Approach to a patient of Upper G.I. Bleed & Its

Management

Dr Rahul SinghADMO , LNM Rly

Hospital , Gorakhpur

Sources of GI Bleeding

•Upper GI Tract• Proximal to the Ligament of Treitz

•80% of acute GI Bleeds

•Lower GI Tract• Distal to the Ligament of Treitz

•20% of acute GI Bleeds

Ligament Of Treitz

Upper GI BleedingUpper GI bleed : Lower GI bleed = 4:1Incidence: 170 patients/ 100,000 population /year(usa data).40% due to peptic ulcer(Most common). 80% are self-limited.Patients on anti platelet therapy has two fold increase in

bleed as compared to normal ones .

Types Of Upper GI bleeds

VARICEAL 20% of UGI BleedsNON – VARICEAL 80 % of UGI Bleeds

OTHER CAUSES OF UGI BLEEDINGDieulafoy’s lesionGastroesophageal reflux

diseaseTrauma from foreign bodyEsophageal ulcerCameron lesionStress ulcerDrug induced erosionsAngiomaWatermelon stomachPortal hypertensive

gastropathyAorta-enteric Fistula

Radiation telangiectasis/ Enteritis

Benign tumoursMalignant tumourBlue rubber bleb nevus

syndrome Osler-Weber- Rendu

syndromeHaemobiliaHemosuccus pancreatitisInfections(CMV,HSV)Stomal ulcer Zollinger-ellison

syndrome

Approach in Acute GI BleedImmediate Assessment &

Resuscitation

Stabilization of hemodynamic status

Identify the source of bleeding

Stopping the active bleeding

Treat the underlying

Prevent recurrent bleeding

Immediate Assessment & Resuscitation

Assess airway , breathing and circulation ( ABCs) .Vital Signs:

• Pulse, BP, Temperature, Respiratory RateAssess magnitude of bleeding .Initiate appropriate monitoring .History and examination .Laboratory evaluation .

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

History to be noted• Confirm the GI Bleed - Hemoptysis or Hemetemesis ???• Manner of Presentation of a GI Bleed

• Hemetemesis• Malena• Hematochezia• Occult Blood loss• Symptoms of Blood loss

• Is it only the GI Bleed ??• Assessment of the bleed

• Dizziness, Syncope, Chest Pain, SOB

Features Hemoptysis HaematemesisDefinition Coughing out of blood Vomiting out of bloodSymptoms Symptoms of pulmonary

and CVS diseaseSymptoms of upper GI tract diseases

Content & colour Mixed with sputum &bright red in colour

Mixed with food particles & coffee-ground in colour

Premonitory symptoms Cough, salty sensation in throat

Nausea , vomiting, retching, abdominal discomfort.

Melaena Does not occur Usually followed by melaena the next day

Amount Relatively less Huge in amountReaction Alkaline(Blue litmus remain

unchanged)Acidic(Blue litmus remains unchanged

Laboratory Evaluation•CBC•Bleeding &Coagulation profile (BT, CT,PT, a PTT)

•Liver Function Test•Complete S. Biochemistry•Relevant lab test for underlying disease

General Medical Management• FLUID RESUSCITATION

• Vitals are monitored• Assessment of severity of blood loss :- An orthostatic decrease of 20

mm Hg in systolic blood pressure or increases in the pulse of 20 beats / min. indicate – 10% blood loss, if pt is pulsless and in shock- > 20% loss.

• Order hemoglobin, hematocrit, BUN, grouping and cross matching of blood.

• Insertion of central venous line may be beneficial to measure adequacy of fluid replacement and perfusion of vital organ .

• Monitor urine output.• Fluid resuscitation is done by crystalloids such as normal saline or RL

if hypoalbuminemia is detected use colloids.• Placing the patient in trendelenburg position to maintaine cerebral

blood flow.

General Medical Management1.Oxygen support to prevent hypoxia of tissues2.IV route - Crystalloid solution/Colloids | blood.3. Blood transfusion:• maintain Hct at 30% in the elderly, esp. with comorbid

diseases e.g.. CHF, CRF, IHD,COPD)• 20-25% in younger pt. • 25-28% in portal HTN• administration of vit k4.In symptomatic thrombocytopenia (<50000 )infused

platelets. 5.FFP-The transfusion of plasma should not be based solely on

the patient’s abnormal INR and/or PTT. The decision to transfuse should be based on the patient’s

clinical condition.

