Upper GI Bleed
Haematemesis – vomiting blood – bright red or coffee grounds
Melaena – black motions often like tar – altered blood
Both indicate upper GI bleed
Causes:
There are many causes for upper GI hemorrhage. Causes are usually anatomically
divided into their location in the upper gastrointestinal tract.
Patients are usually stratified into having either variceal or non-variceal sources of
upper GI hemorrhage, as the two have different treatment algorithms and prognosis.
Gastric ulcer in antrum of stomach with overlying clot. Pathology was consistent with
gastric lymphoma. Reproduced with permission of patientThe causes for upper GI
hemorrhage include the following:
Esophageal causes:
Esophageal varices
Esophagitis
Esophageal cancer
Esophageal ulcers
Gastric causes:
Gastric ulcer
Gastric cancer
Gastritis
Gastric varices
Gastric antral vascular ectasia, or watermelon stomach
Dieulafoy's lesions
Duodenal causes:
Duodenal ulcer
Vascular malformations, including aorto-enteric fistulae. Fistulae are usually
secondary to prior vascular surgery and usually occur at the proximal anastomosis at
the third or fourth portion of the duodenum where it is retroperitoneal and near the
aorta.[1][2][3]
Hematobilia, or bleeding from the biliary tree
Hemosuccus pancreaticus, or bleeding from the pancreatic duct
History
Previous GI bleeds, dyspepsia, known ulcers
Known liver disease or varices
Dysphagia, vomiting, weight loss
Check drugs and alcohol consumption
Any serious co-morbidity – worse prognosis
Examination
Signs of chronic liver disease
PR to check for melaena
Is the patient shocked? Faint when sits up, peripherally cool and clammy, prolonged
capillary refill
Assess GCS
Poor urine output e.g.<25ml/h
Tachycardia (with JVP not raised)
Hypotensive or postural drop in BP
Calculate Rockall Risk Score
0 pts
Pre-endoscopy
Age
<60
Systolic BP
Sys BP <100
(shock) and
PR <100
pulse
Co-morbidity
Nil major
Post-endoscopy
Diagnosis
Recent
haemorrhage on
endoscopy
Mallory-weiss
No lesion
No recent bleed
None or dark
red spot
1 pt
2 pts
60-79
BP>100
PR>100
>80
BP<100
Cardiac failure
IHD
Renal failure
Liver failure
All other
diagnoses
Upper GI
malignancy
3 pts
Metastases
Blood in
upper GIT,
adherent clot,
visible vessel
Acute Management
Protect airway and give high flow oxygen
2 large bore IV cannulae and take blood for FBC (early blood may be normal), U+E
(high urea out of proportion to creatinine is indicative of a massive blood meal), LFT,
clotting and cross match 4-6 units
Give IV crystalloid to restore intravascular volume while waiting for blood to be
cross-matched: in dire emergency give group 0 rh –ve
Insert a urinary catheter and monitor hourly urine output
Organise CXR, ECG, check ABG
Consider CVP line to monitor and guide fluid replacement
Transfuse with cross-matched blood until haemodynamically stable
Monitor pulse, BP, CVP at least hourly
Urgent endoscopy
Inform surgeons
Further Management
Re-examine after 4 hours and give FFP if >4 units transfused
Monitor observations and urine output hourly, if stable – 4 hourly
Keep haemoglobin >10g/dl – keep 2 units in reserve
Give omeprazole 40mg IV after endoscopy (reduces risk of re-bleed and need for
surgery)
Check FBC, U+E, Clotting
Nil by mouth for 24 hrs, clear fluid after 24 hours, light diet after 48 hours as long as
no evidence of re-bleed
Endoscopy
Arrange after resuscitation, within 4 hrs of suspected variceal haemorrhage, or when
bleeding ongoing within 24 hours admission
It can identify site of bleed, estimate risk or re-bleed, administer treatment, preferably
2 of adrenaline, sclerotherapy, variceal banding or argon plasma coagulation
Endoscopic signs
Active arterial bleed, visible vessel, adherent clot/black dots
Re-bleed
40% die of complications
Identify high risk patients and monitor closely for signs of re-bleed
IV omeprazole has a preventative role
Get help – inform surgeon at once if
 Haematemasis and melaena
 Tachycardia
 Reduced CVP
 Reduced BP
 Reduced urine output
Indications for surgery
Onset of severe re-bleed despite 6U transfusion if >60 yrs
Re-bleeding
Active or uncontrollable bleed at endoscopy
Initial Rockall score>3 or final score>6
Varices
Portal hypertension causes dilated collateral veins at sites of portosystemic
anastomosis
Most commonly form in lower oesophagus but can also be found around umbilicus
(caput medusae) and in the rectum
Develop in patients with cirrhosis once portal pressure is >10mmHg
If >12mmHg, bleeding may develop- associated with mortality of 30-50 % per
episode
Other causes of portal hypertension
Pre-hepatic – portal vein thrombosis, splenic vein thrombosis
Hepatic – cirrhosis, shistosomiasis, sarcoidosis, myeloproliferative disorders
Post-hepatic – Budd-Chiari syndrome, Right heart failure, constrictive pericarditis,
veno-occlusive disorders
Suspect varices if alcohol abuse or cirrhosis – look for signs of chronic liver disease,
splenomegaly, encephalopathy, ascities, coagulopathy and thrombocytopenia
Prophylaxis
Primary – non-selective beta blockade – propranolol 40-80mg/12h po
Repeat endoscopic banding ligation
Secondary – same as above plus transjugular portosystemic shunt if resistant to
banding
Acute management of variceal bleed
Resuscitate until stable (do not give saline)
Correct clotting abnormalities with vitamin K and FFP
IV terlipressin 2mg bolus
Endoscopic banding or sclerotherapy
If bleeding uncontrolled – sengstaken-blakemore tube – balloon tamponade