UPPER GI BLEEDING

DR IMAN NAOUFI
Epidemiology
(GI) bleeding is a common and potentially life-threatening condition
encounter in the emergency department 

Annual hospital admissions for GI bleeding in the USA and UK have

been estimated at up to 150 patients per 100000 population

mortality rate of 5%-10%

 The accurate diagnosis of GI bleeding relies on prompt resuscitation,

initial risk evaluation, provisional clinical diagnosis followed by
appropriate definitive investigation which enables specific interventions.
 DEFINITIONS

Overt (visible) = clinically evident and Acute

can present in the form of
 hematemesis,
 coffee-ground” emesis,
 melena,
 hematochezia

occult (chronic) not visible

present as Hemoccult-positive stools with or without iron deficiency anemia
Obscure
10-20% of GI bleeding
Recurrent bleeding in which a source is not identified after upper endoscopy
and colonoscopy.
Many from small intestine: “Mid-GI bleeding” (mostly from angioectasia)
Obscure bleeding may be either overt or occult
• > 50 c.c. of blood in the stomach to turn stool
(melena)
> 1000 c.c. (4 cups ) to cause hematochezia
5c.c. Of blood enough to turn toilet water bright red
• O blood or tarry stool could persist for 1-5 d after
manage the bleeding
• 2c.c. Of blood in stool necessary to produce a
+ FOBT
 GI Bleeding Defintion
o Acute < 3d

o Chronic ( present as anemia )

o Massive / sever GI bleeding

 hemodynamic instability (shock,
orthostatic hypotention , > 6% in Hct
>2 u RBC transfution
Or
 Active bleeding ( hematemesis BRB per NG or hematochezia )
 GI Bleeding Defintion
Upper vs lower
UGI Beed
Upper GI bleeding
hemorrhage originating
from the esophagus to the ligament of Treitz
Treitz

Lower GI bleeding
LGI Beed
bleeding that originates
from a site distal to the ligament of Treitz
 GI Bleeding Defintion
Recently
upper GI bleeding
has been redefined as bleeding above the ampulla of Vater
within reach of an upper endoscopy

lower GI bleeding has been further subdivided into

mid GI bleeding
coming from the small bowel between the ampulla of Vater to the
terminal ileum

lower GI bleeding
coming from the colon
 Upper GI bleeding
Epidemiology

annual incidence that ranges from 40-150 episodes per 100000 persons

morality rate of 6%-10% (Despite a decreased incidence of ulcer disease and

improvements in the management of acute upper GI bleeding )

more common in men than women

its prevalence increases with age

 Upper GI bleeding
Divided into
Variceal va non variceal
20% 80%
 Upper GI bleeding
• Etiology
Varices
Mallory Weiss
Esophagitis
Gastric Ulcer NSAID’s/
Aspirin

Neoplasm

Duodenal Acute
Ulcer Gastritis
Arterio-Venous
Malformation
 Upper GI bleeding
• Etiology
• Peptic ulcer diseases -50% Most
• Gastroesophageal varices 10-20% common

• Erosive esophagitis 14%

• Gastritis 10-25%
• Mallory Weiss tear 5%
• Vascular ectasia 1-2 %
• Malignancy – 4%
• Dieulafoy’s lesion 1-3%
• Aortoenteric fistula Rare, but cannot
miss
• Hemobilia
 Upper GI bleeding
Risk factors for ulcers and bleeding
Risk factor

H. pylori • 70-90% in non-bleeding duodenal ulcers

• Lower in bleeding ulcers and gastric ulcers

NSAIDs/ASA • Increased risk of ulcers and bleeding with

(dose dependent) doses as low as 75 mg day ASA

Corticosteroid • Little increased risk when used alone

+ NSAIDs • With NSAIDs increased risk:
• Ulcer complications – 2 x
• GI bleeding – 10 x

Oral anti- • Increased risk of bleeding vs. controls:

coagulants • Alone – 3.3
+/- NSAIDs • With NSAIDs – 12.7
 Upper GI bleeding
Clinical presentation
Hematemesis vomiting of fresh blood suggests ongoing moderate to
sever bleeding from esophagus stomach or duodenum
Coffee-ground” emesis (vomiting of dark altered blood) suggestes
more limited bleeding that may have stopped
Melena black tarry stool due to degradation of blood by intestinal
bacteria 70 – 80%
Hematochezia (passing of red blood from rectum)
15 % of pat presenting with hematochezia have an UGI source
suggests active UGB with rapid transit
Other presentations hemodynamic instability, abdominal pain
lethargy, fatigue, syncope and angina
 Upper GI bleeding

The first decision point in managing GI bleeding is

defining :

 The site

 and cause of bleeding

 Upper GI bleeding
Focused history
• Age
• Onest of bleeding
• History of prior GIB
• NSAID/aspirin use
• history of dyspepsia
• Liver disease/cirrhosis
• history of chronic alcohol use
• Vascular disease
• Aortic valvular disease,
• chronic renal failure
• AAA repair
• Radiation exposure
• Family history of GIB
• cancer
 physical examination
• Always remember to assess A,B,C’s
• Assess degree of hypovolemic shock
• Pulse and BP should be checked in supine and upright positions to note the effect
of blood loss. Significant changes in vital signs with postural changes indicate an
acute blood loss of approximately 20% or more of the blood volume
Class I Class II Class III Class IV
Blood loss (mL) 750 750-1500 1500-2000 >2000

Blood volume < 15% 15-30% 30-40% >40%

loss (%)
Heart rate <100 >100 >120 >140
SBP No change Orthostatic Reduced Very low, supine
change
Urine output >30 20-30 10-20 <10
(mL/hr)
Mental status Alert Anxious Aggressive/drows Confused/unconsciou
y s
 physical examination

Skine , lips and buccal mucosa ( finding of telangiectasias may indicate

the rare case of Osler-Weber-Rendu syndrome )

exclude nasopharyngeal bleeding

Abdominal ( tenderness , mass , ascites , splenomegaly)

Signs of chronic liver disease should be noted

Signs of tumor are uncommon but portend a poor prognosis.

