Upper GI tract bleeding can present with hematemesis (vomiting of blood) which resembles coffee grounds, indicating bleeding from the esophagus, stomach or duodenum. Common causes include peptic ulcers, esophageal varices, erosive gastritis, esophagitis, Mallory-Weiss syndrome, stomach cancer, and bleeding disorders. Peptic ulcers are caused by an increase in acid secretion or a decrease in mucosal resistance. Esophageal varices develop due to portal hypertension from liver cirrhosis. Management of upper GI bleeding involves intravenous fluids, monitoring, and endoscopy within 24 hours to control bleeding.

1. Upper GI tract bleed

2.  Upper GI bleed presents with
hematemesis
 Hematemesis means vomiting of blood
 The appearance of hematemesis
resembles coffee grounds
 It indicates bleeding from upper GI
usually from esophagus, stomach and
duodenum above ligament of treitz
 Conditions which cause hematemesis can
also cause melena

3. Causes of Upper GI bleed
 Peptic ulcer
 Esophageal varices
 Erosive gastritis
 Esophagitis
 Mallory weiss syndrome
 Carcinoma stomach
 Hereditary hemorrhagic telengeictasia
 Bleeding disorders

4. Peptic ulcer
 It means ulcers in those parts of the gut
which are exposed to acid.
 Common sites are duodenum , stomach and
can also occur in lower esophagus.
 Causes:
 Increase acid secretion(duodenal ulcer)
 Decrease mucosal resistance(gastric ulcer)
 NSAIDs ingestion
 H.Pylori infection
 Zollinger Ellison syndrome (uncommon)

5.  Peptic ulcer pain is felt in the epigastrium and is well
localized. Patient points with one finger to the site of
pain- the ‘pointing sign’-
 Duodenal ulcer
 Occurs in the 1st part of duodenum.
 Symptoms include
 Pain epigastrium aggravated by empty
stomach(hunger pain), relieved by food and antacids
 Nocturnal pains occur
 Pain in the morning is not due to peptic ulcer
 History of periodicity may be present.
 Signs
 Localized tenderness in the epigastrium

6. Investigation
 Barium meal shows duodenal
deformity/ulcer crater.
 Endoscopy confirms ulcer presence.

7. Gastric ulcer
 Symptoms
 Relation of pain to meals and timings is variable
 May be relieved or aggravated by food
 Nocturnal pain is uncommon
 Signs
 Epigastric tenderness
 Investigation
 Barium meal shows ulcer crater
 Endoscopy confirms
 Every gastric ulcer must be biopsied to exclude
malignancy

8. Treatment
 1st line therapy includes
 PPI ,Antibiotics( clarithromycin and amoxicillin)
 2nd line therapy includes quadruple therapy
 PPI ,Antibiotics(clarithromycin and amoxicillin)
bismuth
 For long term ulcer use only PPI
 Complications of peptic ulcer
 Bleeding
 Perforation
 Chronicity
 Gastric outlet obstruction

9. Esophageal varices
 These are dilated tortuous veins in the
esophagus
 These are communication channels
between the portal and systemic venous
systems and become dilated in portal
hypertension
 Most common cause of portal
hypertension is hepatic cirrhosis

10.  Symptoms
 Hematemesis is massive and recurrent
 Distention of abdomen due to ascites
 History of jaundice
 Hematemesis may be the first manifestation of
cirrhosis
 Signs
 Jaundice
 Dependent edema
 Gynecomastia and testicular atrophy
 Palmar erythema, dupuytren’ contracture, Spider
angiomas, parotid swelling (common in alcoholic
cirrhosis)

11.  Veins of abdominal wall may be prominent
 Liver may be enlarged/shrunken
 Palpable spleen
 Ascites in advanced disease
Investigation
 Endoscopy

12. treatment
 I.V fluid replacement with 0.9% saline
 Vasopressor
 Prophylactic antibiotics (cephalosporin)
 Variceal band ligation
 PPI
 Lactulose

13. Erosive gastritis
 In addition to inflammation of stomach, there are multiple
mucosal erosions and petechiae.
 Causes
 A. drugs
 Aspirin and NSAIDS
 Theophylline
 Potassium chloride
 B. stress
 Head injury
 Shock
 Trauma
 Burns
 Sepsis
 Hepatic encephalopathy

14. Symptoms
 Hematemesis with or without epigastric
pain
 h/o drug intake
Signs
 Tenderness in the epigastrium
Investigation
 Endoscopy

15. Esophagitis
 Abnormal reflux of gastric contents into
lower esophagus is the most common
cause of esophagitis
 Smokers and obese are more prone
Symptoms
 Retrosternal burning and pain(heart
burn), increases on bending forward or
lying flat
 Relieved by antacids

