This document provides an overview of upper gastrointestinal bleeding, including its causes, presentation, diagnosis, treatment, and prognosis. The most common causes are peptic ulcer disease, erosive gastritis/esophagitis, and esophageal varices. Patients may present with hematemesis, melena, or occult blood loss. Diagnosis involves history, examination, endoscopy, and other investigations. Treatment depends on the underlying cause but generally involves resuscitation, endoscopic interventions, medications, and sometimes surgery. Prognosis depends on factors like the Rockall score which considers presentation, resuscitation, comorbidities, and underlying disease.

1. UPPER GI BLEEDING
Dr. Atul Sharma
FCCCM Exam Student 2023

2. OUTLINE
• Introduction
• Aetiology
• Presentation
• Resuscitation
• Diagnosis
1. History
2. Clinical
examination
3. investigations
• Treatment
• Complications
• Follow up
• Prognosis
• conclusion

3. INTRODUCTION
• Bleeding of GIT proximal to ligament of treitz.
• Ligament of treitz- a fibromuscular band which extends from
right crus of diaphragm to duodenojejunal flexure.

4. Presents as:
• Haematemesis,, malena, hematochezia or occult blood.
• Malena can present with loss of 50-60ml of blood.
• May be acute or chronic
• 100 cases per 100,000 person per year.

5. • Accounts for 3-5% of all hospitalizations
• The incidence is 2- fold greater in males but death rate is similar
in both sexes.
• Overall mortality from acute bleeding is 20% .
• Mortality & morbidity increases as age advances (>60 yrs)

6. AETIOLOGY (COMMON CAUSES)
1. Peptic ulcer disease
≥ 50% of cases
• Duodenal ulcer
• Gastric ulcer
• Stomal ulcer

7. AETIOLOGY (COMMON CAUSES)
2. Erosive gastritis,
esophagitis, duodenitis
15-30% of cases
Common causative factors are:
ETOH [alcohol], ASA, NSAID’S,STEROIDS.

8. AETIOLOGY (COMMON CAUSES)
3. Esophageal and gastric varices
10-20% of cases
caused by portal hypertension

9. AETIOLOGY (COMMON CAUSES)
4. Mallory- Weiss syndrome
• 5% of cases
• Characterized by longitudinal mucosal tear in the
cardioesophageal region.
• Result from repeated vomitting or retching.
• Common in male alcoholic patients

10. AETIOLOGY
Less common
• Oesophagitis
• Malignant gastric tumor
• Benign gastric tumors
• Oesophageal ulcer
• Oesophageal tumors
• A-V malformations
Rare
• Duodenal tumous
• Pancreatic tumors
• Arterial aneurysm
• Blood dyscrasia
• Hereditary telangiectasia
• Haemobilia

11. MALIGNANCY
• In 3% of cases presentation is with upper GI bleeding
• Gastric cancer
• Oesophageal cancer

12. CLINICAL PRESENTATION
A. Chronic upper GI bleeding
• Anemia.
• Weakness.
• Fatigueness.
• Pt :looks pale.
• Malena.
• Occult blood positive.

13. B. Acute upper GI bleeding
• Presents as emergency with hemetemesis or malena.
• Hypovolaemia:
i. Mild: no significant hypovolaemia.
ii. Moderate: hypovolaemia which responds to volume
replacement.
iii. Severe: hypovolaemia with continued active major
bleeding making resuscitation difficult even with blood
transfusions.
These patients are difficult to manage.
Patients will show all signs of shock.

14. Note: all patients should be examined for stigmata of CLD.
• H/O drugs (NSAIDS).
• H/O ulcers.
• H/O alcohol abuse.

15. RESUSCITATION
Initial management has 4 primary goals:
1. Quick assessment with attention to hemodynamic status
2. Appropriate resuscitation (ABC) & monitoring
3. Identify major source of bleeding
4. Specific therapeutic intervention.

16. RESUSCITATION (GENERAL MEASURES)
• Airway cleared of clot.
• Oxygen inhalation.
• Maintain IV line with at least 2 wide bore
cannulae
• Sample to blood bank for cross matching.
• Class I + II hemorrhage replace with
crystalloid.
• Class III + IV hemorrhage replace with
crystalloid & blood.
• Pass NG tube for diagnostic & therapeutic
purpose.
• Catheterize the patient.
• Sedation may be needed.

17. SEVERITY
Estimated Fluid and Blood Losses in Shock
Class 1 Class 2 Class 3 Class 4
Blood Loss,
mL
Up to 750 750-1500 1500-2000 >2000
Blood Loss,%
blood volume
Up to 15% 15-30% 30-40% >40%
Pulse Rate,
bpm
<100 >100 >120 >140
Blood
Pressure
Normal Normal Decreased Decreased
Respiratory
Rate
Normal or
Increased
Decreased Decreased Decreased
Urine
Output,
mL/h
14-20 20-30 30-40 >35
CNS/Mental
Status
Slightly
anxious
Mildly
anxious
Anxious,
confused
Confused,
lethargic
Fluid
Replacement,
3-for-1 rule
Crystalloid Crystalloid
Crystalloid
and blood
Crystalloid
and blood

18. SPECIFIC MEASURES
• If stable following resuscitation, proceed for upper GI
endoscopy.
• Endoscopy ideally done within 4-24 hrs.
• If patient could not be stabilized, an emergency laparatomy
may be necessary.

19. DIAGNOSIS
History of:
• Epigastric pain or retrosternal burning
• hematemesis, melena, or hematochezia.
• Vomiting, weight loss, alteration of bowel habits.
• Aortic graft surgery
• Use of ASA, NSAID’S, steroids, alcohol addiction

20. DIAGNOSIS
Physical examination
• Vital signs may show hypotension &
tachycardia.
• Cool, clammy skin.
• Petechiael hemorrhage & purpura seen in
coagulopathy.
• Signs of chronic liver disease.
• Proper abdominal & rectal examination.

