Upper Gastrointestinal Bleeding

UPPER
GASTROINTESTINAL
BLEEDING
Definition
Hemorrhagein theupper
gastrointestinal tract.
The anatomic cut-off for upper GI
bleeding is theligament of Treitz, which
connects the fourth portion of
theduodemumto thediaphragm near
thesplenic flexureof thecolon.
Common. Incidence about 300 per
100000
Mortality 5-10% and increased in elderly
CAUSES ?
PEPTIC ULCERS
Common sites for peptic ulcers are the first
part of the duodenum and the lesser curve of
the stomach.
In general, the ulcer occurs at a junction
between different types of epithelium, it
occurs in the epithelium least resistant to
acid damage.
infection with H. pylori is the most important
factor in the development of peptic
ulceration.
other factors: NSAIDs, Cigarette smoking
Duodenal ulceration
Most duodenal ulcers occur in the first
part of the duodenum.
Anteriorly placed ulcers tend to
perforate and, in contrast, posterior
duodenal ulcers tend to bleed,
sometimes by eroding a large vessel
such as the gastroduodenal artery.
malignancy in this region is
uncommon.
Gastric ulceration
Same as with duodenal ulceration, H. pylori,
NSAIDs and smoking are the important
etiological factors in gastric ulceration.
gastric ulceration is substantially less
common than duodenal ulceration.
equal between the sexes.
population with gastric ulcers tends to be
older age.
more prevalent in low socioeconomic
groups.
Large chronic ulcers may erode

posteriorly into the pancreas and, on
other occasions, into major vessels
such as the splenic artery.
Less commonly, they may erode into
other organs such as the transverse
colon.
Chronic gastric ulcers are associated
with malignancy.
Clinical features of
peptic ulcers
Epigastric pain
Periodicity
Alteration in weight
Bleeding
Vomiting
Complications of
peptic ulceration
Perforation
Bleeding
Stenosis
GASTRIC EROSIONS
occurs when themucous
membranelining
thestomachbecomes inflamed
Common in elderly especially those
taking NSAIDs.
Fortunately, most such bleeding
settles spontaneously.
MALLORYWEISS SYNDROME
In MalloryWeiss syndrome, vigorous
vomiting produces a vertical split in
the gastric mucosa, immediately below
the squamocolumnar junction.
at the cardia in 90% of cases.
In only 10% is the tear in the
oesophagus.
The condition presents with
haematemesis.
DIEULAFOYS DISEASE
Is a gastric arterial venous malformation
that has a characteristic histological
appearance.
The lesion itself is covered by normal
mucosa and, when not bleeding, it may be
invisible.
If it can be seen during the bleeding, all that
may be visible is profuse bleeding coming
from an area of apparently normal mucosa.
AORTOENTERIC FISTULA
Considered in any patient with haematemesis
and melena that cannot be otherwise
explained.
bleeding from such patients is not always
massive, although it can be.
The vast majority of patients will have had an
aortic graft
It is usually secondary to an abdominal aortic
aneurysm repair.
CT angiography scan typically allow the
diagnosis to be made with certainty.
In the endoscopy you will find nothing.
Other causes
Stress ulceration
commonly occurs in patients who have a
major injury or illness, who have
undergone major surgery or who have a
major comorbidity.
Curlings ulcer : is the stress
ulceration that occur in burn patients.
Cushings ulcer: is the stress
ulceration that occur in patients with
head injury.
only 5% develop significant gastric
NSAID
50% of patients > 60 yr presented
with UGIB has history of NSAID.
Poorly controlled Anticoagulant

therapy.
Signs & Symptoms of UGIB
Hematemesis
Melena
Syncope
Shock
Fatigue
Hematochezia
Epigastric pain
Weight loss
Hematemesis is the vomiting of blood that is

either bright red or resembling coffee-ground in
appearance. Usually indicates a bleeding
source proximal to the ligament of treitz.
Coffee-ground hematemesis indicates that
the blood has been in contact with gastric acid
long enough to become converted from
hemoglobin to methemoglobin.
Melena is the passage of black, usually tarry,

