1. WELCOME TO
THE SEMINAR
SESSION
2013-2014

2. Dr.Vignesh.S
Resident of Internal Medicine
Guided by Prof.Dr.R.L.Meena
RNT Medical college and Hospital

3.  Upper GI Tract
◦ Proximal to the Ligament of Treitz
◦ 70% of GI Bleeds
 Lower GI Tract
◦ Distal to the Ligament of Treitz
◦ 30% of GI Bleeds

5. 





Initial Assessment and Resuscitation
History and Physical Examination
Assessment of the bleeding source
Differential Diagnosis
Investigations
Management
◦ Conservative
◦ Therapeutic

6. 


Airway, Breathing and Circulation
Vital Signs:
◦ Pulse, BP, Temperature, Respiratory
Rate
Fluid and Resuscitation Plan
◦ Co-morbidities

7. Estimated Fluid and Blood Losses in Shock
Class 1
Class 2
Class 3
Class 4
Blood Loss,
mL
Up to 750
750-1500
1500-2000
>2000
Blood Loss,%
blood volume
Up to 15%
15-30%
30-40%
>40%
<100
>100
>120
>140
Normal
Normal
Decreased
Decreased
Normal or
Increased
Decreased
Decreased
Decreased
14-20
20-30
30-40
Slightly
anxious
Mildly
anxious
Anxious,
confused
Crystalloid
Crystalloid
Crystalloid
and blood
Pulse Rate,
bpm
Blood
Pressure
Respiratory
Rate
Urine
Output,
mL/h
CNS/Mental
Status
Fluid
Replacement,
3-for-1 rule
>35
Confused,
lethargic
Crystalloid
and blood
Ref: Sleisinger and Fordtrans Gastrointestinal and Liver disease

8. 

Confirm the GI Bleed - Hemoptysis or
Hemetemesis ???
Manner of Presentation of a GI Bleed
◦
◦
◦
◦
◦


Hemetemesis
Malena
Hematochezia
Occult Blood loss
Symptoms of Blood loss
Is it only the GI Bleed ??
Assessment of the bleed
◦ Dizziness, Syncope, Chest Pain, SOB

9. Bleeding etiology
Leading History
Mallory-Weiss tear
Multiple Emesis before hematemesis, alcoholism
Esophageal ulcer
Dysphagia, Odynophagia, GERD,
Peptic ulcer
Epigastric pain, NSAID or aspirin use
Stress gastritis
Patient in an ICU, gastrointestinal bleeding occurring
after admission, respiratory failure, multiorgan failure
Varices, portal
gastropathy
Alcoholism, Cirrhosis
Gastric antral
vascular ectasia
Renal failure, cirrhosis
Malignancy
Recent involuntary weight loss, dysphagia, cachexia,
early satiety
Angiodysplasia
Chronic renal failure, hereditary hemorrhagic
telangiectasia
Aortoenteric fistula
Known aortic aneurysm, prior abdominal aortic
aneurysm repair

10.  Anticoagulation
 Use
(warfarin/heparin)
of Drugs
NSAIDs,Steroids,Bisphosphonates
 Similar episodes before
 H/o Jaundice in past
 H/o Abdominal Surgery
 H/o Alcoholism
 H/o Smoking or Tobacco abuse
 H/o Cocaine abuse

11.  Pt’s
Consciousness, Orientation
 Pallor, Icterus, Clubbing, Pedal
Edema
 Lymphadenopathy, JVP
 Signs of Liver Failure
 Systemic Examination
◦ Abdomen, CVS, RS, CNS

12. 





Alopecia, Pallor, Icterus, Fetor Hepaticus,
Glossitis, Parotid Swelling
Leukonychia, Clubbing, Palmar Erythema,
Dupuytren’s Contracture, Asterexis
Loss of Axillary hair, Spider naevi,
Gynaecomastia,
Ascitis, Spleenomegaly, Caput Medusae
Testicular Atrophy, Loss of Pubic Hair
Pedal Edema

16. Gynaecomastia
Ascitis

17. Special Cases
Virchow’s node
Palmar Tylosis

18. 
Major causes










Peptic ulcer disease
Esophageal and gastric varices
Hemorrhagic gastritis
Esophagitis
Duodenitis
Mallory-Weiss tear
Angiodysplasia
Upper gastrointestinal malignancy
Anastomotic ulcers (after bariatric surgery)
Dieulafoy lesion

