ACUTE UPPER GI BLEED

1. UPPER GI BLEEDUPPER GI BLEED
Dr Anoop.K.RDr Anoop.K.R
Asst professorAsst professor
MMCHMMCH
CalicutCalicut

2. DEMARCATION OF UPPER ANDDEMARCATION OF UPPER AND
LOWER GUTLOWER GUT
 The World Organization of Gastroenerologists definesThe World Organization of Gastroenerologists defines
acute upper GI bleeding as:acute upper GI bleeding as:
 The anatomic cut-off for upper GI bleeding isThe anatomic cut-off for upper GI bleeding is
thethe ligament of Treitzligament of Treitz, which connects the, which connects the
fourth portion of thefourth portion of the duodenumduodenum to theto the
splenic flexuresplenic flexure of theof the coloncolon..

3. ETIOLOGYETIOLOGY
 EpidemiologyEpidemiology
 Accounts for 350,000 hospitalizations in U.S.Accounts for 350,000 hospitalizations in U.S.
yearlyyearly
 Risk factorsRisk factors
 AspirinAspirin oror NSAIDNSAID use (most common cause)use (most common cause)
 Helicobacter PyloriHelicobacter Pylori infectioninfection
 Elderly (especially over age 70 years)Elderly (especially over age 70 years)

4. Adults with acute massiveAdults with acute massive GI BleedGI Bleedinging
 Duodenal UlcerDuodenal Ulcer (30-37%)(30-37%)
 Gastric UlcerGastric Ulcer (19-24%)(19-24%)
 Esophageal VaricesEsophageal Varices (6-10%)(6-10%)
 GastritisGastritis oror DuodenitisDuodenitis (5-10%)(5-10%)
 Esophagitis or esophageal ulcer (5-10%)Esophagitis or esophageal ulcer (5-10%)
 Mallory-Weiss tear (3-7%)Mallory-Weiss tear (3-7%)
 Gastrointestinal malignancy (1-4%)Gastrointestinal malignancy (1-4%)

5.  Dieulafoy's Lesion (1%)Dieulafoy's Lesion (1%)
 Artery at gastric fundus may bleed heavilyArtery at gastric fundus may bleed heavily
 Difficult to identify on endoscopyDifficult to identify on endoscopy
 Gastric antral vascular ectasia (0.5 to 2%)Gastric antral vascular ectasia (0.5 to 2%)
 Longitudinal erythematous stripes on gastric mucosaLongitudinal erythematous stripes on gastric mucosa
 Known as Watermelon stomachKnown as Watermelon stomach
 Arteriovenous malformationArteriovenous malformation
 Angiodysplasia of stomach or duodenum,Angiodysplasia of stomach or duodenum,

6. Adults with chronic intermittentAdults with chronic intermittent
GI BleedGI Bleedinging
 GastritisGastritis (18 to 35%)(18 to 35%)
 Esophagitis (18 to 35%)Esophagitis (18 to 35%)
 Gastric UlcerGastric Ulcer (18 to 21%)(18 to 21%)
 Duodenal UlcerDuodenal Ulcer (3 to 15%)(3 to 15%)
 Angiodysplasia (5 to 23%)Angiodysplasia (5 to 23%)
 Gastric CancerGastric Cancer

7. Adults - most commonly missed upperAdults - most commonly missed upper
GI sourcesGI sources
 LargeLarge Hiatal HerniaHiatal Hernia ErosionErosionss
 Arteriovenous malformationArteriovenous malformation
 Peptic Ulcer DiseasePeptic Ulcer Disease

10. POSTERIOPR WALL DUODENALPOSTERIOPR WALL DUODENAL
ULCERULCER

11. GASTRIC ULCER IN ANTRUMGASTRIC ULCER IN ANTRUM

12. VARICEAL BLEEDVARICEAL BLEED

13. HISTORYHISTORY
 Has the patient been vomiting or retching beforeHas the patient been vomiting or retching before
the episode of haematemesis? -> Mallory-Weissthe episode of haematemesis? -> Mallory-Weiss
teartear
 Enquire about the colour of the vomitusEnquire about the colour of the vomitus
 Was there a previous incident of peptic ulcer orWas there a previous incident of peptic ulcer or
haematemesis/melaena?haematemesis/melaena?
 Heartburn -> Reflux oesophagitisHeartburn -> Reflux oesophagitis
 Drug history (including aspirin and over theDrug history (including aspirin and over the
counter medicines -> peptic ulcer)counter medicines -> peptic ulcer)
 Alcohol -> Liver failure -> oesophageal varices ->Alcohol -> Liver failure -> oesophageal varices ->
upper GI bleedupper GI bleed

