3. INTRODUCTION
• The gastrointestinal
tract extend from the
mouth to the anus and
divided into two parts;
• Upper GIT
• Lower GIT
• By the ligament of treitz
at the duodenojejunal
junction.
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4. INTRODUCTION
• The part above the ligament is the upper GI
Definition:
Any bleeding from GI tract proximal to
ligament of treitz.
It is a common cause of emergency hospital admission
and accounts for 5-10% mortality which increase in
the elderly.
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6. INTRODUCTION
• Hematemesis Vomiting of fresh or old blood
(40-50%) Proximal to Treitz ligament
Bright red blood = significant bleeding
Coffee ground emesis = no active bleeding
• Melena Passage of black & foul-smelling stools
(70-80%) Usually upper source – may be right colon
• Hematochezia Passage of bright red blood from rectum
(15-20%) If brisk & significant → UGI source
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7. PRINCINPLES OF MANAGEMENT
• INITIAL ASSESSMENT
• RESUSCITATION
• DETERMINATION OF BLEEDING SITE
• TREATMENT/INTERVENTION
• PREVENTION OF RECURRENCE
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8. PRINCIPLES
Immediate Assessment
Stabilization of hemodynamic status
Identify the source of bleeding
Stopping the active bleeding
Treat the underlying
Prevent recurrent bleeding
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9. ASSESSMENT
Patient presenting with cardiovascular
instability requires prompt resuscitation before
detailed history and examination to find the
cause of bleeding and other co-morbidity
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10. ASSESSMENT
Severity of bleeding can be determined:
• Level of consciousness - obtundation
• Pulse rate >100bpm
• Postural hypotension.
• Severe blood loss—Vagal slowing of the heart
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12. RESUSCITATION
• Aggressiveness of resuscitation depends on
the bleeding severity
• Resuscitation is proportional to bleeding
severity
• Inadequate resuscitation leads to Multi-organ
failure.
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13. RESUSCITATION
• Ensure a patent airway and breathing.
• Elevate foot of bed to about 15⁰
• Secure IV access, take samples; PCV, U/Ecr, GXM, Platelet
count, LFT.
• IV crystalloid, N/S R/L 1L over 30-45min
• Pass urethral catheter, empty the bladder then monitor urine
output. (0.5-1ml/kg/min)
• Reassess PR,BP,CVP, urine output, to determine the rate of
infusion
• Supplemental Oxygen---enhances oxygen carrying capacity of
blood
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14. RESUSCITATION
• Pass N-G tube-
– Decompression, prevent aspiration
– Cold saline lavage
• Transfuse;
– significant blood loss or pcv <30
– on going bleeding,
– inadequate response to fluid resuscitation,
– elderly and
– presence of cardiopulmonary disease
• Sedation
– Phenobarb to quieten patient.
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15. HISTORY
• History to find the cause, co-morbidity and
character(onset, volume and frequency) of
bleeding. Careful history and physical
examination may yield no definitive cause in
50%.
– HX of PUD
– Alcohol ingestion
– NSAID
– Dysphagia
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16. HISTORY
• COMMON CAUSES
• Duodenal ulcer
• Gastric ulcer
• Stress ulcer
• Oesophageal varices
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17. HISTORY
• LESS COMMON CAUSES
• Oesophagitis
• Mallory- Weiss syndrome
• Malignant gastric tumours
• Benign gastric tumours
• Oesophageal ulcers or tumour
• Para-oesophageal hiatal hernia
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20. EXAMINATION
• Collapse subcutaneous veins
• Tachycardia
• Hypotension
• Restlessness
• Features of CLD, gastric ca, abdominal masses,
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21. RISK SCORING
• ROCKALL’S RISK SCORE
• Score that predicts poor prognosis, i.e.
rebleeding and mortality from upper GI
haemorrhage
• It uses clinical criteria (increasing age, co-morbidity,
shock) as well as endoscopic finding
(diagnosis, stigmata of spontaneous
haemorrhage -SSH)
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24. MANAGEMENT AS PER RISK
• Low risk (0-2);usually 80% of patients recovers
spontaneously with medical treatment(PPI) +
hospitalization for 24hrs and may be discharge
if uneventful.
