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DISCUSS THE MANAGEMENT OF UPPER 
GASTROINTESTINAL HAEMORRHAGE 
DR BASHIR YUNUS 
SURGERY DEPARTMENT 
AKTH 
14th October 2014 
10/13/2014 1
OUTLINE 
•INTRODUCTION 
•PRINCIPLE OF 
MANAGEMENT 
•COMPLICATIONS 
•PROGNOSIS 
•CONCLUSION 
•REFERENCES 
10/13/2014 2
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. 
10/13/2014 3
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. 
10/13/2014 4
INTRODUCTION 
• modes of presentation 
– Hematemesis- 40-50% 
– Melena-70-80% 
– Hematochezia- 15-20% 
10/13/2014 5
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 
10/13/2014 6
PRINCINPLES OF MANAGEMENT 
• INITIAL ASSESSMENT 
• RESUSCITATION 
• DETERMINATION OF BLEEDING SITE 
• TREATMENT/INTERVENTION 
• PREVENTION OF RECURRENCE 
10/13/2014 7
PRINCIPLES 
Immediate Assessment 
Stabilization of hemodynamic status 
Identify the source of bleeding 
Stopping the active bleeding 
Treat the underlying 
Prevent recurrent bleeding 
10/13/2014 8
ASSESSMENT 
Patient presenting with cardiovascular 
instability requires prompt resuscitation before 
detailed history and examination to find the 
cause of bleeding and other co-morbidity 
10/13/2014 9
ASSESSMENT 
Severity of bleeding can be determined: 
• Level of consciousness - obtundation 
• Pulse rate >100bpm 
• Postural hypotension. 
• Severe blood loss—Vagal slowing of the heart 
10/13/2014 10
ASSESSING SEVERITY 
eeding 
Bleeding severity Vital Signs Blood loss (%) 
Minor Normal < 10 % 
Moderate Postural 
(Orthostatic hypotension) 
10 – 20 % 
Massive Shock 
(Resting hypotension) 
20 – 25 % 
10/13/2014 11
RESUSCITATION 
• Aggressiveness of resuscitation depends on 
the bleeding severity 
• Resuscitation is proportional to bleeding 
severity 
• Inadequate resuscitation leads to Multi-organ 
failure. 
10/13/2014 12
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 
10/13/2014 13
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. 
10/13/2014 14
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 
10/13/2014 15
HISTORY 
• COMMON CAUSES 
• Duodenal ulcer 
• Gastric ulcer 
• Stress ulcer 
• Oesophageal varices 
10/13/2014 16
HISTORY 
• LESS COMMON CAUSES 
• Oesophagitis 
• Mallory- Weiss syndrome 
• Malignant gastric tumours 
• Benign gastric tumours 
• Oesophageal ulcers or tumour 
• Para-oesophageal hiatal hernia 
10/13/2014 17
HISTORY 
• RARE CAUSES 
– Duodenal tumours 
– Aorto-enteric fistula 
– Blood dyscrasia 
– Hereditary talengiectasia 
– Angiodysplasia 
– Dieulafoy’s lesion 
10/13/2014 18
EXAMINATION 
– Pallor 
– Sweating 
– Cold extremities 
– Nostrils/ pharynx 
– Epigastric tenderness 
10/13/2014 19
EXAMINATION 
• Collapse subcutaneous veins 
• Tachycardia 
• Hypotension 
• Restlessness 
• Features of CLD, gastric ca, abdominal masses, 
10/13/2014 20
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) 
10/13/2014 21
ROCKALL’S SCORE 
10/13/2014 22
Risk category: 
High (> 5) 
Intermediate (3–5) 
Low (0–2) 
10/13/2014 23
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 
10/13/2014 24
DETERMINATION OF BLEEDING SITE 
• NG-tube aspiration 
• Endoscopy 
• Barium studies 
• Angiography 
• Tagged rbc scan 
10/13/2014 25
LOCALIZATION 
10/13/2014 26
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. 