16.  History of regurgitation
 Water brash
 Bitter taste in the morning
 Persistent dysphagia indicates peptic stricture
 Aspiration of regurgitant material cause
laryngitis and aspiration pneumonia
 Signs
 Pallor may occur
 Investigation
 Barium swallow demonstrates reflux
 Esophageal ulcers may be seen

17.  Endoscopy shows
 Hyperemic mucosa with or without ulcers
 If mucosa looks normal , biopsy will
demonstrate microscopic inflammation
 PH monitoring <4 for >4% of time is
suggestive of acid reflux
 Treatment
 Lifestyle modification
 PPI
 H2 antagonists
 Prokinetic drugs

18. Mallory weiss syndrome
 Repeated retching and vomiting can cause
vertical mucosal tear at gastroesophageal
junction
Symptoms
 H/o repeated vomiting and retching
before hematemesis

19. Sign
 Epigastric tenderness
Investigation
 Endoscopy

20. Carcinoma stomach
 Occurs after age of 40 years
 Risks include
 Pernicious anemia
 Partial gastrectomy
 Gastroenterostomy
 Symptoms
 Loss of appetite, nausea and discomfort after meal
 Vague epigastric pain and feeling of distention after
meals
 Early satiety is common
 Persistent vomiting if gastric outlet obstruction
 Marked loss of weight

21.  Signs
 Pallor
 Epigastric mass may be palpable
 In later stages, patient may have enlarged scalene lymph
nodes, nodular liver and ascites due to metastases
 Investigation
 Iron deficiency anemia
 Barium meal shows filling defect
 Endoscopy shows mass/ulcer
 Biopsy confirms diagnosis. In case of ulcer, six biopsies
should be taken
 Treatment
 Gastrectomy (partial and complete)
 Palliative treatment

22. Hereditary hemorrhagic
telengeiectasis
 It is an autosomal dominant disease.
 Bleeding occurs from multiple
telangiectasias which consists of localized
collection of non-contractile capillaries.
Symptoms
 Recurrent
hematemesis/epistaxsis/hemoptysis

23.  Sites of telangiectasias
 Face
 Hands
 Mucous membranes of nose, oral cavity
and GIT
Investigation
 Telengiectasia may be seen in gastric
mucosa on Gastroscopy

24. Bleeeding disorders
 Causes
 A. Defects of blood vessels:
 Vascular purpura
 Hereditary hemorrhagic telengiectasia
 B. Platelet disorders
 Thrombocytopenia
 Thrombocythemia
 Thromboasthenia

25.  C. Clotting disorders
 Hereditary
 Hemophilia
 Christmas disease
 Von willebrand disease
 Acquired
 Vitamin K deficiency
 Oral anticoagulant therapy
 Advanced liver disease
 D. Consumption coagulopathy
 DIC

26. Basic investigations
 Full blood count show anemia
 Urea and electrolytes :elevated urea with
normal creatinine concentration implies
severe bleeding
 Liver function tests may show evidence of
chronic liver disease
 Prothrombin time shows bleeding
disorders and liver synthetic dysfunctions

27. Management of upper GI bleeding
 Intravenous access using one large bore cannula
 Initial clinical assessment
 Define circulatory status
 Seek evidence of liver disease
 Identify other comorbidity
 Resuscitation with crystalloids or transfusion in severe
bleeding
 Ventilation with oxygen mask
 Monitoring of B.P and urinary output
 Endoscopy should be performed within 24 hours. It is used
in treatment of bleeding from peptic ulcer using injection of
epinephrine and thermal clips.in varicial bleeding band
ligation is also done endoscopically.
 Surgery

28. History taking related to GI
bleeding
 Duration
 Episodes of hematemesis
 Quantity
 Color(coffee ground appearance)
 Blood in stools (maroon colored stools can be
present in acute severe upper GI bleeding)
 History of jaundice(cirrhosis)
 History of epigastric pain (peptic ulcer,
esophagitis, erosive gastritis)
 Weight loss (carcinoma stomach)

29. Signs in upper GI bleeding
 Anemia
 Epigastric tenderness
 Ascites
 Hepatomegaly and spleenomegaly
 Jaundice
 Palmar erythema ,dupuytren contracture,
Spider angiomas ,parotid swelling in alcoholic cirrhosis
 Gynecomastia and testicular atrophy
 Prominent abdominal veins
 Dependent edema
 Abdominal mass
 Palpable scalene, paraumblical , virchow’ lymph nodes

30. Thanks