Dr. Darpan Nepali presented on the gastrointestinal system, specifically on the causes, diagnosis, and management of upper gastrointestinal bleeding. The presentation reviewed the major causes of upper GI bleeding including esophageal and gastric sources. Initial management focuses on resuscitation, risk stratification using scoring systems, and urgent endoscopy. Endoscopic findings and scoring systems can help determine need for hemostatic therapy and predict rebleeding risk. Management differs for variceal versus non-variceal bleeding sources.

2. Presenter :- Dr. Darpan Nepali
1st Year PG (General Practice &
Emergency Medicine)
Preceptor:- Dr. Sandeep Kumar Raut

3. SUBJECT
 This is a subject of Clinical Medicine
 It will take around 30-45minutes
 Gastrointestinal system
SYSTEM

4. LEARNING OBJECTIVES
1. GENERAL OBJECTIVES:
- At the end of the session , participants will be able to
approach cases with upper gastrointestinal bleeding.

5. 2. SPECIFIC OBJECTIVES
 Review the major causes of upper GI bleeding.
 Understanding the management of upper GI bleeding.

6. Case senario
 A 45yr old man presented to Emergency department with 5
day history of passing black tarry stool and abdominal
pain. Complains of postural dizziness since 1 week .
Consumes 30-40 units alcohol / day.
 h/o weight loss (6kg)
 In ED the pt had giddiness and had vomited dark stained
material looking like coffee ground.

7.  Vitals BP-90/60 mmHg ,HR -120b/min, moderate dehydration
present conjuntical pallor +
 PA- epigastric tenderness, no organomegaly
 PR- black tarry stool, no freshbleeding.
 ECG – sinus tachycardia with no evidence of ischemia
 Diagnosis?

8. ANATOMY
The ligament of Treitz (in the 4th
portion of duodenum ) is the
anatomic cut-off between an
upper and lower Gastrointestinal
(GI) bleed.

9. Cont..
 Upper GI bleeds
presents with
melena and
hematemesis.
 A brisk upper GI
bleed may
sometimes present
with hematochezia
Lower GI bleeds
presents with
hematochezia

10. CHARACTERISTICS OF BLEEDING
 Hematemesis- vomitus of red blood or coffee- ground.
red blood- moderate to severe bleeding
coffee ground –slower bleed
 Melena –black , tarry stool. It indicates blood has been
present in GI tract for at least 14 hours.
 Hematochezia – passage of red or maroon blood from
rectum.

11. Cont…
 Occult GI bleed – bleeding not clinically visible. Presents
with symptoms of blood loss and anaemia or positive fecal
occult blood test.
 Obscure bleed – bleeding in which source is unclear,
cannot be detected by gastroscopy and colonoscopy.

13. MAJOR CAUSES
Oesophagus Stomach
-Oesophageal varices -Gastric ulcer
-Oesophageal CA -Erosive gastritis
-Reflux oesophagitis - Gastric CA
- Mallory- Weiss tear - Gastric lymphoma
-Gastric leiomyoma
Duodenum
- Duodenal ulcer
-Duodenitis
LOCAL

14. CONT…
- Haemophilia
-Leukemia
-Thrombocytopenia
-Anti- coagulant therapy
GENERAL

15. RISK FACTORS
 Old age
 Co-existing illness – IHD,CLD
 Drugs- NSAIDs, Dual anti-platelets, anti-coagulants
 Malignancies

16. SEVERE UPPER GI BLEED
 Large volume hematemesis
 Tachycardia, hypotension
 Orthostatic hypotension
 Pallor
 Syncope
 Drop in Hb >2g

17. HISTORY: Important risk factors
 Past medical history: prior GI bleeds, ulcers, H.pylori,
diverticulitis, hemorrhoids, IBD
 Medications: NSAIDs , anticoagulants, anti platelets, iron
supplements.
 Social history: smoking , heavy alcohol use

18. Cont…
 Co-morbid conditions: cirrhosis, renal disease, cancer
 Associated symptoms: dysphagia, abdominal pain ,weight
loss, preceding emesis, change in bowel habits.

