Upper GI bleeding refers to bleeding proximal to the ligament of Treitz and can present as hematemesis, melena, or hematochezia. Initial assessment involves ABCs and resuscitation followed by endoscopy to identify the source of bleeding which is most commonly a peptic ulcer. Endoscopy allows for cauterization or injection to stop bleeding from ulcers or varices. If endoscopy fails or is contraindicated, angiography or surgery may be required while prevention involves testing and treating H. pylori or reducing NSAID use.

1. Upper GI Bleeding
Upper GI Bleeding
By: Khalid Ali Dirie
Department of medicine

2. Upper GI Bleeding
Overview
• Definitions
• Initial Patient Assessment
– ABC & Resuscitation
• Differential Diagnosis
• Identify the Source & Stop the Bleeding
– History & Physical
– Endoscopy & Potential Complications
– Other diagnostics tests
• Role of Surgery
• Prevention

3. Upper GI Bleeding
Definitions
• Upper GI Bleeding = proximal to ligament of
Treitz
• Hematemesis = vomiting blood
– This is diagnostic of upper GI bleeding
• Melena = passage of tarry or maroon stool
– Can be upper or lower (more commonly upper)
• Hematochezia = Bright red blood per rectum
– Usually characteristic of colonic hemorrhage

4. Upper GI Bleeding
Initial Patient Assessment
• Get to patient’s bedside, assess ABC
• Can the patient protect his airway?
– Does he need to be intubated?
• Is the patient hemodynamically unstable?
– Is he in hemorrhagic shock?
• 2 large bore IV, Bolus 2L fluids, Type &
Cross blood, send CBC & Coags
• Place patient on O2 & continuous monitor
• Place an NGT and lavage with NS
– To confirm if the bleeding source is upper GI

5. Upper GI Bleeding
Differential Diagnosis
• Peptic Ulcer Disease (PUD) >50% cases
• Gastritis / Duodenitis (15-30%)
– Subset due to NSAID use
• Varices from portal hypertension (10-20%)
• Mallory-Weiss tears at GE junction (5%)
• Esophagitis (3-5%)
• Malignancy (3%)
• Nasopharyngeal bleed – swallowed blood
• Other- Aortoenteric fistula, angiodysplasia,
Crohn’s disease, hemophilia,

6. Upper GI Bleeding
History & Physical
• History of prior ulcers, NSAID use, stress
• History of Helicobacter pylori & treatment
• Alcohol abuse
– Retching -> Mallory Weiss tear
– Alcoholic cirrhosis -> portal hypertension and
varices
• On Physical Exam, assess hydration
• Look for stigmata of cirrhosis & portal HTN

7. Upper GI Bleeding
Management – Acute UGI Bleed
• Once again, make sure pt is resuscitated
• If anemic and symptomatic, give blood
• Place NGT/lavage (helps for endoscopy)
• Perform Upper endoscopy (EGD)
– For ulcers: if visible clot, visible vessel, or active
bleeding, should cauterize/coagulate and inject
sclerosing agent
– For acute variceal bleeding: sclerotherapy +
somatostatin or endoscopic band ligation. If
fail/rebleed: surgical shunt. Balloon tamponade is an
emergency temporizing measure
• Start proton pump inhibitor (PPI) infusion

8. Upper GI Bleeding
Potential Complications
• Perforation of esophagus
• Aspiration
• Desaturation or respiratory distress
• Adverse reaction to conscious sedation
• ↑risk of complications with:
– Inadequate resuscitation or hypotension
– Comorbidities
• Consider elective intubation prior to EGD if
active bleeding, altered respiratory or
mental status

9. Upper GI Bleeding
Other Diagnostic Tests
• If bleeding is unresolved with endoscopy
or endoscopy is contraindicated
• 1. Angiography (Diagnostic & Therapeutic)
– Intra-arterial vasopressin
– Embolization
• 2. Tagged red blood cell (TRBC) scan
– Only diagnostic & usually for occult bleeding
– More sensitive than angiography
– Can detect bleeding rate of 0.1-0.5 mL/min

10. Upper GI Bleeding
Role of Surgery
• If medical and endoscopic therapy fail
• In the event that bleeding source is
unidentified -> exploratory laparotomy
• Recurrent bleeding peptic ulcers
– Anti-ulcer surgery (i.e. vagotomy/antrectomy,
or vagotomy/pyloroplasty, or selective vagot)

11. Upper GI Bleeding
Prevention
• After the acute situation is resolved,
educate patient on preventive measures
• Top 2 reasons for ulcers: Hpylori & NSAID
• 1. Testing for H.pylori (i.e. antral biopsy
during endoscopy)
• 2. Treat H.pylori (amoxicill, clarithromycin
x1wk plus PPI x4wk)
• 3. Reduce intake of NSAID

12. Upper GI Bleeding
Take Home Points
• Always, always perform ABC’s first &
resuscitate with two #16ga IV’s & isotonic
crystalloids (blood if pt doesn’t respond)
• NGT/lavage to confirm active bleeding
• Focused H&P looking for common
causes: ulcers, varices, “-itis”, Mallory-
Weiss, AVM
• Endoscopy is 1st
line for acute UGIB
– Don’t forget to start intravenous PPI infusion
• Endoscopy has associated complications
• Angio or surgery if still bleeding