Upper GI bleeding

1. UPPER GI BLEEDING
O. Owoseni.

2. Case scenario
 60yr old woman with arthritis of both
knees.
 Presents at the ER with a 2- day
history of vomiting of a ‘brownish
substance’, easy fatigability and
breathlessness
 ?? Differentials
 ?? Management
 ?? Prognosis

3. Outline
 Introduction-
 Causes
 Clinical Features
 Investigations
 Treatment
 Prognosis

4. Introduction
 UGIB is a common cause of
emergency admission to hospital.
 Defined as bleeding occuring along
the GI tract from the mouth to the
ligament of Trietz.
 Mortality: 5 - 10%. Increased in the
elderly.

6. AETIOLOGY

7. Commonest causes
 Duodenal ulcer
 Gastric ulcer
 Esophageal varices
 Mallory-Weiss tear

8. Rare causes

9. The causes of UGIB
[anatomically]:
Esophageal causes:
◦ Esophageal varices
◦ Esophagitis
◦ Esophageal cancer
◦ Esophageal ulcers
◦ Mallory-Weiss tear
 Gastric causes:
◦ Gastric ulcer
◦ Gastric cancer
◦ Gastritis
◦ Gastric varices
◦ Gastric antral vascular ectasia
◦ Dieulafoy’s lesions

10. Causes ctd
Duodenal causes:
◦ Duodenal ulcer
◦ Vascular malformation, including aorto-enteric
fistulae. Fistulae are usually secondary to prior
vascular surgery and usually occur at the
proximal anastomosis at the third or fourth
portion of the duodenum where it is
retroperitoneal and near the aorta.
◦ Hematobilia , or bleeding from the biliary tree
◦ Hemosuccus pancreaticus, or bleeding from the
pancreatic duct
◦ Severe superior mesenetric artery syndrome

11. UGIB - An Emergency!!!
 The aims of taking a quick history and
physical examination is to determine
the severity of the bleeding, possible
aetiology and co- morbidities.

12. Clinical features
 Symptoms - Acute UGIB-
 Excessive weakness, easy fatiguability,
dizziness, palpitations.
 Haematemesis, melaena stool,
haematochezia
 Past history of NSAID use, dyspepsia,
PUD, chronic alcohol ingestion, steroid
use, anti- coagulant therapy.
 History of jaundice or contact with
jaundiced person.

13. Clinical features ctd
 Co – morbidities [cardiovascular
disease, Chronic Kidney Disease,
respiratory disease] – bad prognosis
Chronic UGIB
 Asymptomatic
 Past history of jaundice,
 Other features as in acute.

14. Signs
 Mainly – vital signs, features of CLD &
portal HTN; DRE. Thus:
 Features of blood loss- Pallor,
Diaphoresis, Tachycardia, Thready pulse,
Hypotension, Restlessness, Confusion.
 DRE- melena stool, bright red blood
 Features of co- morbidities like renal
failure, heart failure etc

15. Assessing haemodynamic status
Pt’s haemodynamic
status (vital signs)
Blood loss (% of
intravascular volume
loss)
Severity of bleed
Normal– PR<100;
SBP> 100mmHg
<10% (500ml) Minor
Postural hypotension–
PR >100; SBP> 100mmHg
10-20% (500-1000ml) Moderate
Shock– PR>100;
SBP< 100mmHg
20-25% (1000-1250ml) Severe

16. Rockall score

17. Signs ctd
 Peripheral signs of chronic liver dx-
parotid fulness, fluffy hair,
gynaecomastia, spider naevi, finger
clubbing, Dupuytren’s contracture,
wasting of thenar & hypothenar
eminences, testicular atrophy, female
hair pattern distribution
 Enlarged or shrunken liver, jaundice,
nodular liver

18. Investigations
 Esophageogastroduodenoscopy(EGD)-
diagnostic/therapeutic/prognosticate
 Only after the pt is stable
haemodynamically
 Can identify high or low risk lesions, thus
directing specific therapy and minimising
hospital stay and costs