19. PHYSICAL EXAMINATION
-Anaemic
-Bruising / Purpura
- Cachexic
-Dehydrated
- Icteric
GENERAL INSPECTION

20. Cont…
INSPECTION
-distension, scar, prominent vein
PALPATION
-tenderness
- mass / organomegaly
PERCUSSION
- shifting dullness
- fluid thrill
AUSCALTATION
- hyperactive bowel sound
ABDOMEN

21. Cont…
-Perianal skin lesion
- Masses
-Melaena
-Supraclavicular LN
-Cervical LN
-Axillary LN
-Inguinal LN
RECTAL
LYMPH NODES

22. CONT…
 Clinical sign
 Systolic BP < 100mmHg
 Pulse rate > 100bpm
 Postural sign :
- pulse rate rises 25% or more
- systolic BP falls 20mmHg or more

23. CONT…
 Sign of liver diseases or portal hypertension
 Sign of GI diseases
 Sign of bleeding abnormalities
 Bloody / black stool on per rectal examination

24. EARLY RESUSCITATION AND
SUPPORTIVE MEASURES ARE CRITICAL
TO REDUCE MORTALITY FROM UPPER
GI BLEED

25. MANAGEMENT
1. Stabilize the patient : protect airway, restore circulation.
2. Identify the source of bleeding
3. Definitive treatment of the cause
Priorities are:

26. RESUSCITATION AND INITIAL
MANAGEMENT
 Protect airway:position the patient on side
 IV access: use 1-2 wide bore cannula
 Take blood for : Hb, PCV ,PT and cross match
 Restore the circulation : if pt is haemodynamically stable give
N.S infusion , if not give colloid 500ml/hr and then crystalloid
and continue until blood is available.

27.  Monitor urine output
 Watch for sign of fluid overload(raised JVP, pulmonary
edema, peripheral edema)
 Commence IV PPI, omeprazole 80mg IV followed by 8mg/hr
for 72hours
 Keep the patient nill by mouth for the endoscopy.

28. Transfuse blood for
 Obvious massive blood loss
 Hematocrit < 25% with active bleeding
 Symptoms due to low hematocrit and haemoglobin
 Platelet transfudion should be offered to patients who are
actively bleeding and have a platelet count <50000

29. Cont…
 Fresh frozen plasma should be used for patients who have
either a fibrinogen level <1 g/l or INR > 1.5 times normal.

30. Utility of NG Tube
 Most useful situation :pt with severe haematochezia and
unsure if UGIB vs LGIB
- positive aspirate ( blood/ coffee ground )indicates
UGIB
- prevent aspiration
 Can provide prognostic info:
-red blood per NGT: predictive of high risk endoscopic
lesion
- coffee ground : less severe / inactive bleeding

31. Cont…
 Negative aspirate : not as helpful ;15-20% of patients
with UGIB have negative NG aspirate.

32. INITIAL ASSESSMENT

33. Blood Tests
 Haemoglobin: may be normal during acute stages
until haemodilution occurs.
 Urea and electrolytes : elevated urea suggests severe
bleeding
 Cross matching
 Liver function test and coagulation profile.

34. Cont…
 The BUN-to- Creatinine ratio increases with UGIB. A ratio >36
in a patient without renal insufficiency is suggestive of UGIB
 Prothrombin time(PT), activate partial thromboplastin time
and International Normalized Ratio(INR) should be checked .

35. ENDOSCOPY
 Initial diagnostic examination for all patients
presumed to have UGIB.
 Endoscopy should be performed immediately after
endotracheal intubation(if indicated), hemodynamic
stabilization, and adequate monitoring in an ICU.