stools. Although melena signifies a longer time
within the GI tract than bright red blood, it does
not guarantee that the bleeding is from the
upper tract.
Hematochezia is the passage of

bright red blood by rectum. Although it
indicates GI bleeding, it does not
specify the level within GI tract. (if
profuse, UGIB)
RISK FACTORS
Aspirin / NSAIDS / anticoagulant /
steroid
Cigarettes , alcohol
Recurrent vomiting
Burn / trauma
Liver disease , hx of PUD ,
esophageal varices, portal
hypertension
MANAGEMENT
Three steps:
o Resuscitation
o Establishment of a diagnosis
o Management of specific
conditions
1. RESUSCITATION
ABC (pulses, Measure BP and HR)

- hypotensive & tachycardia with
upper GI bleeding
Two large IV lines
Protect airway and give high-flow
oxygen
NPO: for 24 hr
Draw blood samples for:

A. CBC (Hb,platelets).
B. KFT (K,Na,Urea,Creatinine)
C. LFT.(13% of UGIB is secondary
to liver dis. )
D. PT, PTT.( liver dis. , inadequately
controlled warfarin therapy)
E. Blood group and cross match.
IV plasma expanders:
Crystalloid(ringer lactate) or colloid
(Hess).
Admission (if SBP < 100 or HR
>100
ICU admission).
Start blood transfusion when ready.
How much to give? It depends on the
patient response to resuscitation
we monitor by:
1-Insert Foleys catheter: to monitor
the urine out put hourly(discard 1st
pass..). Must be >30 ml/hr
NG tube
- blood upper
- bile & gastric contents not upper
- only gastric contents endoscopy
to rule out duedonal bleeding)
2. ESTABLISHMENT OF
A DIAGNOSIS
After stabilization Upper GI endoscopy.
Never send a patient with upper GI
bleeding to endoscopy while he is
hemodynamically unstable.
Doing endoscopy depends on many
factors: ideally should be within 24 hrs of
admission, but the perfect situation is to
be done within 4 hours from stabilization.
Advantages of
endoscopy:
1. Determination of the size and number of

lesions in most cases.
2. Assessment of which site is actively
bleeding
3. Assessment of rate of bleeding.
4. Distinction between an ulcer, varices,
gastritis and a tear in the
esophagus(Mallory-weiss syndrome) that
follows forceful vomiting.
5. Determination of whether a lesion is
benign or malignant.
6. Therapeutic hemostatic procedures
MANAGEMENT OF
SPECIFIC CONDITIONS
1. BLEEDING Duodenal ulcer:
. The bleeding artery is the gastroduodenal
artery (branch of right gastirc artery)
. Methods of stopping bleeding:
1. Inject Adrenaline:
2. Cautery
3. Laser.
. The bleeding stops and the patient stays 1-2

days NPO given PPI for 6 weeks, after 1-2 days
the patient can eat and drink.
. Alcohol also stop bleeding but it cause
necrosis of the duodenal wall and may lead to
2.
BLEEDING Gastric ulcer:

Same modality for treatment of
doudenal ulcer but we give him PPI
for 8 weeks plus eradication for
H.pylori.
Gastric Ulcer could be MALIGNANT
but looks benign. Should take
biopsy to rule out malignancy .
3.
ESOPHAGEAL VARICES
High mortality and morbidity and high

recurrence rate.
1) Injection sclerotherapy :
ethanolamine or Tetradecaylsulfate.
2) Rubber band ligation : by endoscope
3) Transjugular intrahepatic portosystemic shunt (TIPSS) : the shunt
inserted using fluoroscopic or
Ultrasonography guidance through IJV
and SVC , between the hepatic vein
and portal vein which will treat the
portal hypertension .
4) Blakemore Sengstaken (Manisota)