10/13/2014 27
ENDOSCOPY 
• Diagnostic; direct visualization of source of 
bleeding 
• Therapeutic; control of active bleeding 
• To assess the prognostic indicator using the 
Forrest classification 
10/13/2014 28
Modified Forrest Classification for 
Upper GI bleeding 
10/13/2014 29
10/13/2014 30
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 
10/13/2014 31
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 
10/13/2014 32
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 
10/13/2014 33
TREATMENT 
• Non-operative 
• Operative 
10/13/2014 34
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 
10/13/2014 35
ENDOSCOPIC MODALITIES AVAILABLE FOR THE 
MANAGEMENT OF U.G.I. BLEED 
 INJECTION 
 Adrenalin 
 Fibrin glue 
 Human Thrombin 
 Sclerosants 
 Alcohol 
 THERMAL 
 Heater Probe 
 Bicap Probe 
 Gold Probe 
 Argon plasma coagulation 
 Laser therapy 
 MECHANICAL 
 Haemoclips 
 Banding 
 Endoloops 
 Staples 
 Sutures 
10/13/2014 36
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. 
10/13/2014 37
NON-OPERATIVE 
• VARICES 
• Balloon tamponade 
• Pharmacological 
• Endoscopic 
• Transjugular intrahepatic portosystemic stent-shunt (TIPSS) 
– Balloon tamponade: 
– Initially temporizing measure in all pts, now < 10% 
temporary hemostasis in 85%, near 100% re-bleed on removal 
– 20% complication rate 
Esophageal rupture, Tracheal rupture, Duodenal rupture, 
Respiratory tract obstruction, Aspiration, Tracheoesophageal 
fistula, Esophageal necrosis / ulcer 
10/13/2014 38
Sengstaken blakemore tube 
10/13/2014 39
Sengstaken blakemore tube 
10/13/2014 40
• 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. 
10/13/2014 41
• 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 
10/13/2014 42
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% 
10/13/2014 43
• Band Ligation; is efficacious and is now 
preferred to Sclerotherapy 
• Endoscopic surveillance; 
– 3 monthly for 1year then 
– 6monthly for 1year then 
– Annually 
10/13/2014 44
• TIPSS; 
– In refractory bleeding after sclerotherapy or band 
ligation. 
– A shunt is established between the portal vein and 
the right or middle hepatic vein 
10/13/2014 45
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 
10/13/2014 46
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 
10/13/2014 47
OPERATIVES 
• AIMS; 
– To stop the bleeding 
– To prevent a recurrence 
– To cure underlying cause 
10/13/2014 48
DEFINITIVE PROCEDURES 
• Peptic ulcer disease 
– Laparotomy 
– Upper mid-line incision 
– Duodenal ulcer: most common, posterior bleed; 
• longitudinal anterior duodenotomy 
• Under-run the vessel (i.e. gastroduodenal artery) using 
non-absorbable suture preferable prolene 4-O. 
• Quickest and safest operation 
10/13/2014 49
Anterior longitudinal duodenotomy 
10/13/2014 50
• Common complications 
– Re-bleeding 
– Injury to the common bile duct. 
10/13/2014 51
Gastric ulcer: 
1 
• wedge excision gastric ulcer – (always send for frozen to r/o 
cancer) 
• Under-running the vessel 
• Followed by post-OP PPI, H.P. therapy, follow-up endoscopy 
• Effective and quicker 
2 
Billroth 1 partial gastrectomy 
3 
truncal vagotomy and pyloroplasty with excision of the 
ulcer 
10/13/2014 52
vagotomy 
10/13/2014 53
vagotomy 
10/13/2014 54
• Complications 
– gastric atony, 
– alkaline reflux gastritis, 
– Dumping 
– diarrhea. 
10/13/2014 55
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) 
10/13/2014 56
VARICES 
• Surgical Shunts: 
• bleeding control rate >90% 
• No differences in survival rates: ~5%. 