• Intermediate risks(3-5); same treatment +
hospitalization for at least 72 hrs.
• High risk(>5); same treatment +
hospitalization in ICU
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27. N-G TUBE ASPIRATION
Nasogastric aspiration with saline lavage is
beneficial
• to detect the presence of intragastric blood,
• to determine the type of gross bleeding,
• to clear the gastric field for endoscopic
visualization
• to prevent aspiration of gastric contents.
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28. ENDOSCOPY
• Diagnostic; direct visualization of source of
bleeding
• Therapeutic; control of active bleeding
• To assess the prognostic indicator using the
Forrest classification
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31. BARIUM MEAL
• In the absence of endoscopy, barium is
attempted. It may show ulcer craters, varices,
filling defect or tumors in the stomach.
• Double contrast is preferred; it shows small
ulcers
• Disadvantages;
– Source remains undetected in ≥ 50% of patients
– Blood clot obscures gross lesion
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32. ANGIOGRAPHY
• It identifies the bleeding vessel
• Targeted therapy for ongoing hemorrhage;
may prevent need for surgery (with
embolization).
• Angio ≥ 1 ml/min
• Disadvantages; Invasive,expensive,requires
special expertise, exposure to radiation, risk of
contrast media–induced nephropathy,
bleeding from arterial puncture site
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33. TAGGED RBC SCAN
• Utilizes technetium labelled rbc extravasation
into bowel is detected by scintillation camera.
• RBC scan may not accurately locate bleed.
• 0.5 – 1 ml/min bleeding requirement,
set up req. 1-2 hours, test time 1-2 hours
• Contraindicated in;
– initial Hct < 24,
– hemodyn unstable patient,
– ongoing > 100-200 cc/h bleed
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35. NON OPERATIVE
Peptic ulcer disease
• Endoscopic
• PPI
• Elimination of H. pylori
• Endoscopic therapy:
– Injection of adrenaline at the base of the vessel/
Sclerotherapy
– Bipolar electro- / thermal probe coagulation
– Argon plasma / laser photocoagulation
– Hemostatic materials, including biologic glue
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37. NON-OPERATIVE
• If bleeding controlled:
• PPI- proton pump inhibitor
– omeprazole/pantoprazole, 80 mg bolus
then 8 mg/hr infusion x 24 hrs.
then 40 mg IV OD/BD
then transition to oral PPIs for 6-8 wks.
• Helicobacter pylori treatment, if present
triple drug regimen x 2-3 wks.
recurrent colonization 70-90% within few month to years.
• Repeat endoscopy < 6-8 wks.
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41. • Pharmacologic treatment :
• Vasopressin splanchnic vasoconstriction; 20IU in 250ml
of 5% DW over 30min, 4hrly. It improves hemostasis.
Telipressin (pro-drug) better hemostasis and survival
benefits. And longer duration of action.
– Side effects
• Pallor
• Hypertension
• Abdominal colic
• Cerebral and coronary ischemia
• purgation
– Nitroglycerine 40 mcg/min may be given simultaneously
to prevent coronary ischemia.
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42. • Nitroglycerine systemic hypotension and venous
pooling, counteract cardiac effects of vasopressin;
titrate to SBP 90-100.
• Glypressin; contains both nitroglycerin and
vasopressin
• Beta-Blockers: Propranolol 40 mg bd; lowers
portal pressure. Daily oral dose after bleeding has
stopped is found to stop re-bleeding in about
80%.
• Octreotide: 250 mcg bolus, 250 mcg/hr infusion;
Decreases gastric acid, pepsin, gastric blood flow
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43. Endoscopy
• Sclerotherapy;
– Ethanolamine oleate (3-5ml) or sodium morrhuate
is injected into each varies.
– If the bleeding is controlled, injection is repeated
weekly, then at 3weeks and at 3monthly until
varies obliterate.
– Use of cyanoacrylate tissue adhesive.
• Initial success rate -> 90%, re-bleed 30-50%
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44. • Band Ligation; is efficacious and is now
preferred to Sclerotherapy
• Endoscopic surveillance;
– 3 monthly for 1year then
– 6monthly for 1year then
– Annually
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45. • TIPSS;
– In refractory bleeding after sclerotherapy or band
ligation.