tube : A tube which has 4 lumens
labeled
EI : Esophageal inflation
EA : Esophageal aspiration
GI : Gastric inflation
GA : Gastric aspiration
Insert the tube through the mouth, by GA aspirate
the gastric blood, then by GI inflate by 250 ml
saline, we pull the tube from the mouth so the
GI part will press at the gastric element of
Gastro-esophageal varices, if the bleeding
continue ..
By EA we aspirate esophageal blood the by EI
inflate by air (not saline) and monitor the
pressure not to be more than 35 mmHg .
5) Gastric deconnection.
6) Gastric transection
4.
GASTRIC EROSIONS
Treatment is conservative
Nil by mouth
IV H2 blocker or proton pump inhibitor.
Total gastrectomy for persistent
bleeding high mortality
5. MALLORY-WEISS TEAR
Conservative, NPO, blood transfusion
if needed, local injection of
adrenaline
If bleeding persist do LaparotomyDirect suturing.
6. Vascular malformations
Dieulafoys disease
Endoscopic hemostasis.
Adrenaline injection ,
electrocoagulation, injection
sclerotherapy, heater probe,
laser photocoagulation
7. Portal hypertensive
gastropathy
one in seven patients with portal
hypertensive gastropathy will
develop bleeding
Treatment :
Electrocautery , cryotherapy by
endoscope
TIPSS
HEMODYNAMICALLY
UNSTABLE PATIENT
In the cases of giving the pt blood and
no improvement or in cases of
significant rebleeding
Indication for surgery depends on age
1. >60 years if needs > 4 units of blood
2. <60 years if needs > 6 units of blood
Emergency surgery
. In bleeding DU, open the duodenum and
do figure of eight stitch
Aorto-enteric fistula
Aortic aneurysm graft
Any pt who has upper GI bleeding and
a history of aortic surgery suspect
aorto-duodenal fistula
Because of high morbidity and
mortality associated with AEF , surgery
is always recommended
However , the morbidity and mortality
of treated AEF is also high 75%
ROCKALLS RISK SCORE

Score that predicts poor prognosis,
i.e. death, from upper GI
haemorrhage
It uses clinical criteria (increasing
age, co-morbidity, shock) as well as
endoscopic finding (diagnosis,
stigmata of acute bleeding)
Variable
Score
0
Age (years)
<60
60-79
>80
Shock
No shock
Tachycardia,
Hypotension
< 100
> 100
> 100
> 100
< 100
Pulse rate
SBP (mmHg)
Comorbidity
No
Diagnosis
Mallory-Weiss tear,
no lesion identified
and no SRH/blood
Major SRH
(
)
None or dark spot

only
Stigmata of recent heamorrhage
Cardiac failure, ischaemic

heart disease, any major
comorbidity
All other
diagnosis
Malignant lesion of UGIT
Blood in the UGIT,

adherent clot, visible or
spurting vessel
Renal failure, liver

failure, disseminated
malignancy
Score
of Total%
Rebleeding
Death
5.6
4.9
11
3.2
12.8
0.3
15.9
12.2
17.8
13.8
4.2
14.5
16.9
7.9
9.4
29.4
15.1
39.6
19.8
8<
5.1
47.7
39.1
Score
Mean Hospital Stay

(days)
3.7
4.1
6.1
7.6
9.3
10.8
10.6
12.7
8<
15.3
Total
8.6
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Upper Gastrointestinal Bleeding

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Upper Gastrointestinal Bleeding

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UPPER

Large chronic ulcers may erode

Poorly controlled Anticoagulant

Signs & Symptoms of UGIB

Hematemesis is the vomiting of blood that is

Melena is the passage of black, usually tarry,

Hematochezia is the passage of

ABC (pulses, Measure BP and HR)

Draw blood samples for:

1. Determination of the size and number of

. The bleeding stops and the patient stays 1-2

BLEEDING Gastric ulcer:

High mortality and morbidity and high

4) Blakemore Sengstaken (Manisota)

ROCKALLS RISK SCORE

None or dark spot

Stigmata of recent heamorrhage

Cardiac failure, ischaemic

Malignant lesion of UGIT

Blood in the UGIT,

Renal failure, liver

Mean Hospital Stay

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