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    Upper Gi Bleed

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    Atul Sharma
    Upper GI bleeding is a common medical emergency that requires prompt resuscitation and treatment. The most common causes are peptic ulcer disease, erosive gastritis, and esophageal varices. Endoscopy allows for diagnosis and intervention to stop bleeding. Treatment depends on the cause but may include endoscopic methods, medications, surgery, or TIPS procedure. Complications can arise from the bleeding, resuscitation efforts, underlying diseases, or treatments. Prognosis is based on factors like the Rockall scoring system, which evaluates presentation, resuscitation, comorbidities, and underlying disease.

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    Upper Gi Bleed

    Uploaded by

    Atul Sharma
    80 views47 pages
    Upper GI bleeding is a common medical emergency that requires prompt resuscitation and treatment. The most common causes are peptic ulcer disease, erosive gastritis, and esophageal varices. Endoscopy allows for diagnosis and intervention to stop bleeding. Treatment depends on the cause but may include endoscopic methods, medications, surgery, or TIPS procedure. Complications can arise from the bleeding, resuscitation efforts, underlying diseases, or treatments. Prognosis is based on factors like the Rockall scoring system, which evaluates presentation, resuscitation, comorbidities, and underlying disease.

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    Upper Gi bleed

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    Upper GI bleeding is a common medical emergency that requires prompt resuscitation and treatment. The most common causes are peptic ulcer disease, erosive gastritis, and esophageal varices. Endoscopy allows for diagnosis and intervention to stop bleeding. Treatment depends on the cause but may include endoscopic methods, medications, surgery, or TIPS procedure. Complications can arise from the bleeding, resuscitation efforts, underlying diseases, or treatments. Prognosis is based on factors like the Rockall scoring system, which evaluates presentation, resuscitation, comorbidities, and underlying disease.

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    80 views47 pages

    Upper Gi Bleed

    Uploaded by

    Atul Sharma
    Upper GI bleeding is a common medical emergency that requires prompt resuscitation and treatment. The most common causes are peptic ulcer disease, erosive gastritis, and esophageal varices. Endoscopy allows for diagnosis and intervention to stop bleeding. Treatment depends on the cause but may include endoscopic methods, medications, surgery, or TIPS procedure. Complications can arise from the bleeding, resuscitation efforts, underlying diseases, or treatments. Prognosis is based on factors like the Rockall scoring system, which evaluates presentation, resuscitation, comorbidities, and underlying disease.

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    of 47

    UPPER GI BLEEDING

    Dr. Atul Sharma


    FCCCM Exam Student 2023
    OUTLINE

    • Treatment
    • Complications
    • Follow up
    • Prognosis
    • conclusion
    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.
    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.


    • 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)


    AETIOLOGY (COMMON CAUSES)

    1. Peptic ulcer disease


    ≥ 50% of cases

    • Duodenal ulcer
    • Gastric ulcer
    • Stomal ulcer
    AETIOLOGY (COMMON CAUSES)

    2. Erosive gastritis,
    esophagitis, duodenitis
    15-30% of cases

    Common causative factors are:


    ETOH [alcohol], ASA, NSAID’S,STEROIDS.
    AETIOLOGY (COMMON CAUSES)

    3. Esophageal and gastric varices

    10-20% of cases

    caused by portal hypertension


    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
    AETIOLOGY

    Less common Rare

    • Oesophagitis • Duodenal tumous


    • Malignant gastric tumor • Pancreatic tumors
    • Benign gastric tumors • Arterial aneurysm
    • Oesophageal ulcer • Blood dyscrasia
    • Oesophageal tumors • Hereditary telangiectasia
    • A-V malformations • Haemobilia
    MALIGNANCY

    • In 3% of cases presentation is with upper GI bleeding

    • Gastric cancer

    • Oesophageal cancer
    CLINICAL PRESENTATION

    A. Chronic upper GI bleeding


    • Anemia.
    • Weakness.
    • Fatigueness.
    • Pt :looks pale.
    • Malena.
    • Occult blood positive.
    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.
    Note: all patients should be examined for stigmata of CLD.
    •H/O drugs (NSAIDS).
    •H/O ulcers.
    •H/O alcohol abuse.
    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.
    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.
    SEVERITY
    Estimated Fluid and Blood Losses in Shock