 Upper GI bleeding
Do not miss digital rectal examination
Rectal examination may reduce
admissions,
endoscopies,
and medical therapy

The American Journal of Medicine, Vol 130,

No 7, July 2017
 Laboratory test

CBC HCT not reflect blood loss accurately because need 24 to 72 h to give reality
value patient bleed whole blood

PT PTT
BUN , CR (assess the patient for hemoconcentration , ratio increases (UGIB)> 36 in a
patient without renal insufficiency is suggestive of UGIB).

Type and cross match

ALT ,AST , Albumin, total protein , bilirubin
 Upper GI bleeding
Risk Stratification Assessment

• Identify patients at high risk for adverse outcomes

• Helps determine disposition (ICU vs. floor vs. outpatient)

• May help guide appropriate timing of endoscopy

• Decreased morbidity and mortality

 Upper GI bleeding
Prognostic Factors
Clinical:
¨ Haemodynamic instability
¨ Fresh red blood in the emesis
¨ Haematochezia
¨ Increasing number of units transfused
¨ Age > 60 years
¨ Co-morbidity
¨ Onset while hospitalised for other reasons
¨ Recurrent bleeding
 Upper GI bleeding
Risk Stratification Assessment
In order to stratify the risk of complications, rebleeding, need of clinical
intervention or death, several clinical scores are in use

the most frequently cited ones are the Rockall score and the Glasgow
Blatchford score (GBS).

 Rockall score, 2 components: clinical + endoscopic has been validated to

predict mortality

 GBS is based on clinical and laboratorial parameters, has been studied to

predict the need of clinical intervention.
 Upper GI bleeding ,

Glasgow Blatchford score (GBS)

• The GBS ranges from 0 to 23

• Predicts need for endoscopic

therapy

• Based on readily available clinical

and lab data
 Upper GI bleeding
Blatchford Score
• Most useful for safely discriminating low risk UGIB
patients who will likely NOT require endoscopic hemostasis
• “Fast track Blatchford” – patient at low risk if:

BUN < 18 mg/dL

Hb > 13 (men), 12 (women)
SBP >100
HR < 100
 Upper GI bleeding
Rockall Scoring System
•Validated predictor of mortality in patients with UGIB
•2 components: clinical + endoscopic
Variable 0 1 2 3
Age <60 60-79 ≥ 80
Shock No Tachycardia Hypotension-
SBP ≥ 100 SBP ≥ 100 SBP <100
P<100 P>100

Comorbidity No major Cardiac failure, CAD, Renal failure,

other major liver failure,
comorbidity malignancy

Diagnosis Mallory-Weiss tear, All other Malignancy of UGI

no lesion identified diagnoses tract
and no SRH
Major SRH None or dark spot Blood in UGI tract,
only adherent clot, visible
or spurting vessel

< 3 good prognosis

>8 high risk of mortality
 Upper GI bleeding
AIMS65
• Simple risk score that predicts length of stay, cost of
hospitalization, and in-hospital mortality

Albumin <3.0 Mortality rates

INR > 1.5 0 risk factors: 0.3%
Mental status altered 1-2 risk factors: 1-3%
3-4 risk factors: 9-15%
Systolic BP <90 5 risk factors: 25%
65+ years old
Increased score also associated with increased length of stay and
increased cost
 Upper GI bleeding
Baylor bleeding score (BBS )
predicting rebleeding ranges from 0 to 24,divided :
1) a pre-endoscopy score based on age and number and severity of concurrent
diseases
2) endoscopic score based on site and stigmata of bleeding
Pre-endoscopy score 1 2 3 4 5
Age 30-49 50-59 ≥ 80 > 70
No of illnesses 1-2 3-4 >5
Severity of illnesses No major chronic Acute2
Endoscopy Score
Site of bleed Posterior wall
bulb
Stigmata of bleeding Clot Visible Active bleeding
vessel

≥ 6 in the pre-endoscopy part and ≥ 11 in the total score have 100% sensitivity for predicting the
risk of re-bleeding ,
score of ≤ 5 before endoscopy and ≤ 10 after endoscopy are associated with low re-bleeding risk
Which patients may be evaluated as outpatients, and which
require the emergency department or hospitalization?

 Outpatient management if low-risk for rebleeding:

 Rockall score 0–2
 Glasgow–Blatchford score 0

 Inpatient management & consider admission to ICU:

 Brisk, active bleeding
 Other parameters for high risk for rebleeding, mortality
 Chronic alcoholism
 Higher Rockall or Glasgow–Blatchford score
 Endoscopy when should perform:
Endoscopy once the patient is stable is beneficial for diagnosis
and treatment

 Early endoscopy (≤24h admission)

Patients with coffee-ground vomiting , melena

 Urgent endoscopy (<12h admission)

 Haematemesis with or without melena
 Suspected variceal bleeding
Upper GI bleeding
Management