21. INVESTIGATIONS
• Upper GI endoscopy.
• Arteriography.
• Barium swallow
• Ultrasound
• Lab investigations

22. ENDOSCOPY
• Most important investigation
• For diagnosis & intervention
• Establishes diagnosis in 90% of patients
• Can be repeated more than once.

23. ARTERIOGRAPHY
• In pts who bleeds contineously & site can not be
identified.
• Has accuracy of 50-90%.
• Accuracy is increased if there is active bleeding
during investigation.
• Demonstrates bleeding of 0.5-1.0ml/min
• With technetium-labelled RBC, 0.1-0.5ml/min
• Embolisation may be done at same time

24. BARIUM SWALLOW / MEAL
• Used when endoscopy is not available
• Double contrast study is ideal
• May show varices, esophagitis, peptic ulcers, gastric tumors
etc

25. ABDOMINAL ULTRASOUND SCAN
• To assess both liver architecture and portal circulation
• More widely available than Arteriography
• Should be performed before more invasive procedures

26. LAB INVESTIGATIONS
• CBC
• Electrolytes
• Glucose
• Coagulation studies
• Liver function studies
• Blood grouping and cross-match

27. LAB INVESTIGATIONS
• CBC, urea/creatinine, S/Electrolytes, ABGs.
• ed urea/ creatinine in upper GI bleeding.
• Iron deficiency anemia in chronic blood loss.

28. TREATMENT ( PEPTIC ULCER
DISEASE)
At endoscopy
• 10ml epinephrine at ulcer base
• Thermal treatment with bipolar diathermy
• Laser photocoagulation
• Rebleed is treated similarly
• A second rebleed is treated by surgery

29. Post endoscopy treatment
• Continuous intravenous infusion of Octretide (somatostatin
analogue)
• Proton pump inhibitors
• H. pylori treatment may be required.

30. SURGERY- PUD
Surgical options are:
• Truncal vagotomy & drainage
• Highly selective vagotomy
• Partial gastrectomy

31. SURGERY - PUD
Indications for surgery are:
• Exsanguinating hemorrhage
• Visible spurting arterial bleed
• Concomitant perforation
• Pts >60 yrs, who rebleed once or need 4 units at resuscitation
or 8 units in 48 hrs
• Younger pts requiring 8 units at initial resuscitation or 12
units in 48 hrs
• Rare blood group

32. TREATMENT
GASTRIC EROSIONS / STRESS
ULCERS
• Treatment of underlying cause
• Intraluminal antacids
• IV proton pump inhibitors
• Bleeding usually subsides in 24-48 hrs

33. TREATMENT
ESOPHAGEAL VARICES
1. Endoscopic sclerotherapy
• Repeated at 3 weeks interval then 3 monthly until varices
disappear
• Some sclerosing agents are ethanolamine
oleate, sodium morrhuate, 3% tetradecyl
sulphate, absolute alcohol
2. Rubber band ligation
3. Vasoconstriction therapy (octreotide, vasopressin,
propranolol)

34. 4. Balloon tamponade: if above measures fail
Modified Sengstaken- Blakemoore tube
Minnesota tube, Linton tube, Foley catheter
• Balloon tamponade applied for 12 hrs
• Stop bleeding in 80% of cases
• Must be followed by surgery as bleeding is likely to recur after
removal.

35. SURGERY – ESOPHAGEAL
VARICES
• TIPS: in refractory bleed
Shunt established between portal vein & Rt or
middle hepatic vein
• Stapling transection of esophagus at CEJ
• Distal splenorenal shunt
• Portosystemic shunts
• Spleenectomy in hypersplenism
• Liver transplantation

36. TREATMENT
• Mallory- weiss
observe
if persist, suture mucosal tear
• Esophagitis
Observe
• Benign gastric tumors
Excise
• Dieulafoy’s lesion
Endoscopic electrocoagulation, sclerotherapy

37. COMPLICATIONS
• Of presenting problem
• Of resuscitative measures
• Of underlying disease
• Of treatment

38. COMPLICATIONS OF
MASSIVE HEMORRHAGE
• Hemorrhagic shock
• Acute renal shut down
• MODS
• Death

39. COMPLICATIONS OF
RESUSCITATION
• Fluid overload
• Pulmonary edema
• CCF
• Blood transfusion reaction
• Cardiac arrest
• Hypothermia
• Esophageal perforation

40. COMPLICATIONS OF
UNDERLYING DISEASES
• Rebleed in PUD & varices
• Gastric outlet obstruction in PUD
• Progressive CLD causing portal hypertension, ascites &
coagulopathies

41. COMPLICATIONS OF
DEFINITIVE SURGERY
• PUD
Early & late dumping
gastric tumors
Iron deficiency anemia
• Bypass procedures for portal hypertension
mucosal ulceration
Hepatic encephalopathy

42. FOLLOW-UP
• To monitor progress of non- surgical treatment
• To prepare pts for elective definitive surgery
• To look out for, and treat complications of surgery

43. PROGNOSIS
Depends upon
ROCKALL scoring system
this includes :
• The state / time of presentation of pt
• energetic resuscitation
• underlying disease
• Co morbidities

44. ROCKALL SCORING SYSTEM

45. ADVERSE PROGNOSTIC FACTORS

46. CONCLUSION
• Upper GI bleeding is not uncommon & may be life
threatening.
• Prompt intervention could be life saving.
• It require multidisciplinary approach.
• Definitive treatment depends upon the final diagnosis.

47. THANK YOU