19. Mallory –Weiss tear

20. NSAID- induced gastritis

21. Ulcer with clean base

22. Oozing

23. Spurting

24. Oesophageal varices

25. Investigations contd.
Complete blood count
Liver function tests
Viral markers
Urea breath test/stool antigen for H. pylori
Coagulation profile
Abdominal scan
ECG
Liver biopsy
Histology of samples obtained at EGD

26. Other investigations
 Chest x-ray – oesophageal masses or
rupture with pneumomediastinum (eg
Boerhaave syndrome)
 Serum gastrin levels
 Angiography
 Tagged (technetium labelled) red cell
scan- more specific than angiography

27. Treatment
Goals
 to stop active bleeding and
 to prevent recurrent bleeding
Options are
 pharmacotherapy;
 endoscopic procedures;
 surgery
Thus requires a focused
multidisciplinary approach

28. E.R. management
 2 large bore IV catheters ; N/S or Ringer’s
lactate rapidly, aim to restore vitals
 If >2litres of crystalloid are needed,
consider blood transfusion
 Supplemental O₂ by face mask or nasal
catheter
 Monitor vitals and urine output hourly
[>30mls/ hr]
 Give blood/ blood products as soon as
available[bld products in pts with
coagulopathy -CLD]

29. Pharmacotherapy
 PUD -- high dose proton pump
inhibitor (PPI) eg iv omeprazole 80mg
stat, then 8mg/hr for 72h, then oral
 Portal hypertension– ivi octreotide (or
somatostatin); vasopressin/terlipressin
(may add nitrate)
 GERD/ oesophagitis – high dose PPI

30. Endoscopic therapy
 Injection– adrenaline, saline, water,
ethanol, sclerosants, thrombin, fibrin
glue
 Thermal methods– laser
photocoagulation, heater probe,
monopolar electrocoagulation, bipolar/
multipolar electrocoagulation
 Haemoclips
 Argon plasma coagulation

31. Endo therapy for variceal
bleed
Variceal ligation
Sclerotherapy
Balloon Tamponade –
Sengstaken- Blakemore
Endoloop

32. Surgery
PUD
Simple oversewing;
Partial gastrectomy;
Pyloroplasty with drainage
procedures
VARICES
Shunt surgery – TIPS, Peritoneo-
venous shunts

33. Indications for surgery
 Failure of medical and endoscopic therapy
 Severe life threatening bleeding
unresponsive to resuscitative measures,
initial Rockall score >3 or post endoscopy
>6.
 Prolonged bleeding with loss of at least
50% of blood volume
 Previous hospitalisation for UGIB
 Another indication for surgery eg
perforation, obstruction, malignancy

34. Prognosis
 Mortality 8-10%
 80% self limited, resolve
spontaneously, require only supportive
care
 Most important factors that determine
outcome are the cause of bleeding
and presence of comorbidity

35. Poor prognostic factors
 Age> 65y
 Comorbidities especially BVF, renal
failure, liver failure, cardiovascular
disease, malignancy
 Variceal bleeding
 Shock/hypotension on presentation
 Red blood in emesis or stool
 Increased number of units transfused
>6

36. Poor prognostic factors ctd
Active bleeding at EGD– spurting,
oozing, visible vessel, adherent clots
Bleeding from a large ulcer >2cm
Onset of bleeding in hospital
Need for emergency surgery

37. Low- risk criteria for pts that
can be discharged home
 No comorbid diseases
 Normal vital signs
 Normal or trace positive stool guaiac
 Negative gastric aspirate, if done
 Normal or near-normal
hemoglobin/haematocrit
 Adequate home support
 Proper understanding of signs and
symptoms of significant bleeding
 Immediate access to emergent care if
needed

38. Case scenario - answers
 60yr old woman with arthritis of both
knees.
 Presents at the ER with a 2- day
history of vomiting of a ‘brownish
substance’, easy fatigability and
breathlessness
 ?? Differentials
 ?? Management
 ?? Prognosis

39. Summary
 What is UGIB?
 It is an emergency!!
 Common causes?
 Clinical features
 Treatments
 Indications for surgery
 Prognostic score

40. Thank you