify the risk of rebleeding
using the Forrest criteria
Acute haemorrhage
Forrest Ia
Forrest Ib
Active spurter
Active oozing
Signs of recent haemorrhage
Forrest IIa
Forrest IIb
Forrest IIc
Non-bleeding visible vessel
Adherent clot
Flat pigmented haematin on
ulcer base
Lesions without active
bleeding
Forrest III
Clean-based ulcer

23. Forrest Ia gastric ulcer with
an active spurter
Forrest Ib ulcer with active
oozing

24. Forrest IIa ulcer with a visible
vessel
Forrest IIb ulcer with an
adherent clot, the clot must be
removed by vigorous and
meticulous flushing in order to
reveal underlying visible
vessels

25. Forrest IIc ulcer with a
pigmented spot
Forrest III ulcer at antrum with
clean base

27. Medical Management
• All ulcerogenic medication such as salicylates, NSAIDs, and SSRIs should be
stopped.
• Eradication of H.Pylori-
• Reduces the risk of rebleeding hence eradication with triple therapy is
recommended in all bleeders infected with H pylori.
• long-term acid suppression-
• Gastric acid impair clot formation, promote platelet disaggregation,
and increase fibrinolysis. Therefore, long term use of PPI significantly
reduce the risk of ulcer rebleeding

28. Endoscopic Management
• Patients with high-risk stigmata on
endoscopy require hemostatic
intervention, like injection or thermal or
mechanical therapy.
• Addition of any one of these to
adrenaline injection further reduces
rebleeding rates, the need for surgery,
and mortality

29. • Failure of endoscopic therapy likely in patients with-
• including previous ulcer bleeding
• shock on presentation
• active bleeding during endoscopy
• ulcers >2 cm in diameter
• a large underlying bleeding vessel ≥2 mm in diameter
• ulcers on the lesser curvature or the posterior or superior
duodenal bulb.
• Repeat endoscopy should only be considered in cases of recurrent
hemorrhage or unsuccessful first treatment.

30. Surgical Management
• Surgery is now done not as first-line or curative treatment but
instead only when other modalities have failed because of newer
pharmacologic and endoscopic treatments.

31. • INDICATIONS OF SURGERY-
• ABSOLUTE-
• Persistent blood loss refractory to endoscopic therapy
• Shock with recurrent haemorrhage
• Slow bleeding requiring more than 3 units blood transfusion per day
• RELATIVE-
• Shock on admission
• Elderly patient
• Severe comorbidity
• Transfusion in excess of 6 units

32. Operative Procedure for Duodenal Ulcers
• A longitudinal duodenotomy or duodenopyloromyotomy provides
good exposure of bleeding sites in the duodenal bulb.
• Direct pressure provides temporary arrest of the bleeding, and
should be followed by suture ligation of bleeding vessel.
• Four-quadrant suture ligation will achieve hemostasis in anterior
ulcers.
• Posterior ulcers, will require suture ligation of the artery both
proximal and distal as well as a U-stitch underneath the ulcer to
control the pancreatic branches to the ulcer for adequate control of
hemorrhage.

34. OPERATIVE PROCEDURE FOR
GASTRIC ULCERS
• Unlike the duodenal ulcer, gastrotomy with oversewing of bleeding is not
adequate surgical treatment due to-
• A high risk of rebleeding
• Underlying malignancy in gastric ulcers.
• A distal gastrectomy for ulcers of the antrum and distal stomach is the surgical
treatment of choice
• Resection of the ulcer alone is associated with a 20% rebleeding rate, but can
be considered in combination with an acid reducing procedure (eg, vagotomy
and pyloroplasty) in patients who cannot tolerate a formal gastrectomy.

35. • Management of bleeding ulcers at the gastro-esophageal junction
and the proximal stomach is challenging.
• In these cases, less aggressive operations, can be considered, like-
• distal gastrectomy with resection of a tongue of proximal
stomach to excise the ulcer
• wedge resection of the ulcer, or
• simple oversewing with a vagotomy and pyloroplasty

36. Mallory–Weiss Tears
• lacerations of the esophagus or stomach caused by severe vomiting.
• The majority of lesions are managed conservatively
• Patients with persistent bleeding may require endoscopic or
angiographic intervention.
• Surgery may be required and hemorrhage can be stopped by a high
gastrotomy and suture of the mucosal laceration.

37. Cameron Lesions
• Rare cause of upper GI bleeding is an erosion or ulcer of the
stomach that occurs within a hiatal hernia.
• requires an experienced endoscopist.
• Treatment involves repair of the paraesophageal or hiatal hernia.

38. Stress-Related Mucosal Bleeding
• Seen in Critically ill patients
• Due to combination of mucosal ischemia & reperfusion injury and impairment of host
defenses.
• The most important risk factors are
• prolonged mechanical ventilation (>48 hours) and coagulopathy
• shock, severe sepsis
• neurological injury/neurosurgery,
• >30% burns, and multiorgan failure.
• Patients with these factors should receive prophylaxis with antacids, H2-receptor blockers,
proton pump inhibitors,

39. • Management:
• Acid suppression is sufficient to control hemorrhage in stress-related
mucosal bleeding.
• For persistent bleeding-
• options include selective infusion of octreotide or vasopressin via
the left gastric artery,
• endoscopic measures, or
• angiographic embolization.
• Surgery rarely required, but if necessary, involves vagotomy and
pyloroplasty with oversewing of discrete regions of hemorrhage or subtotal
gastrectomy.