    Class 1 Class 2 Class 3 Class 4

    Blood Loss,
    Up to 750 750-1500 1500-2000 >2000
    mL

    Blood Loss,%
    Up to 15% 15-30% 30-40% >40%
    blood volume

    Pulse Rate,
    <100 >100 >120 >140
    bpm

    Blood
    Normal Normal Decreased Decreased
    Pressure

    Respiratory Normal or
    Decreased Decreased Decreased
    Rate Increased

    Urine
    Output, 14-20 20-30 30-40 >35
    mL/h

    CNS/Mental Slightly Mildly Anxious, Confused,


    Status anxious anxious confused lethargic

    Fluid
    Crystalloid Crystalloid
    Replacement, Crystalloid Crystalloid
    and blood and blood
    3-for-1 rule
    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.
    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
    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.
    INVESTIGATIONS

    • Upper GI endoscopy.
    • Arteriography.
    • Barium swallow
    • Ultrasound
    • Lab investigations
    ENDOSCOPY

    • Most important investigation


    • For diagnosis & intervention
    • Establishes diagnosis in 90% of patients
    • Can be repeated more than once.
    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
    BARIUM SWALLOW / MEAL

    • Used when endoscopy is not available


    • Double contrast study is ideal
    • May show varices, esophagitis, peptic ulcers, gastric tumors etc
    ABDOMINAL ULTRASOUND SCAN

    • To assess both liver architecture and portal circulation


    • More widely available than Arteriography
    • Should be performed before more invasive procedures
    LAB INVESTIGATIONS

    • CBC
    • Electrolytes
    • Glucose
    • Coagulation studies
    • Liver function studies
    • Blood grouping and cross-match
    LAB INVESTIGATIONS

    • CBC, urea/creatinine, S/Electrolytes, ABGs.


    • ed urea/ creatinine in upper GI bleeding.
    • Iron deficiency anemia in chronic blood loss.
    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
    Post endoscopy treatment

    • Continuous intravenous infusion of Octretide (somatostatin analogue)

    • Proton pump inhibitors

    • H. pylori treatment may be required.


    SURGERY- PUD

    Surgical options are:


    • Truncal vagotomy & drainage
    • Highly selective vagotomy
    • Partial gastrectomy
    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
    TREATMENT
    GASTRIC EROSIONS / STRESS
    ULCERS

    • Treatment of underlying cause


    • Intraluminal antacids
    • IV proton pump inhibitors
    • Bleeding usually subsides in 24-48 hrs
    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)
    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.
    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
    TREATMENT

    • Mallory- weiss
    observe
    if persist, suture mucosal tear
    • Esophagitis
    Observe
    • Benign gastric tumors
    Excise
    • Dieulafoy’s lesion
    Endoscopic electrocoagulation, sclerotherapy
    COMPLICATIONS

    • Of presenting problem
    • Of resuscitative measures
    • Of underlying disease
    • Of treatment
    COMPLICATIONS OF
    MASSIVE HEMORRHAGE

    • Hemorrhagic shock
    • Acute renal shut down
    • MODS
    • Death
    COMPLICATIONS OF
    RESUSCITATION
    • Fluid overload
    • Pulmonary edema
    • CCF
    • Blood transfusion reaction
    • Cardiac arrest
    • Hypothermia
    • Esophageal perforation
    COMPLICATIONS OF
    UNDERLYING DISEASES

    • Rebleed in PUD & varices


    • Gastric outlet obstruction in PUD
    • Progressive CLD causing portal hypertension, ascites & coagulopathies
    COMPLICATIONS OF
    DEFINITIVE SURGERY
    • PUD
    Early & late dumping
    gastric tumors
    Iron deficiency anemia

    • Bypass procedures for portal hypertension


    mucosal ulceration
    Hepatic encephalopathy
    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
    PROGNOSIS

    Depends upon
    ROCKALL scoring system
    this includes :
    • The state / time of presentation of pt
    • energetic resuscitation
    • underlying disease
    • Co morbidities
    ROCKALL SCORING SYSTEM
    ADVERSE PROGNOSTIC FACTORS
    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.
    THANK YOU

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