36. TYPES OF SCORING
 Glasgow blatchford score
 Clinical rockall score
 Fast track blatchford
 Bleed criteria
 AIMS65
PREDICTS MORTALITY
PRE-ENDOSCOPIC ENDOSCOPIC
 Rockall score
 Forrest classification
 Cedar sinai score
 Baylor score
PREDICTS REBLEEDING

37. BLEED CRITERIA
 B : ongoing bleeding
 L : low systolic BP
 E : elevated PT
 E : erratic mental status
 D: disease i.e unstable medical comorbidity

38. Simple scoring systems
 Albumin <3.0
 INR>1.5
 Mental status altered
 Systolic BP<90
 65+years old
Mortality, length of stay
AIMS65
 BUN < 18mg/dl
 Hg >13/12 g%
 SBP>100mmHg
 HR<100bpm
Low risk patient
FAST TRACK BLATCHFORD

39. Rockall scoring system

40. RISK CATEGORY
 Rockall score >8 means high risk of death.
 Rockall score <3 means excellent prognosis

41. BLATCHFORD SCORE
 Predicts need for endoscopic therapy
 Based on readily available clinical and lab data
 Most useful for safely discriminating low risk UGIB
patients who will likely Not require endoscopic hemostasis.

43. Pre- endoscopic Pharmacotherapy
 For Non- Variceal UGIB
-IV PPI:80mg bolus then 8mg/hr drip
-rationale: suppress acid, facilitates clot formation and
stabilization
-Duration: atleast until endoscopy, then based on findings

44. ENDOSCOPY –NONVARICEAL UGIB
 Early endoscopy (within 24hrs) is recommended for most
patients with acute UGIB.
 Achieves prompt diagnosis, provides risk stratification and
hemostasis therapy in high- risk patients,

45. Endoscopic Hemostasis Therapy
 Epinephrine injection
 Thermal
electrocogulation
 Mechanical
(hemoclips)
 Combination therapy
superior to
monotherapy

46. Nonvariceal UGIB- POST-
endoscopy management
 Patients with low risk ulcers can be fed promptly , put on oral
PPI therapy.
 Patients with ulcers requiring endoscopic therapy should
receivePPI ggt for 72hour.
*significantly reduces 30 day re-bleeding rate vs placebo(67%
vs. 22.5%)
N Engl J med 2000;343;3010
Arch intern Med 2010

47. VARICEAL BLEEDING
 Occurs in 1/3 of patients with cirrhosis
 1/3 initial bleeding episodes are fatal
 Among survivors, 1/3 will rebled within 6 weeks
 Only 1/3 will survive
1 year or more

48. VARICEAL BLEED
 Vasoconstrictor therapy
 Antibiotics
 Resuscitation
 ICU level care
 Endoscopy
 Alternative / rescue therapies
 Beta blockers

49. Vasoconstrictor therapy
 Goal :reduces splanchnic blood flow
 Terlipressin –only agent shown to improve control of bleeding
and survival
 Octreotide (somatostatin analog)
- standard dose: 50mcg bolus, then 50mcg/hr drip for 2-5
days.

50. Antibiotics
 Prophylactic antibiotics reduces incidence of bacterial
infection, significantly reduces early rebleeding
- ceftriaxone 1g IV Qd for 5-7 days
- Alt : Norfloxacin 400 mg BD

51. Resuscitaion
 Promptly but with caution
 Goal : maintain haemodynamic stability , Hbg 7-8g% , CVP
4-8mmHg
 Avoid excessively rapid expansion of volume, may
increase portal pressure, greater bleeding

52. ALTERNATIVE THERAPY

53. Alternative therapy

55. Cont…

57. Cont…

58. Beta blockers

59. OBSCURE GIB EVALUATION

60. INDICATIONS FOR SURGERY
 Persistent hypotension
 Failure of medical management or endoscopic hemostasis
 Co-existing condition( perforation, obstruction,
malignancy)
 Transfusion requirement (4units in 24hrs)
 Recurrent hospitalization

61. TAKE HOME MESSAGE
 Early resuscitation
 Nasogastric lavage
 High dose PPI therapy
 Urgent endoscopy therapy for moderate to severe UGI
bleeding.
 Nonvariceal bleed should be treated with combination
therapy
 Patient should be treated for specific cause/ disease.

62. REFERENCE
 Davidson`s Principle and practice of medicine 21st edition
 Harrison`s Principle of Internal Medicine 20th edition
 API Medicine update 2014
 www. medscape.com