Approach to Variceal Bleeding

Actively bleeding varices

Effective control after variceal banding

Variceal BleedingPatients with variceal hemorrhage have poorer outcomes than patients with

other sources of UGIB .Ligation is the endoscopic therapy of choice for esophageal varices Primary Prophylaxis Non-selective beta blockersChronic therapy with beta blockers plus endoscopic ligation is recommended for

prevention of recurrent esophageal variceal bleeding.Endoscopic Management

• EVL, Sclerotherapy( CyanoAcrylate , Na morrhuate , ethanolamine ,etc)Surgical Management

• TIPSS, Oesophageal Transection, Suguira Procedure• Liver Transplantation

Balloon Tamponade -Sengstaken Blakemore Tube

Sengstaken Blakemore Tube

Surgical Alternative - Sugiura Procedure

• A transthoracoabdominal oesophageal transection• paraoesophageal devascularisation, oesophageal

transection and reanastomosis, splenectomy, and pyloroplasty.

Transjugular intrahepatic portosystemicshunt (TIPS)

Approach to non-variceal UGI Bleed

Approach to peptic ulcer bleeding

ENDOSCOPIC MODALITIES AVAILABLE FOR THE MANAGEMENT OF U.G.I. BLEED

• INJECTION• Adrenalin• Fibrin glue• Human Thrombin• Sclerosants• Alcohol

• THERMAL• Heater Probe• Bicap Probe• Gold Probe• Argon plasma coagulation• Laser therapy

• MECHANICAL• Haemoclips• Banding• Endoloops• Staples• Sutures

SECOND LOOK ENDOSCOPY

Routine second-look endoscopy is not recommended for most patients with peptic ulcer bleeding.

Typically done 24 hours after the initial endoscopy.Any persistent stigmata of haemorrhage are treated.It is beneficial in certain circumstances, especially after

injection monotherapy.

Gastric antral ulcer with a clean base

Duodenal ulcer with flat pigmented spots

Duodenal ulcer with a dense adherent clot

Duodenal ulcer with active spurting (arrow)

MALLORY WEISS SYNDROME / TEARS• Mucosal lacerations at the gastroesophageal junction or in the

cardia of the stomach• Patients generally present with hematemesis or coffee-ground

emesis after alcohol intake• Typically have a history of recent nonbloody vomiting with

excessive retching followed by hematemesis• Endoscopy usually reveals a single tear that begins at the

gastroesophageal junction and extends several millimeters distally into a hiatal hernia sac/within cardiac portion of stomach.

Mallory-Weiss tear at the gastroesophageal junction

• Occasionally, more than one tear is seen.• The bleeding stigmata of Mallory-Weiss tears can include a

clean base, oozing, or active spurting.• Bleeding stop spontaneously in 80 – 90% of the patients and

mucosa often heals within 72 hours .In 0 – 5% of the patient bleeding recurs

Endoscopic electro-coagulation of the tearsAngiography therapy with intra arterial infusion of

vasopressin or embolisation.Operative therapy with oversewing of tear.

RISK FACTORS AND RISK STRATIFICATION

• To identify patients with nonvariceal UGI bleeding at greatest risk for mortality and rebleeding.

• Pts may be categorised as low, intermediate and high risk .

Most patients need intervention if their score is 6 or higher.

ROCKALL SCORING SYSTEMVariable Points

0 1 2 3Age(yr) <60 60-79 >80 -Pulse rate <100 >100 - -Systolic BP Normal >100 <100 -Comorbidity None - IHD, Cardiac

failure.Renal failure, hepatic failure , metastatic cancer.

Diagnosis Mallory Weiss tear or no lesion observed

All other diagnosis

Malignant lesions

-

Endoscopic stigmata

No stigmata or dark spot in ulcer base

- Blood in UGI tract , visible vessel etc

-

Risk category: High (> 5)

Intermediate (3–5) Low (0–2)

Total score Mortality rate(%) Rebleeding rate(%0 0 4.91 0 3.42 0.2 5.33 2.9 11.24 5.3 14.15 10.8 24.16 17.3 32.97 27.0 43.8

≥8 41.1 41.8

Management as per risk • 1- Low risk(0-2)-Usually 80 % of the pt recovers

spontaneously with medical Tt( PPI)+ Hospitalisation for 24 hrs and may be discharge if uneventful.

• 2-Intermediate risk(3-5)- same Tt + Hospitilisation for at least 72 hrs.

• 3- High risk(>5%)- Same Tt+ Hospitilisation in I.C.U.

Angioembolization – Gelatin Sponges, Polyvinyl Alcohol, Cyano Acrylic Glues, Coils.

TAKE HOME MESSAGE• Early Resuscitation.• Nasogastric wash + look for GH.• High dose PPI therapy for at least 72 hrs.• Urgent Endoscopic therapy for mod to severe UGI

bleeding. • Combination therapy preferred along with medical

management.• Relook endoscopy should be preffered only for mod to

severe bleeding.• Pt should also be treated for specific cause/disease.

THANK YOU