• Complications; 
– Re-bleeding 
– Encephalopathy 
– Ascites 
10/13/2014 57
• 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 
10/13/2014 58
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 
10/13/2014 59
COMPLICATION OF UPPER GI BLEEDING 
• Anaemia 
• Sepsis 
• DIC 
• MODS 
10/13/2014 60
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 
10/13/2014 61
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. 
10/13/2014 62
CHALLANGES 
• ICU space limited 
– Hemodynamic instability 
– Massive 
• Delayed definitive diagnosis 
10/13/2014 63
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. 
10/13/2014 64
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 
10/13/2014 65
»THANK YOU 
10/13/2014 66

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Discuss the management of upper gastrointestinal haemorrhage

  • 1. DISCUSS THE MANAGEMENT OF UPPER GASTROINTESTINAL HAEMORRHAGE DR BASHIR YUNUS SURGERY DEPARTMENT AKTH 14th October 2014 10/13/2014 1
  • 2. OUTLINE •INTRODUCTION •PRINCIPLE OF MANAGEMENT •COMPLICATIONS •PROGNOSIS •CONCLUSION •REFERENCES 10/13/2014 2
  • 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. 10/13/2014 3
  • 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. 10/13/2014 4
  • 5. INTRODUCTION • modes of presentation – Hematemesis- 40-50% – Melena-70-80% – Hematochezia- 15-20% 10/13/2014 5
  • 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 10/13/2014 6
  • 7. PRINCINPLES OF MANAGEMENT • INITIAL ASSESSMENT • RESUSCITATION • DETERMINATION OF BLEEDING SITE • TREATMENT/INTERVENTION • PREVENTION OF RECURRENCE 10/13/2014 7
  • 8. PRINCIPLES Immediate Assessment Stabilization of hemodynamic status Identify the source of bleeding Stopping the active bleeding Treat the underlying Prevent recurrent bleeding 10/13/2014 8
  • 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 10/13/2014 9
  • 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 10/13/2014 10
  • 11. ASSESSING SEVERITY eeding Bleeding severity Vital Signs Blood loss (%) Minor Normal < 10 % Moderate Postural (Orthostatic hypotension) 10 – 20 % Massive Shock (Resting hypotension) 20 – 25 % 10/13/2014 11
  • 12. RESUSCITATION • Aggressiveness of resuscitation depends on the bleeding severity • Resuscitation is proportional to bleeding severity • Inadequate resuscitation leads to Multi-organ failure. 10/13/2014 12
  • 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 10/13/2014 13
  • 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. 10/13/2014 14
  • 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 10/13/2014 15
  • 16. HISTORY • COMMON CAUSES • Duodenal ulcer • Gastric ulcer • Stress ulcer • Oesophageal varices 10/13/2014 16
  • 17. HISTORY • LESS COMMON CAUSES • Oesophagitis • Mallory- Weiss syndrome • Malignant gastric tumours • Benign gastric tumours • Oesophageal ulcers or tumour • Para-oesophageal hiatal hernia 10/13/2014 17
  • 18. HISTORY • RARE CAUSES – Duodenal tumours – Aorto-enteric fistula – Blood dyscrasia – Hereditary talengiectasia – Angiodysplasia – Dieulafoy’s lesion 10/13/2014 18
  • 19. EXAMINATION – Pallor – Sweating – Cold extremities – Nostrils/ pharynx – Epigastric tenderness 10/13/2014 19
  • 20. EXAMINATION • Collapse subcutaneous veins • Tachycardia • Hypotension • Restlessness • Features of CLD, gastric ca, abdominal masses, 10/13/2014 20
  • 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) 10/13/2014 21
  • 23. Risk category: High (> 5) Intermediate (3–5) Low (0–2) 10/13/2014 23
  • 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 10/13/2014 24
  • 25. DETERMINATION OF BLEEDING SITE • NG-tube aspiration • Endoscopy • Barium studies • Angiography • Tagged rbc scan 10/13/2014 25
  • 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. 10/13/2014 27
  • 28. ENDOSCOPY • Diagnostic; direct visualization of source of bleeding • Therapeutic; control of active bleeding • To assess the prognostic indicator using the Forrest classification 10/13/2014 28