19. 
Minor causes
 Gastric antral vascular ectasia (watermelon
stomach)
 Portal hypertensive gastropathy
 Gastric polyps
 Aortoenteric fistula
 Connective tissue disease
 Postprocedural: nasogastric tube erosions,
endoscopic biopsy, endoscopic polypectomy,
endoscopic sphincterotomy

20. Sources of Bleeding
Proportions of Patients %
Ulcers
31-67
Varices
6-39
Mallor Weiss Tears
2-8
Gastroduodenal Erosions
2-18
Erosive Oesophagitis
1-13
Neoplasm
2-8
Vascular ectasias
0-6
No source identified
5-14
Ref :Harrison Table 41-1

24. 
Massive bleeding cause significant risk for myocardial
infarction from coronary artery hypoperfusion from
hypovolemia.

It is estimated that 16% who had severe gastrointestinal
bleeding had ended up with myocardial infarction.

Patients who have myocardial infarction consequent to
massive bleeding often do not experience chest pain, or the
chest pain may be misinterpreted as epigastric pain

25. 







Complete Blood count, ESR,
Liver and Renal Function Tests, Electrolytes
Prothrombin Time and INR
BUN / Creatinine – ratio > 30 sensitivity of
68% and a specificity of 98%
Stool Occult Blood Test
Grouping and Cross Matching
ECG, Cardiac enzymes(if essential)
HIV, HbsAg, AntiHCV Markers

27. 





Explain NSP
Nil by Mouth
NG Tube insertion and Lavage
Hemodynamically Unstable – Hypotension,
Tachycardia, Postural Changes Urgent
Endoscopy
Hemodynamically Stable  Plan Early
Endoscopy
IV PPI Therapy

28. 
A grossly bloody aspirate in the atraumatic NG

intubation CONFIRMS a UGI Bleed
The type of bleed
 Red blood - active bleeding
 Coffee ground - recently active bleeding.




Continued aspiration of red blood - severe, active
hemorrhage.
Clears the field for endoscopic visualization
Prevent aspiration of gastric content
However, lavage may not be positive if bleeding has
ceased or arises beyond a closed pylorus.

32. • PPI Infusion
 IV Omeperazole 80mg bolus then 8mg/hr infusion
• Endoscopic Therapy
 Bipolar Coagulation, Heater Probe, Injection
Therapy(Absolute Alcohol, 1:10,000 epinephrine),
Hemoclips

Medical Management
◦ Antacids, H2 receptor Antagonists, PPIs,
◦ Cytoprotective Agents - Bismuth Preparations, Prostaglandin
Analogues
◦ H.Pylori Eradication

Surgical Management
◦ Duodenal Ulcer
◦ Gastric Ulcer

35. 


Primary Prophylaxis – Beta Blockade
Prevention of Rebleeding
Medical Management
◦ Vasoconstricting Agents


Baloon Tamponade – Sengstaken Blakemore
Tube
Endoscopic Management
◦ EVL, Sclerotherapy(CyanoAcrylate)

Surgical Management
◦ TIPSS, Oesophageal Transection, Suguira Procedure
◦ Liver Transplantation

37. 
A transthoracoabdominal oesophageal
transection,
◦ paraoesophageal devascularisation,
oesophageal transection and reanastomosis,
splenectomy, and pyloroplasty.

The prognosis - liver function left at the
time of operation but not on whether
operation was done as an emergency,
elective, or prophylactic measure.

38. 




Hemodynamic instability
despite vigorous
resuscitation (>6 units
transfusion)
Failure of endoscopy
Recurrent hemorrhage
after initial stabilization
Shock associated with
recurrent hemorrhage
Continued slow bleeding
with a transfusion
exceeding 3 units/day
One of the criteria used to determine the need for surgical intervention is
the number of units of transfused blood required to resuscitate the patient.
The more units required, the higher the mortality rate (Larson, 1986).
Operative intervention is indicated once the blood transfusion number
reaches more than 5 units, as noted in the following table (Larson, 1986).
Number of Units Need for Mortality
Transfused Surgery, % Rate, %
0
4
4
1-3
6
14
4-5
17
28
>5
57
43

41. 