– A shunt is established between the portal vein and
the right or middle hepatic vein
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46. OPERATIVE
• Indications;
– Massive bleeding
– Severe haemorrhage continues or recurs/not
responsive to resuscitative efforts
– Associated perforation
– Blood not readily available
– Failure of medical therapy and endoscopic
hemostasis with persistent / recurrent bleeding
– A second hospitalization for peptic ulcer
hemorrhage
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47. OPERATIVE
• Factors predicting further bleeding from a
peptic ulcer and possible need for surgery
– Age > 60years
– Hb <8g/dl
– Shock on admission
– Visible spurting vessel on endoscopy
– Giant ulcer >2cm
– Ulcer on the posterior lesser curvature or
posterior inferior wall of the duodenal bulb
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48. OPERATIVES
• AIMS;
– To stop the bleeding
– To prevent a recurrence
– To cure underlying cause
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56. VARICES
• Surgical Shunts:
• Goal: decompression of the high-pressure
portal venous system
into a low-pressure systemic
venous system and
devascularization of the distal
esophagus and proximal stomach
• Portacaval shunt (end-to-side,
side
to side, interposition graft)
• Mesocaval shunt (Large- or small
diameter interposition graft)
• Distal splenorenal (Warren)
shunt
• Esophagogastric
devascularization,
• Esophageal transsection, &
reanastomosis
• Orthotopic liver transplantation
• Splenectomy (for splenic vein
thrombosis)
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57. VARICES
• Surgical Shunts:
• bleeding control rate >90%
• No differences in survival rates: ~5%.
• Complications;
– Re-bleeding
– Encephalopathy
– Ascites
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58. • Stress ulcers
– Numerous ulcers- vagotomy + hemi-gastrectomy
– Few - oversewn
• Mallory-Weiss syndrome
– Mucosal laceration is sutured
• Aorto-enteric fistula
– Fistula disconnected and closed
– Aorta grafted with antibiotic primed graft and covered
with omentum
– Antibiotic cover
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59. NEGATIVE LAPAROTOMY
• No lesion may be found in the eosophagus,
stomach or duodenum
• The small and larged intestined are carefully
examined for possible source of bleeding
• If negative, the abdomen is closed
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61. PROGNOSIS
• Overall mortality is 10-15%
• 33% in patient over 70years
• 70-80% of bleeding peptic ulcer stop bleeding
sponteneously
• Predictors of mortality:
– Age
– Shock
– Co-morbidities
– Delay in diagnosis
– Re-bleeding
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62. PROGNOSIS
• 20% re-bleed in 5-10years when treated
conservatively
• When treated surgically, 4.5% re-bleed in 5-
10years
• With H.pylori eradication, the re-bleeding rate
is likely to go down.
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64. CONCLUSION
• Even though 70-80% stops spontaneously,
• Bleeding frighten the patient it requires
expeditious work-up ,prompt diagnosis and
treatment.
• Accurate patient evaluation and early
resuscitation before
esophagogastroduodenoscopy (EGD) is critical
to decrease the morbidity and mortality.
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65. REFERENCES
• E.A. Badoe, E.Q. Arcampompong, J.T Rocha; “Principles and Practice of surgery
including pathology in the tropics”. 4th edition, Assembly of God Literature Center
ltd, 2009. P 637-641
• Souba, Wiley et al; “ACS Surgery principles and practice” 6th edition, WebMD Inc.
(Professional Publishing), 2007.
• Sriram Bhat M; “SRB’s Manual of surgery” . 4th edition, Jaypee brothers medical
publishers ltd, 2013.
• Mitchell S. Cappell, David Friedel,; Initial Management of Acute Upper
Gastrointestinal Bleeding: From Initial Evaluation up to Gastrointestinal Endoscopy.
Med Clin N Am 92 (2008) 491–509
• Ingrid Lisanne Holster, Ernst Johan Kuipers; Management of acute nonvariceal
upper gastrointestinal bleeding: Current policies and future perspectives. World J
Gastroenterol 2012 March 21; 18(11): 1202-1207
• Jiwon Kim; management and prevention of upper GI bleeding: Gastroenterology
and Nutrition. PSAP -VII
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