14. ASSESSMENTASSESSMENT
 One should first determine theOne should first determine the amount of bloodamount of blood
lossloss, and the site of bleeding., and the site of bleeding.
 The measurement ofThe measurement of vital signsvital signs provides the onlyprovides the only
accurate assessment of blood loss (orthostatics, heartaccurate assessment of blood loss (orthostatics, heart
rate, complaints of weakness or dizziness, syncope).rate, complaints of weakness or dizziness, syncope).
 AnAn NG tubeNG tube should be placed as part of theshould be placed as part of the
assessment. The gastric lavage may aid the endscopistassessment. The gastric lavage may aid the endscopist
to obtain a clear view of the bleeding site. to obtain a clear view of the bleeding site.

15. PHYSICAL EXAMINATIONPHYSICAL EXAMINATION
 Vital signsVital signs, in order to determine the severity of, in order to determine the severity of
bleeding and the timing of interventionbleeding and the timing of intervention
 AbdominalAbdominal andand rectalrectal examination, in order toexamination, in order to
determine possible causes of hemorrhagedetermine possible causes of hemorrhage
 Assessment forAssessment for portal hypertensionportal hypertension andand
stigmata of chronic liver diseasestigmata of chronic liver disease in order toin order to
determine if the bleeding is from a varicealdetermine if the bleeding is from a variceal
source.source.

16. DIAGNOSISDIAGNOSIS
 Sometimes, theSometimes, the source can be naso-orsource can be naso-or
oropharyngealoropharyngeal.. A careful exam of the naresA careful exam of the nares
and oral pharynx should be done.and oral pharynx should be done.
 The presence ofThe presence of "coffee ground emesis"coffee ground emesis
represents blood altered by gastric contentsrepresents blood altered by gastric contents
and usually means that there has beenand usually means that there has been slowslow
bleeding from the region between thebleeding from the region between the
esophagus and the duodenum.esophagus and the duodenum.

17.  AA positive NG tube aspiratepositive NG tube aspirate for blood usuallyfor blood usually
signifies that the site of bleeding is proximal tosignifies that the site of bleeding is proximal to
the ligament of Treitz.the ligament of Treitz.
 Other characteristics of upper GI bleeding areOther characteristics of upper GI bleeding are
elevated BUNelevated BUN andand hyperactive bowelhyperactive bowel
soundssounds..
 The source of bleeding can be identified in 90%The source of bleeding can be identified in 90%
of cases if endoscopy is done within the first 24of cases if endoscopy is done within the first 24
hours.hours.

18. Upper GI Bleeding ScoreUpper GI Bleeding Score
 CriteriaCriteria
 Blood Urea NitrogenBlood Urea Nitrogen (BUN)(BUN)
 BUN 18.2 to 22.4 mg/dl: Score 2BUN 18.2 to 22.4 mg/dl: Score 2
 BUN 22.4 to 28 mg/dl: Score 3BUN 22.4 to 28 mg/dl: Score 3
 BUN 28 to 70 mg/dl: Score 4BUN 28 to 70 mg/dl: Score 4
 BUN >70 mg/dl: Score 6BUN >70 mg/dl: Score 6

19.  HemoglobinHemoglobin
 MenMen
 HemoglobinHemoglobin 12 to 13 g/dl: Score 112 to 13 g/dl: Score 1
 HemoglobinHemoglobin 10 to 12 g/dl: Score 310 to 12 g/dl: Score 3
 HemoglobinHemoglobin <10 g/dl: Score 6<10 g/dl: Score 6
 WomenWomen
 HemoglobinHemoglobin 10 to 12 g/dl: Score 110 to 12 g/dl: Score 1
 HemoglobinHemoglobin <10 g/dl: Score 6<10 g/dl: Score 6

20.  SystolicSystolic Blood PressureBlood Pressure (SBP)(SBP)
 SBP 100 to 109 mmHg: Score 1SBP 100 to 109 mmHg: Score 1
 SBP 90 to 99 mmHg: Score 2SBP 90 to 99 mmHg: Score 2
 SBP <90 mmHg: Score 3SBP <90 mmHg: Score 3

21.  Miscellaneous MarkersMiscellaneous Markers
 Pulse >100 per minute: 1Pulse >100 per minute: 1
 Presentation withPresentation with MelenaMelena: 1: 1
 Presentation withPresentation with SyncopeSyncope: 2: 2
 Hepatic disease: 2Hepatic disease: 2
 Cardiac function: 2Cardiac function: 2

