MANAGEMENT
OF
UPPER GI BLEEDING
M K ALAM MS; FRCSEd
ILOs
At the end of this presentation students will be able to:
 Define upper GI haemorrhage.
 Describe the resuscitative measures.
 Enumerate the causes of upper GI bleeding.
 Describe the symptoms & signs of UGI bleeding.
 Describe diagnostic work up.
 Describe the non-surgical management and
indications for surgical intervention.
Introduction
• UGIB is defined as bleeding derived from a
source proximal to the ligament of Treitz (D J flexure)
UGIB
• A potentially life-threatening emergency.
• A common cause of hospitalization
• More common in male.
• 4 times more common than lower GI bleeding.
• Mortality 6-10%
Mortality in UGIB
• Comorbid illness (72%) rather than actual
bleeding, is the major cause of death.
• Comorbid illness- 51% of patients.
• Rebleeding or continued bleeding- associated
with increased mortality
Causes of UGIB
• Peptic ulcer disease (duodenal & gastric ulcer)
• Oesophageal varices (portal hypertension)
• Mallory-Weiss syndrome- mucosal tears of the esophagus.
• Erosive gastritis /esophagitis.
• Dieulafoy lesion.
• Gastric cancer.
• Ulcerated gastric stromal tumor (GIST)
• Aortoenteric fistula- erosion of the aortic graft into the bowel.
• Angiodysplasia- dilated, thin-walled vessels appearing
as cherry spots
Sources of bleeding
• Arterial hemorrhage- ulcer disease, mucosal tears as in
Mallory-Weiss syndrome.
• Low-pressure venous hemorrhage, as in telangiectasias.
• Variceal hemorrhage is due to elevated portal pressure
(>12 mmHg) transmitted to esophageal and gastric
varices and resulting in rupture of varices. Mucosal
ulceration can be a bleeding source.
Peptic ulcer disease (PUD)
• The most common cause of UGIB.
• High-risk for PUD: H pylori, alcohol abuse, chronic renal failure,
and/or nonsteroidal anti-inflammatory drug (NSAID) use.
• Duodenal ulcers are more common than gastric ulcers
• Ulcer burrows deeper into the mucosa, causes weakening and
necrosis of the arterial wall, leading to a pseudoaneurysm. The
weakened wall ruptures, producing hemorrhage.
• Approximately 80% bleeding from PUD stops spontaneously.
NSAID in UGIB
• Cause gastric and duodenal ulcers by inhibiting
cyclooxygenase - ↓ mucosal prostaglandin
synthesis- results in impaired mucosal defenses.
• Daily NSAID: 40-fold increase in gastric ulcer &
8-fold increase in duodenal ulcer creation.
Bleeding Prepyloric ulcer
Oesophageal Varices
• Portal hypertension leads to portosystemic shunting.
• Development of varices- lower oesophagus and gastric fundus
• Elevated portal pressure transmitted to esophageal / gastric
varices resulting in rupture of varices.
• Mucosal ulceration can be a bleeding source.
• Normal portal pressure 5-15 cm of H₂O
• Bleeders- usually > 25 cm of H₂O
• 20 % may have peptic ulcer or gastritis
Causes of portal hypertension
• Pre-hepatic:
Congenital atresia of PV,
PV thrombosis,
Compression of PV (tumours)
• Intrahepatic:
Pre-sinusoidal- Schistosomiasis
Sinusoidal- Cirrhosis
• Post-hepatic (Post-sinusoidal):
Budd-Chiari syndrome,
Constrictive pericarditis
Bleeding Oesophageal Varices
Bleeding Oesophageal Varix
Mallory-Weiss syndrome
• Mallory-Weiss tears -15% of acute upper UGIB
• Mucosal laceration- result of forceful vomiting
• 80-90%- tear along the lesser curve of the stomach just
distal to the gastro-esophageal junction
Mallory-Weiss syndrome
Acute stress gastritis
• Seen in shock, multiple trauma, acute respiratory
distress syndrome, systemic respiratory distress
syndrome, acute renal failure, and sepsis patients.
• Predisposing conditions alter local mucosal
protective barriers, such as mucus, bicarbonate, blood
flow, and prostaglandin synthesis.
• Disruption of balance of these factors results in diffuse
gastric mucosal erosions.
• The principal mechanisms- decreased splanchnic
mucosal blood flow and altered gastric luminal acidity.
Acute stress gastritis
Dieulafoy lesion
• A vascular malformation of the proximal stomach.
• 2-5% of acute UGIB episodes.
• Endoscopic appearance: large ulcerated submucosal vessel.
• Bleeding can be massive and brisk.
• Vessel rupture occurs in the setting of chronic gastritis
• Alcohol use is associated with the Dieulafoy lesion.
