2. 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
3.
4. Initial Assessment and Resuscitation
History and Physical Examination
Assessment of the bleeding source
Differential Diagnosis
Investigations
Management
◦ Conservative
◦ Therapeutic
5. Airway, Breathing and Circulation
Vital Signs:
◦ Pulse, BP, Temperature, Respiratory
Rate
Fluid and Resuscitation Plan
◦ Co-morbidities
6. 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%
Pulse Rate,
bpm
<100 >100 >120 >140
Blood
Pressure
Normal Normal Decreased Decreased
Respiratory
Rate
Normal or
Increased
Decreased Decreased Decreased
Urine
Output,
mL/h
14-20 20-30 30-40 >35
CNS/Mental
Status
Slightly
anxious
Mildly
anxious
Anxious,
confused
Confused,
lethargic
Fluid
Replacement,
3-for-1 rule
Crystalloid Crystalloid
Crystalloid
and blood
Crystalloid
and blood
Ref: Sleisinger and Fordtrans Gastrointestinal and Liver disease
7. 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
8. 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
9. Anticoagulation (warfarin/heparin)
Use 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
23. 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
24. 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
25.
26. 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
27. 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.
36. 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.
37. 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
Oneofthecriteriausedtodeterminetheneedforsurgicalinterventionis
thenumberofunitsoftransfusedbloodrequiredtoresuscitatethepatient.
Themoreunitsrequired,thehigherthemortalityrate(Larson,1986).
Operativeinterventionisindicatedoncethebloodtransfusionnumber
reachesmorethan5units,asnotedinthefollowingtable(Larson,1986).
NumberofUnits
Transfused
Needfor
Surgery,%
Mortality
Rate,%
0 4 4
1-3 6 14
4-5 17 28
>5 57 43
42. 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
43. 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. 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
47. 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.
48.
49.
50.
51. 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
52. 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
53.
54. 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) 1
Presentation with melaena 1
Presentation with syncope 2
Hepatic disease 2
Cardiac failure 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
55. 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
56. 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.