22. InterpretationInterpretation
 Assesses probability for interventionAssesses probability for intervention
 EndoscopyEndoscopy
 SurgerySurgery
 Score predicting resolution without intervention:Score predicting resolution without intervention:
<4<4
 Score predicting intervention: >5Score predicting intervention: >5

23. MANAGEMENTMANAGEMENT
 INITIAL:INITIAL:
 Nasogastric TubeNasogastric Tube with aspiratewith aspirate
 Fresh blood suggests persistant bleedingFresh blood suggests persistant bleeding
 Avoid lavage due to aspiration riskAvoid lavage due to aspiration risk
 If severe bleeding and suspected variceal sourceIf severe bleeding and suspected variceal source
 SeeSee Esophageal VaricesEsophageal Varices
 Octreotide 50 ug bolus, then 50 ug/hourOctreotide 50 ug bolus, then 50 ug/hour

24. Management: General MeasuresManagement: General Measures
 Helicobacter PyloriHelicobacter Pylori managementmanagement
 Empiric acid reduction (Empiric acid reduction (Proton Pump InhibitorProton Pump Inhibitor))
 Not proven in-vivo to aid clottingNot proven in-vivo to aid clotting
 No proven benefit in mortality and otherNo proven benefit in mortality and other
outcomesoutcomes
 Does not lower overallDoes not lower overall IncidenceIncidence of re-bleedingof re-bleeding
 OmeprazoleOmeprazole may heal ulcer if near-achlorhydriamay heal ulcer if near-achlorhydria

25. General ManagementGeneral Management
 Blood TransfusionBlood Transfusion
consider on individual basis (particularly comorbidities)consider on individual basis (particularly comorbidities)
indication: Hb <70 g/Lindication: Hb <70 g/L
(except unstable CHD aim Hb > 90 g/L)(except unstable CHD aim Hb > 90 g/L)1-31-3
avoid transfusing patients with suspected varicealavoid transfusing patients with suspected variceal
bleeding to Hb >100 g/Lbleeding to Hb >100 g/L
((portal P may worsen bleeding)portal P may worsen bleeding)4,5-84,5-8
give one unit FFP for each four units of packed RBCgive one unit FFP for each four units of packed RBC
transfusedtransfused99

26. General ManagementGeneral Management
 ConsiderConsider reversal of coagulopathy (in thosereversal of coagulopathy (in those
actively bleeding)actively bleeding)
FFP if INR >1.5 or platelets if count <50 xFFP if INR >1.5 or platelets if count <50 x
10109/9/
LL
simultaneous replacement + scope if INR <3simultaneous replacement + scope if INR <3
delay scope until INR <3 if it is initially higherdelay scope until INR <3 if it is initially higher1010
 ConsiderConsider platelet transfusion ifplatelet transfusion if life threateninglife threatening
bleedingbleeding and taking antiplatelet agents eg aspirinand taking antiplatelet agents eg aspirin

27. Management: Low risk patientsManagement: Low risk patients
 IndicationsIndications
 Hemodynamically stable within 1 hour ofHemodynamically stable within 1 hour of
ResuscitationResuscitation
 Minimal Blood Products required (2 PRBC orMinimal Blood Products required (2 PRBC or
less)less)
 No evidence of active bleedingNo evidence of active bleeding
 Nasogastric Tube aspirate without bloodNasogastric Tube aspirate without blood
 No active comorbid medical conditionsNo active comorbid medical conditions

28.  ProtocolProtocol
 Consider for rapid protocolConsider for rapid protocol
 Immediate Upper Endoscopy Evaluation of GIImmediate Upper Endoscopy Evaluation of GI
BleedingBleeding
 Discharge to home if low-risk endoscopy resultsDischarge to home if low-risk endoscopy results
 Admit if rapid protocol not availableAdmit if rapid protocol not available
 Follow moderate risk patient protocol belowFollow moderate risk patient protocol below
 General measures as aboveGeneral measures as above

29. Management: High risk patientsManagement: High risk patients
 IndicationsIndications
 Active ongoing bleedingActive ongoing bleeding
 Hypotension persists despite ResuscitationHypotension persists despite Resuscitation
 Severe active comorbid condition exascerbationSevere active comorbid condition exascerbation
 Liver disease exascerbationLiver disease exascerbation
 Endotracheal Intubation for airway protectionEndotracheal Intubation for airway protection

