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)
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
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.
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
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.
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
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
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.
