You are on page 1of 46

UPPER

GASTROINTESTINAL
BLEEDING

Definition
• Hemorrhage in the upper
gastrointestinal tract.
• The anatomic cut-off for upper GI
bleeding is the ligament of Treitz, which
connects the fourth portion of
the duodemum to the diaphragm near
the splenic flexure of the colon.
• Common. Incidence about 300 per
100000
• Mortality 5-10% and increased in elderly

CAUSES ?

Cigarette smoking… . the ulcer occurs at a junction between different types of epithelium. In general. it occurs in the epithelium least resistant to acid damage. pylori is the most important factor in the development of peptic ulceration. other factors: NSAIDs.PEPTIC ULCERS Common sites for peptic ulcers are the first part of the duodenum and the lesser curve of the stomach. infection with H.

• malignancy in this region is uncommon. posterior duodenal ulcers tend to bleed. in contrast. • Anteriorly placed ulcers tend to perforate and. .Duodenal ulceration • Most duodenal ulcers occur in the first part of the duodenum. sometimes by eroding a large vessel such as the gastroduodenal artery.

population with gastric ulcers tends to be older age. NSAIDs and smoking are the important etiological factors in gastric ulceration. pylori. equal between the sexes. more prevalent in low socioeconomic groups.Gastric ulceration Same as with duodenal ulceration. gastric ulceration is substantially less common than duodenal ulceration. H. .

• Chronic gastric ulcers are associated with malignancy. .• Large chronic ulcers may erode posteriorly into the pancreas and. they may erode into other organs such as the transverse colon. into major vessels such as the splenic artery. on other occasions. • Less commonly.

Clinical features of peptic ulcers • • • • • Epigastric pain Periodicity Alteration in weight Bleeding Vomiting .

Complications of peptic ulceration • Perforation • Bleeding • Stenosis .

. • Fortunately.GASTRIC EROSIONS •  occurs when the mucous membrane lining the stomach becomes inflamed • Common in elderly especially those taking NSAIDs. most such bleeding settles spontaneously.

at the cardia in 90% of cases. vigorous vomiting produces a vertical split in the gastric mucosa. The condition presents with haematemesis. In only 10% is the tear in the oesophagus. immediately below the squamocolumnar junction. .MALLORY–WEISS SYNDROME In Mallory–Weiss syndrome.

it may be invisible. when not bleeding. . If it can be seen during the bleeding. The lesion itself is covered by normal mucosa and. all that may be visible is profuse bleeding coming from an area of apparently normal mucosa.DIEULAFOY’S DISEASE Is a gastric arterial venous malformation that has a characteristic histological appearance.

The vast majority of patients will have had an aortic graft It is usually secondary to an abdominal aortic aneurysm repair. . bleeding from such patients is not always massive.AORTOENTERIC FISTULA Considered in any patient with haematemesis and melena that cannot be otherwise explained. CT angiography scan typically allow the diagnosis to be made with certainty. In the endoscopy you will find nothing. although it can be.

who have undergone major surgery or who have a major comorbidity. Cushing’s ulcer: is the stress ulceration that occur in patients with head injury. Curling’s ulcer : is the stress ulceration that occur in burn patients. only 5% develop significant gastric .Other causes  Stress ulceration commonly occurs in patients who have a major injury or illness.

. NSAID 50% of patients > 60 yr presented with UGIB has history of NSAID.  Poorly controlled Anticoagulant therapy.

Signs & Symptoms of UGIB • • • • • • • • Hematemesis Melena Syncope Shock Fatigue Hematochezia Epigastric pain Weight loss .

stools. usually tarry. Coffee-ground hematemesis indicates that the blood has been in contact with gastric acid long enough to become converted from hemoglobin to methemoglobin. Melena is the passage of black. Although melena signifies a longer time within the GI tract than bright red blood. . it does not guarantee that the bleeding is from the upper tract.Hematemesis is the vomiting of blood that is either bright red or resembling coffee-ground in appearance. Usually indicates a bleeding source proximal to the ligament of treitz.

• Hematochezia is the passage of bright red blood by rectum. UGIB) . it does not specify the level within GI tract. (if profuse. Although it indicates GI bleeding.

.

alcohol • Recurrent vomiting • Burn / trauma • Liver disease . esophageal varices. hx of PUD . portal hypertension .RISK FACTORS • Aspirin / NSAIDS / anticoagulant / steroid • Cigarettes .

MANAGEMENT • Three steps: o Resuscitation o Establishment of a diagnosis o Management of specific conditions .

RESUSCITATION • • • • ABC (pulses.hypotensive & tachycardia with upper GI bleeding Two large IV lines Protect airway and give high-flow oxygen NPO: for 24 hr . Measure BP and HR) .1.

. LFT.( liver dis. …) D. B.Na.Creatinine…) C.• Draw blood samples for: A. PTT. Blood group and cross match.(13% of UGIB is secondary to liver dis.platelets…). inadequately controlled warfarin therapy…) E. PT.Urea. . KFT (K. CBC (Hb.

).. • How much to give? It depends on the patient response to resuscitation… we monitor by: 1-Insert Foley’s catheter: to monitor the urine out put hourly(discard 1st pass. • Admission (if SBP < 100 or HR >100  ICU admission). Must be >30 ml/hr . • Start blood transfusion when ready.• IV plasma expanders: Crystalloid(ringer lactate) or colloid (Hess).

• NG tube .only gastric contents  endoscopy to rule out duedonal bleeding…) .blood  upper .bile & gastric contents  not upper .