• Mostly- men in their third to tenth decade.
• Can occur anywhere along the GI tract
Dieulafoy lesion
GIST (gastrointestinal stromal tumour)
• Mesenchymal tumour, submucosal lesions
• 50-60%- stomach
• 20-30%- small intestine
• 10%- rectum
• Benign or malignant (positive for c-Kit oncogene)
• Pacemaker cells in smooth muscle
• Asymptomatic, bleeding or obstruction
Bleeding GIST of the stomach
Gastric carcinoma
• Common- chronic blood loss (anaemia)
• Haematemesis- uncommon
Gastric carcinoma
Symptoms and signs
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Hematemesis
Melena
Hematochezia
Syncope
Dyspepsia
Epigastric pain
Heartburn
Diffuse abdominal pain
Dysphagia
Weight loss
Jaundice
Initial workup
• Vital signs: Pulse, BP
• CBC: WBC with differential, platelet
• Hemoglobin level
• Coagulation profile (PT, PTT, INR)
• Type and crossmatch blood
• U & E, LFTs
• Nasogastric lavage
Diagnosis
• Nasogastric lavage
• Endoscopy
• Chest radiography
• Gastrin level (Gastrinoma)
• Angiography (persistent bleeding, source not identified by endoscopy)
• CT scan & ultrasonography:
 Liver disease with cirrhosis
 Pancreatitis with pseudocyst and hemorrhage
 Aortoenteric fistula
Management: Resuscitation
• Airway + O₂
• Two peripheral IV lines
• X-match, CBC, u/e, coagulation profile, LFTs
• Crystalloid solution (RL)- 3:1 ratio
• NG tube: Gastric wash, monitor bleeding, prevent aspiration.
• Foley catheter- evaluation of urinary output.
• Peptic ulcer patients: 80 mg IV PPI.
• Endoscopic hemostatic therapy.
Endoscopic hemostatic therapy
Bleeding peptic ulcers
• Endoscopy: Diagnose + control of bleeding.
• Injection of 1:10,000 adrenaline
• Heater-probe coagulation
• Laser or bipolar electrode coagulation
• Clips or bands
Bleeding peptic ulcer
Recurrent bleeding in PUD
• A minority - recurrent bleeding after endoscopic therapy
• Risk factors for rebleeding:
Age>60 years,
Presence of shock upon admission,
Coagulopathy,
Active pulsatile bleeding,
Presence of cardiovascular disease.
• H pylori infection- recurrent bleeding is extremely low.
Indications for surgery in bleeding
peptic ulcers
• Life-threatening bleeding not responding to resuscitation.
• Failure of endoscopic hemostasis or recurrent bleeding
• Prolonged bleeding, with loss of 50% or more of the
patient's blood volume
• A second hospitalization for peptic ulcer bleeding.
• A coexisting perforation or obstruction.
• Failure of medical therapy
Management of recurrent bleeding
• Re-endoscopy to achieve hemostasis.
• Surgical management:
• Duodenal ulcer:
A) Duodenotomy+ under-run with suture + anti- ulcer medications.
B) (?) Duodenotomy+ under-run with suture + anti-ulcer surgerypyloroplasty+ bilateral truncal vagotomy
• Gastric ulcer:
Young & fit- wedge excision of ulcer.
Old & unfit- Under-run the bleeding point+ biopsy
Benign ulcer: Anti-ulcer medical treatment.
Malignant ulcer: Staging the disease, surgery if indicated.
Acute variceal bleeding- management
• Octreotide infusion- lowers portal pressure
• Endoscopic banding
• Endoscopic injection sclerotherapy
• Balloon tamponade
• TIPPS (Transjugular intrahepatic portosystemic shunting)
• SURGERY:
• Gastro-oesophageal devascularization + stapled oesophageal transection
• Liver transplantation
Sengstaken-Blakemore Tube
TIPPS
Band ligation of OV
Endoscopic sclerotherapy for OV
Prognosis
Risk factors for: Increased mortality, recurrent bleeding, the
need for endoscopic hemostasis, or surgery :
• Age >60 years
• Severe comorbidity
• Active bleeding (witnessed hematemesis,
tube, fresh blood per rectum)
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Hypotension
Blood transfusion ≥ 6 units
Inpatient at time of bleed
Severe coagulopathy
blood in nasogastric
Management of uncommon causes of UGI bleeding
• Conservative/ endoscopic management:
Mallory-Weiss syndromeErosive gastritis /esophagitis.
Dieulafoy lesion.
• Surgical management after stabilization & diagnosis:
Gastric cancer.
Ulcerated gastric stromal tumor (GIST)
Thank you!