Upper GI bleed is an acute condition requiring immediate active intervention for resuscitation .

1. Approach to a patient
of Upper G.I. Bleed &
Its Management
Dr Rahul Singh
ADMO , LNM Rly
Hospital , Gorakhpur

2. Sources of GI Bleeding
•Upper GITract
• Proximal to the Ligament ofTreitz
•80% of acute GI Bleeds
•Lower GITract
• Distal to the Ligament ofTreitz
•20% of acute GI Bleeds

3. Ligament OfTreitz

4. Upper GI Bleeding
Upper GI bleed : Lower GI bleed = 4:1
Incidence: 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 .

5. Types Of Upper GI bleeds
VARICEAL
20% of UGI Bleeds
NON –VARICEAL
 80 % of UGI Bleeds

7. OTHER CAUSES OF UGI BLEEDING
Dieulafoy’s lesion
Gastroesophageal reflux disease
Trauma from foreign body
Esophageal ulcer
Cameron lesion
Stress ulcer
Drug induced erosions
Angioma
Watermelon stomach
Portal hypertensive gastropathy
Aorta-enteric Fistula
Radiation telangiectasis/ Enteritis
Benign tumours
Malignant tumour
Blue rubber bleb nevus syndrome
Osler-Weber- Rendu syndrome
Haemobilia
Hemosuccus pancreatitis
Infections(CMV,HSV)
Stomal ulcer
Zollinger-ellison syndrome

8. Approach in Acute GI Bleed
ImmediateAssessment & Resuscitation
Stabilization of hemodynamic status
Identify the source of bleeding
Stopping the active bleeding
Treat the underlying
Prevent recurrent bleeding

9. Immediate Assessment & Resuscitation
Assess airway , breathing and circulation ( ABCs) .
Vital Signs:
• Pulse, BP,Temperature, Respiratory Rate
Assess magnitude of bleeding .
Initiate appropriate monitoring .
History and examination .
Laboratory evaluation .

10. 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

11. 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

12. Features Hemoptysis Haematemesis
Definition Coughing out of blood Vomiting out of blood
Symptoms Symptoms of pulmonary and
CVS disease
Symptoms 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 amount
Reaction Alkaline(Blue litmus remain
unchanged)
Acidic(Blue litmus remains
unchanged

13. Laboratory Evaluation
•CBC
•Bleeding &Coagulation profile (BT, CT,PT, a PTT)
•Liver FunctionTest
•Complete S. Biochemistry
•Relevant lab test for underlying disease

15. 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.

16. General Medical Management
1.Oxygen support to prevent hypoxia of tissues
2.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 k
4.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.

17. Approach toVariceal Bleeding

19. Actively bleeding varices

20. Effective control after variceal banding

21. Variceal Bleeding
Patients 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 blockers
Chronic 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,OesophagealTransection, Suguira Procedure
• LiverTransplantation

22. BalloonTamponade -Sengstaken BlakemoreTube

23. Sengstaken BlakemoreTube

24. Surgical Alternative - Sugiura Procedure
• A transthoracoabdominal oesophageal transection
• paraoesophageal devascularisation, oesophageal transection and
reanastomosis, splenectomy, and pyloroplasty.

25. Transjugular intrahepatic portosystemic
shunt (TIPS)

27. Approach to non-variceal UGI Bleed

28. Approach to peptic ulcer bleeding

30. ENDOSCOPIC MODALITIES AVAILABLE FORTHE
MANAGEMENT OF U.G.I. BLEED
• INJECTION
• Adrenalin
• Fibrin glue
• HumanThrombin
• Sclerosants
• Alcohol
• THERMAL
• Heater Probe
• Bicap Probe
• Gold Probe
• Argon plasma coagulation
• Laser therapy
• MECHANICAL
• Haemoclips
• Banding
• Endoloops
• Staples
• Sutures

32. 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.

35. Gastric antral ulcer with a clean base

36. Duodenal ulcer with flat pigmented spots

37. Duodenal ulcer with a dense adherent clot

38. Duodenal ulcer with active spurting (arrow)

39. 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.

40. Mallory-Weiss tear at the gastroesophageal
junction

41. • 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 tears
 Angiography therapy with intra arterial infusion of vasopressin or
embolisation.
 Operative therapy with oversewing of tear.

42. 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 .

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

44. ROCKALL SCORING SYSTEM
Variable Points
0 1 2 3
Age(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 MalloryWeiss
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
-

45. Risk category:
High (> 5)
Intermediate (3–5)
Low (0–2)
Total score Mortality rate(%) Rebleeding rate(%
0 0 4.9
1 0 3.4
2 0.2 5.3
3 2.9 11.2
4 5.3 14.1
5 10.8 24.1
6 17.3 32.9
7 27.0 43.8
≥8 41.1 41.8

46. Management as per risk
• 1- Low risk(0-2)-Usually 80 % of the pt recovers
spontaneously with medicalTt( PPI)+ Hospitalisation for 24
hrs and may be discharge if uneventful.
• 2-Intermediate risk(3-5)- sameTt + Hospitilisation for at least
72 hrs.
• 3- High risk(>5%)- SameTt+ Hospitilisation in I.C.U.

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

48. TAKE HOME MESSAGE
• Early Resuscitation.
• Nasogastric wash + look forGH.
• 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.

49. THANK YOU