. but the perfect situation is to be done within 4 hours from stabilization. • Doing endoscopy depends on many factors: ideally should be within 24 hrs of admission. ESTABLISHMENT OF A DIAGNOSIS • After stabilization  Upper GI endoscopy.2. • Never send a patient with upper GI bleeding to endoscopy while he is hemodynamically unstable.

gastritis and a tear in the esophagus(Mallory-weiss syndrome) that follows forceful vomiting. 6. Determination of whether a lesion is benign or malignant. Determination of the size and number of lesions in most cases. 2. 4. varices. Distinction between an ulcer. Assessment of which site is actively bleeding 3. Therapeutic hemostatic procedures .Advantages of endoscopy: 1. Assessment of rate of bleeding. 5.

. The bleeding artery is the gastroduodenal artery (branch of right gastirc artery) . Inject Adrenaline: 2.MANAGEMENT OF SPECIFIC CONDITIONS 1. . Methods of stopping bleeding: 1. The bleeding stops and the patient stays 1-2 days NPO given PPI for 6 weeks. after 1-2 days the patient can eat and drink. Alcohol also stop bleeding but it cause necrosis of the duodenal wall and may lead to . Laser. BLEEDING Duodenal ulcer: . Cautery 3.

Gastric Ulcer could be MALIGNANT but looks benign. Should take biopsy to rule out malignancy . . • • BLEEDING Gastric ulcer: Same modality for treatment of doudenal ulcer but we give him PPI for 8 weeks plus eradication for H.2.pylori.

between the hepatic vein and portal vein which will treat the portal hypertension . 1) Injection sclerotherapy : “ethanolamine or Tetradecaylsulfate.” 2) Rubber band ligation : by endoscope 3) Transjugular intrahepatic portosystemic shunt (TIPSS) : the shunt inserted using fluoroscopic or Ultrasonography guidance through IJV and SVC .3. . • ESOPHAGEAL VARICES High mortality and morbidity and high recurrence rate.

4) Blakemore Sengstaken (Manisota) tube : A tube which has 4 lumens labeled EI : Esophageal inflation EA : Esophageal aspiration GI : Gastric inflation GA : Gastric aspiration Insert the tube through the mouth. . By EA we aspirate esophageal blood the by EI inflate by air (not saline) and monitor the pressure not to be more than 35 mmHg . if the bleeding continue .. we pull the tube from the mouth so the GI part will press at the gastric element of Gastro-esophageal varices. then by GI inflate by 250 ml saline. by GA aspirate the gastric blood.

.

5) Gastric deconnection. 6) Gastric transection .

GASTRIC EROSIONS • Treatment is conservative Nil by mouth IV H2 blocker or proton pump inhibitor. Total gastrectomy for persistent bleeding “high mortality” .4.

MALLORY-WEISS TEAR • Conservative. blood transfusion if needed. .5. local injection of adrenaline If bleeding persist do LaparotomyDirect suturing. NPO.

6. Vascular malformations “Dieulafoy’s disease”  Endoscopic hemostasis. ◦ Adrenaline injection . heater probe. electrocoagulation. injection sclerotherapy. laser photocoagulation .

Portal hypertensive gastropathy • one in seven patients with portal hypertensive gastropathy will develop bleeding • Treatment : Electrocautery . cryotherapy by endoscope TIPSS .7.

HEMODYNAMICALLY UNSTABLE PATIENT In the cases of giving the pt blood and no improvement or in cases of significant rebleeding Indication for surgery depends on age 1. In bleeding DU. <60 years if needs > 6 units of blood  Emergency surgery ◦. >60 years if needs > 4 units of blood 2. open the duodenum and do “ figure of eight stitch” .

.

surgery is always recommended • However . the morbidity and mortality of treated AEF is also high 75% .Aorto-enteric fistula • Aortic aneurysm graft • Any pt who has upper GI bleeding and a history of aortic surgery suspect aorto-duodenal fistula • Because of high morbidity and mortality associated with AEF .

stigmata of acute bleeding) . from upper GI haemorrhage • It uses clinical criteria (increasing age. i. co-morbidity. shock) as well as endoscopic finding (diagnosis.e. death.ROCKALL’S RISK SCORE • Score that predicts poor prognosis.

disseminated malignancy . any major comorbidity All other diagnosis Malignant lesion of UGIT Blood in the UGIT.Variable Score 0 1 2 Age (years) <60 60-79 >80 Shock “No shock” “Tachycardia”. adherent clot. visible or spurting vessel 3 Renal failure. no lesion identified and no SRH/blood Major SRH ( ) None or dark spot only Stigmata of recent heamorrhage Cardiac failure. “Hypotension” < 100 > 100 > 100 > 100 < 100 Pulse rate SBP (mmHg) Comorbidity No Diagnosis Mallory-Weiss tear. ischaemic heart disease. liver failure.

1 47.2 5 14.2 2 4 17.Score of Total% Rebleeding Death 0 5.6 19.9 7.9 6 9.7 39.8 8< 5.5 16.1 .2 0 2 12.8 13.4 15.8 5 0.9 12.4 29.1 7 8 39.9 0 1 11 3.8 4.3 3 15.6 4.

3 5 10.6 4 9.6 .6 7 12.Score Mean Hospital Stay (days) 0 3.1 2 6.7 1 4.8 6 10.3 Total 8.1 3 7.7 8< 15.

THANK YOU .