30. MALLORY-WEISS TEARSMALLORY-WEISS TEARS
 Mostly bleeding stopsMostly bleeding stops
spontaneously ( Recurrence isspontaneously ( Recurrence is
only 0-7 % )only 0-7 % )
 Endoscopic therapy is only forEndoscopic therapy is only for
actively bleeding Mallory weissactively bleeding Mallory weiss
tear.tear.
 Angiographic therapy withAngiographic therapy with
embolization & operative therapyembolization & operative therapy
with over sewing of tear can bewith over sewing of tear can be
done ( but only required rarely )done ( but only required rarely )

31. ESOPHAGEAL VARICESESOPHAGEAL VARICES
I.I. Vasoconstrictors (somatostatin, octreotide,Vasoconstrictors (somatostatin, octreotide,
terlipressin) iv terlipressin infusion at 2 mg 6terlipressin) iv terlipressin infusion at 2 mg 6thth
hourly, generalized vasoconstriction leading tohourly, generalized vasoconstriction leading to
decreased blood flow to venous system.decreased blood flow to venous system.
II.II. Baloon tamponade – Triple lumen or FourBaloon tamponade – Triple lumen or Four
lumen tube with esophageal and gastric balloons.lumen tube with esophageal and gastric balloons.
(Always intubate the patient prior to this(Always intubate the patient prior to this
procedure to prevent aspiration)procedure to prevent aspiration)
III.III. Endoscopic variceal liagation[Band ligation]Endoscopic variceal liagation[Band ligation]
IV.IV. SclerotherapySclerotherapy
V.V. Antibiotic therapyAntibiotic therapy

32.  Quinolones – for patients with cirrhosis decreasesQuinolones – for patients with cirrhosis decreases
the bacterial infection & mortality.the bacterial infection & mortality.
 Non selective Beta blockers – Propranalol,Non selective Beta blockers – Propranalol,
NadololNadolol
 For recurrent esophageal bleeding – c/c therapyFor recurrent esophageal bleeding – c/c therapy
with beta blocker + endoscopic ligationwith beta blocker + endoscopic ligation
 If not subsided with medical therapy, Go for:If not subsided with medical therapy, Go for:

33. INVASIVE THERAPY:INVASIVE THERAPY:
 TIPTIPssss (Transjugular intrahepatic portosystemic(Transjugular intrahepatic portosystemic
shunt)shunt)
 A/E : Hep encephalopathy, shunt stenosis in 1 yrA/E : Hep encephalopathy, shunt stenosis in 1 yr
 Vascular ectasias are treated by endoscopic therapyVascular ectasias are treated by endoscopic therapy
 Estrogen / progesterone components are used inEstrogen / progesterone components are used in
vascular ectasiasvascular ectasias

34.  ProtocolProtocol
 General measures as aboveGeneral measures as above
 Admit to intensive care unit for first 24 hoursAdmit to intensive care unit for first 24 hours
 Observe in hospital for 48 to 72 hours or moreObserve in hospital for 48 to 72 hours or more
 Urgent upper endoscopy when stabilizedUrgent upper endoscopy when stabilized
 See Upper Endoscopy Evaluation of GISee Upper Endoscopy Evaluation of GI
BleedingBleeding
 Consider arteriography if source not evidentConsider arteriography if source not evident

36. OutcomesOutcomes
 Overall Mortality: 2-15% (often related toOverall Mortality: 2-15% (often related to
comorbidity)comorbidity)
 Bleeding stops and does not recur: 70% (<2%Bleeding stops and does not recur: 70% (<2%
Mortality)Mortality)
 Bleeding after initially stopped: 25% (10%Bleeding after initially stopped: 25% (10%
Mortality)Mortality)
 Continued active bleed: 5% (30% Mortality)Continued active bleed: 5% (30% Mortality)

37. PredictorsPredictors
 Bleeding characteristic predictors of poorBleeding characteristic predictors of poor
outcomeoutcome
 Emesis or nasogastric aspirate contains red bloodEmesis or nasogastric aspirate contains red blood
 Low initial HematocritLow initial Hematocrit
 Coagulopathy (low platelets or high INR)Coagulopathy (low platelets or high INR)

38.  Comorbid condition predictors of poor outcomeComorbid condition predictors of poor outcome
 Active Coronary Artery DiseaseActive Coronary Artery Disease
 Congestive Heart FailureCongestive Heart Failure
 Active lung diseaseActive lung disease
 Renal FailureRenal Failure
 SepsisSepsis
 Metastatic cancerMetastatic cancer
 Advanced liver diseaseAdvanced liver disease
 Advanced ageAdvanced age

39. ThanksThanks