40. Esophagitis
• causes of esophagitis are
• GERD is the most common cause
• Crohn’s disease
• Drugs
• radiotherapy, and
• infectious etiologies in the immunocompromised. Infective esophagitis
is uncommon but may lead to torrential hemorrhage
• Management: acid suppressive therapy, occasionally requiring therapeutic endoscopy to
arrest the bleeding.
For infectious esophagitis, identifying and treating the underlying infectious
cause is often successful at stopping bleeding.

41. Dieulafoy Lesion
• Abnormally large submucosal end arteries with the potential for
massive, life threatening hemorrhage upon erosion of the overlying
mucosa.
• Likely, congenital in origin.
• These are commonly located in the stomach within 5 to 7 cm of the
cardia, but may present in the small bowel and colon.
• Endoscopic therapy is often successful, with clipping or banding.

42. Gastric Antral Vascular Ectasia
• Known as “watermelon stomach” because tortuous mucosal
capillaries and veins in the gastric antrum that converge onto the
pylorus, resemble the surface of a watermelon
• Common in women and usually presents with occult blood loss and
iron deficiency anemia.
• Argon plasma coagulation (APC) is the treatment of choice.
• Patients refractory to APC should be considered for surgical
intervention, usually an antrectomy.

44. Malignancy
• Rarely present with significant overt haemorrhage.
• Endoscopy reveals a recurrent bleeding ulcer, a common feature of
GIST, which characteristically appears as a submucosal tumor with
central umbilication and ulceration
• Surgery is the therapy of choice

45. Aortoenteric Fistula
• A rare cause torrential GI hemorrhage.
• Occurs most commonly following abdominal aortic aneurysm (AAA)
repair
• Pathophysiology- It is likely to be infective in origin, leading to the
development of a pseudoaneurysm at the proximal
suture line with fistulation into the adjacent
duodenum
• CT with IV contrast, often demonstrating air within the aortic thrombus or
around the graft

46. • Surgery- excision of the graft with extra-anatomic
bypass or in situ aortic reconstruction

47. Hemobilia
• Rare cause of GI bleeding.
• Causes include trauma, hepatic neoplasms, instrumentation of the
biliary tree, percutaneous radiofrequency liver ablation, and prior
liver transplantation.
• Classical presentation- hemorrhage, right upper quadrant pain, and
jaundice only seen in a minority of patients.
• Endoscopy may reveal blood at the ampulla,
• Angiography and embolization remains the diagnostic and
therapeutic modality of choice.

48. Hemosuccus Pancreaticus
• Rare cause of upper GI bleeding
• Cause- fistulation of a pancreatic pseudocyst into the splenic or
other peripancreatic artery.
• Presentation- abdominal pain, hematemesis, and melena in patients
with a previous history of pancreatitis should raise suspicion of
hemosuccus pancreaticus.
• Angiography is again both diagnostic and therapeutic

49. Iatrogenic Bleeding
• Causes- Prior endoscopic or surgical procedures
• Example;
• PEG tube placement, carries a 3% risk of GI hemorrhage.
• ERCP with sphincterotomy is associated with a 2% risk.
• Bleeding after upper GI surgery often occurs from suture/ staple
lines.
• In most cases, bleeding can be controlled endoscopically with injection
therapy
• surgery rarely required.

50. VARICEAL BLEEDING AND PORTAL
HYPERTENSION
• Variceal bleeding occurs in 30% of cirrhotic patients, and is one of the most
important complications of hepatic cirrhosis.
• Variceal bleeding is associated with-
• Increased risk of rebleeding,
• Higher transfusion requirements,
• Greater length of stay, and
• Higher morbidity and mortality compared with non-variceal
bleeding.

51. • Portal hypertension can also lead to portal
hypertensive gastropathy—the diffuse
dilation of the mucosal and submucosal
venous plexus of the stomach with overlying
gastritis.

53. Management
• Medical-
• Octreotide should be administered immediately when there is a high
index of suspicion for variceal bleeding, and continued for 3 to 5
days after endoscopic confirmation of diagnosis
• Any patient with cirrhosis and GI bleeding should also be given
antibiotic prophylaxis against spontaneous bacterial peritonitis with a
fluoroquinolone.

54. • Endoscopic-
• In suspected variceal bleeding, endoscopy should be performed
urgently, particularly in unstable patients.
• Variceal ligation is the endoscopic treatment of choice, as it has lower
rates of complications compared to sclerotherapy
• Mechanical tamponade-
• useful in temporarily controlling esophageal variceal bleeding when
other methods have failed.
• Recurrent bleeding in 50% of patients; hence, it is reserved as a
temporizing measure in massive hemorrhage before definitive
therapy.

55. • Gastric varices should be managed initially by pharmacotherapy.
Endoscopic therapy is less successful with gastric varices due to the
diffuse nature of portal hypertensive gastropathy.
• Patients with refractory bleeding should be referred early for
decompressive therapy such as TIPS or shunting in gastric varices.
• PREVENTION OF REBLEEDING-
• A combination of nonselective β-blockers with isosorbide
mononitrate is more effective than β-blockers alone in preventing
rebleeding.

56. • Surgical Portal Decompression-
• Portosystemic shunt surgery
• TIPS
• comparing TIPS with DSRS in patients who failed medical or
endoscopic therapy showed no significant difference in the rate of
rebleeding, hepatic encephalopathy, or overall survival.
• However, TIPS patients required close follow-up with a higher rate of
re-intervention.

57. Thank You