Poor prognosis – 5yr survival rate 5%
Surgical Resection –Oesophagectomy
Radiotherapy – 5500 -6000 cGy for SCC
Chemotherapy - 1or 2 drugs mostly cisplatin
Palliative Gastrostomy, Jejunostomy
Expansive Metal Stents
Endoscopic Fulguration

42. 
Gastric Carcinoma

43. 



Distal - Subtotal Gastrectomy
Proximal – Near total Gastrectomy
Radioresistant – RT only for palliation of Pain
Chemotherapy
◦ 5FU + Leucovorin
◦ Cisplatin + Epirubicin/Docetaxel

Debulking the primary – best Palliation

44. 




Mucosal lacerations at the
gastroesophageal junction or in the cardia
of the stomach
A/w repeated retching or vomiting and are
another important cause of nonvariceal
UGIB in Alcoholics
2% to 8% of acute UGIB are secondary to
Mallory-Weiss tears
Some cases are self-limited and do not
require endoscopic hemostasis
Some cases could be severe enough to
require blood transfusions, endoscopic
hemostasis, surgery.

46. Oesophagitis
Angiodysplasia

47. 



Vascular ectasia - Angiomas, AV
malformations and Angiodysplasia
Vascular ectasias 5% to 10% of cases and
the severity - trivial to severe
Vascular ectasias a/w – Congenital, CRF.
The evidence for these associations is
limited.
Management is by endoscopic ligation,
cauterisation and sclero therapy

48. 


Dieulafoy's lesion is a rare etiology in acute UGIB
Dieulafoy's lesions are difficult to identify
endoscopically because they often retract. Their
histopathologic description is a “caliber-persistent
artery” in the submucosal tissue
On endoscopy, a Dieulafoy's lesion is akin to a
visible vessel protruding from an ulcer, yet
without an underlying ulcer.

52. 







Age > 60 yrs
Comorbidities (Renal failure, Liver failure, CHF,
Malignancy)
Variceal bleeding (as compared with nonvariceal
bleeding)
Shock or hypotension on presentation
Increasing number of units of blood transfused
Active bleeding on Endoscopy
Bleeding Ulcer of >2cm or a Spurting vessel
Need for emergency surgery

53. 







No comorbid diseases
Normal vital signs
Normal or trace positive stool guaiac
Negative gastric aspirate, if done
No problem home support
Proper understanding of signs and symptoms
of significant bleeding
Immediate access to emergent care if
needed
Follow-up arranged within 24 hr

55. 



Blood Urea(mg/dl)
◦ 6.5 - 8
2
◦ 8 - 10
3
◦ 10 - 25
4
◦ ≥25
6
Haemoglobin (g/L) for men
◦ 12-13
1
◦ 10-12
3
◦ <10
6
Haemoglobin (g/L) for
women
◦ 10-12
1
◦ <10
6
Systolic BP (mm Hg)
◦ 100–109 1
◦ 90–99
2
◦ <90
3
•Other markers
Pulse ≥100 (per min)
Presentation with melaena
Presentation with syncope
Hepatic disease
Cardiac failure
1
1
2
2
2
•scores ≥ 6 - 50% risk of needing an
intervention.
Score
Score is"0" if :
•Hemoglobin level
>12.9 g(men) or
>11.9 g(women)
•Systolic blood pressure >109 mm Hg
•Pulse <100/minute
•BUN level <18.2 mg/dL
•No melena or syncope
•No liver disease or heart failure

56. Type
Endoscopic
Characteristics
% of Bleeding
% of Mortality
1
Active Bleeding
90
11
2a
Non Bleeding Visible
vessel
50
11
2b
Adhereynt Clot
33
7
2c
Flat Pigmentation
7
3
3
Clean Base
3
2

57. 
Various Endoscopic Modalities
◦ Inj.Epinephrine,Sclerosants,Thermal Cautery,Argon
Plasma Coagulation, Electrocautery, Hemoclips,
Bands, Fibrin Glue, Thrombin




Endoscopic Sprays
Post Endoscopic PPI therapy – lowers 30 day
rebleeding rate
Second Look Endoscopy – 16-24hrs
Angioembolization – Gelatin Sponges,
Polyvinyl Alcohol, Cyano Acrylic Glues, Coils.