  • 29. Modified Forrest Classification for Upper GI bleeding 10/13/2014 29
  • 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 10/13/2014 31
  • 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 10/13/2014 32
  • 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 10/13/2014 33
  • 34. TREATMENT • Non-operative • Operative 10/13/2014 34
  • 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 10/13/2014 35
  • 36. ENDOSCOPIC MODALITIES AVAILABLE FOR THE MANAGEMENT OF U.G.I. BLEED  INJECTION  Adrenalin  Fibrin glue  Human Thrombin  Sclerosants  Alcohol  THERMAL  Heater Probe  Bicap Probe  Gold Probe  Argon plasma coagulation  Laser therapy  MECHANICAL  Haemoclips  Banding  Endoloops  Staples  Sutures 10/13/2014 36
  • 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. 10/13/2014 37
  • 38. NON-OPERATIVE • VARICES • Balloon tamponade • Pharmacological • Endoscopic • Transjugular intrahepatic portosystemic stent-shunt (TIPSS) – Balloon tamponade: – Initially temporizing measure in all pts, now < 10% temporary hemostasis in 85%, near 100% re-bleed on removal – 20% complication rate Esophageal rupture, Tracheal rupture, Duodenal rupture, Respiratory tract obstruction, Aspiration, Tracheoesophageal fistula, Esophageal necrosis / ulcer 10/13/2014 38
  • 39. Sengstaken blakemore tube 10/13/2014 39
  • 40. Sengstaken blakemore tube 10/13/2014 40
  • 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. 10/13/2014 41
  • 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 10/13/2014 42
  • 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% 10/13/2014 43
  • 44. • Band Ligation; is efficacious and is now preferred to Sclerotherapy • Endoscopic surveillance; – 3 monthly for 1year then – 6monthly for 1year then – Annually 10/13/2014 44
  • 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 10/13/2014 45
  • 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 10/13/2014 46
  • 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 10/13/2014 47
  • 48. OPERATIVES • AIMS; – To stop the bleeding – To prevent a recurrence – To cure underlying cause 10/13/2014 48
  • 49. DEFINITIVE PROCEDURES • Peptic ulcer disease – Laparotomy – Upper mid-line incision – Duodenal ulcer: most common, posterior bleed; • longitudinal anterior duodenotomy • Under-run the vessel (i.e. gastroduodenal artery) using non-absorbable suture preferable prolene 4-O. • Quickest and safest operation 10/13/2014 49
  • 51. • Common complications – Re-bleeding – Injury to the common bile duct. 10/13/2014 51
  • 52. Gastric ulcer: 1 • wedge excision gastric ulcer – (always send for frozen to r/o cancer) • Under-running the vessel • Followed by post-OP PPI, H.P. therapy, follow-up endoscopy • Effective and quicker 2 Billroth 1 partial gastrectomy 3 truncal vagotomy and pyloroplasty with excision of the ulcer 10/13/2014 52
  • 55. • Complications – gastric atony, – alkaline reflux gastritis, – Dumping – diarrhea. 10/13/2014 55
  • 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) 10/13/2014 56
  • 57. VARICES • Surgical Shunts: • bleeding control rate >90% • No differences in survival rates: ~5%. • Complications; – Re-bleeding – Encephalopathy – Ascites 10/13/2014 57
  • 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 10/13/2014 58
  • 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 10/13/2014 59
  • 60. COMPLICATION OF UPPER GI BLEEDING • Anaemia • Sepsis • DIC • MODS 10/13/2014 60
  • 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 10/13/2014 61
  • 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. 10/13/2014 62
  • 63. CHALLANGES • ICU space limited – Hemodynamic instability – Massive • Delayed definitive diagnosis 10/13/2014 63
  • 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. 10/13/2014 64
  • 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 10/13/2014 65