Welcome to seminar presentation

Seminar topic:- Upper GI bleeding

Presented by Abere Bekalu..C-1

Sisay Markos..C-1
Bizuayehu Ayele..C-1
Venue-AMH
Moderator ; Dr. DAGNE (Urologist)

2 April 2018 By ABS 1

 out lines

* Definition
* Incidence
*Etiology
*Pt. evaluation and dx work up
*Management

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 Part-1

Definition
Etiology

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 Definition
 UGIB
• Refers tohemorrhage emanating from GIT
proximal to the ligament of Treitz.
It arises from :
 esophagus
 Stomach
 Duodenum
 Liver
 Pancrease
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 It accounts for nearly 80% of significant GI
hemorrhage.
 is a potentially life-threatening abdominal
emergency thatUlcer
remains
with activeableeding
common cause of
hospitalization

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 Incidence
 In UK  116/100,000 population
 It is estimated that 1%-2% of all medical and surgical
admissions are for GI bleeding
 The overall mortality of GI bleeding has remained at
8%-10% despite the proliferation of sophisticated
diagnostic and therapeutic techniques
 Risks for increased mortality include oid age, male
sex,CVD,DM,renal d/se or anticoagulant use.
 Bleeding from the upper GI tract is approximately 4
times as common as bleeding from the lower GI tract

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 Clinical presentation
 Hematemesis
 Grossly bloody emesis
 Coffee-ground emesis
 Melena
 Hemtochezia
 Epigastric pain Heartburn
 Diffuse abdominal pain
 Dysphagia
 Weight loss

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 Common causes of UGIB
Cause Percentage
PUD 40%
gastrites 12%
Oesophagitis 10%
Varices 5%
Mallory-Weiss tear 5%
Erosive disease 6%
Malignancy 4%
Others 18%
Surgery international Vol- ,2003.
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 Cont…
condition percentage

Ulcers 60
-esophageal 6
-gastric 21
-duodenal 33
Erosions 26
-esophageal 13
-gastric 9
-duodenal 4

Mallory-Weis Tear 4

Esophageal Varices 4

Tumors 0.5

Vascular Lesions 0.5

Others 5

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 Rare causes of UGIB
 Vascular malformation
 Deulafoy lesion
 Aortoenteric fistula
 Hemobilia
 Hemosuccus pancreaticus
 Pseudoaneurysm(chronic pancreatitis)
 Portal hypertensive gastropathy

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 Peptic ulcer disease

 Peptic ulcers are localized erosions of the mucosal

lining of the digestive tract.
 Ulcers usually occur in the stomach or duodenum.
Breakdown of the mucosal lining results in damage to
blood vessels, causing bleeding
 Location:- DUpost.wall of duodenal bulb
GUalong the lesser curvature
 the most common cause of UGIB

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 Risks for PUD include those with a history of
alcohol abuse, chronic renal failure, and/or
nonsteroidal anti-inflammatory drug (NSAID)
use.
 is strongly associated with Helicobacter pylori
infection.

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 gastritis
 General inflammation of the stomach lining, which
can result in bleeding.
 It results from an inability of the gastric lining to
protect itself from the acid it produces. Causes of
gastritis include
 NSAIDs or nonsteroidal anti-inflammatory drugs,

like ibuprofen and aspirin

 steroids,

 alcohol,

 burns, andtrauma.

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 Esophageal erosions and ulcers

 Most ulcers found in the presence of Barrett’s

epithelium
 Ulcers are usually located at the junction of
sq.epith. & the proximal extent of metaplastic
columnar epith.
 When hemorrhage is associated with reflux
esophagitis, it is almost always self-limited

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 Varices
 Swelling of the veins of the esophagus or
stomach usually resulting from liver disease.
Varices most commonly occur in
alcoholic liver cirrhosis. When varices bleed,
the bleeding can be massive, catastrophic and
occur without warning.

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 Sites of portosytemic collaterals

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 The extrahepatic portal venous
circulation

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 pathogenesis
 Incompletely understood
 Varices do not develop until portal pressure exceeds 12 mmHg (Normal=5-
10mmHg)
 Polio & Groszmannhypothesis based on
La Place’s Law

 But all these parameters can not be measured clinically ,but Endoscopic
classification schemes that consider size of varices & character such as
cherry-red spots & red wale markings, which are related to thickness of
the overlying epithelium, have improved the predictability of Variceal
bleeding.

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 Mallory-Weiss tear
 A tear in the esophageal or stomach lining,
often as a result of vomiting or retching.
Mucosal tears also can occur afterseizures,
forceful coughing or laughing, lifting,
straining, or childbirth. Physicians often find
tears in people who have recently binged on
alcohol.

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 Malignancy
 One of the earliest signs of esophageal or
stomach cancers may be blood in the vomit or
stool
 Usually present with anemia & occult bleeding
 Gastric neoplasm may be complicated by acute
bleeding due to central tumor necrosis

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 Vascular malformations
 Account for 2-4% of upper GIB
 Typically found in elderly
 Some are congenital
 Bleeding occurs when the lesion is abraded by
food in transit
 Most are amenable to endoscopic ablation
 Surgical resection for large lesions/diffusely
involving the mucosa
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 Deulafoy’s lesion

 Is an abnormally large submucosal artery in

the stomach
 Etiology unknown
 ~ 80% found within 6cm of the GE-junction
 Bleeding is intermittent & brisk

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 Part-2

Pt. evaluation & dx work up

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 History
 Physical examination
 Investigations

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 The history and physical examination of the
patient provide crucial information for the
initial evaluation of persons presenting with a
GI tract hemorrhage
 Important information to obtain includes
potential comorbid conditions, medication
history, and potential toxic exposures, as well
as the severity, timing, duration, and volume of
the bleeding.
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 History findings include weakness, dizziness,
syncope associated with hematemesis (coffee
ground vomitus), and melena (black stools
with a rotten odor).

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 history
*history of prior GIB
*NSAD use, history alcoholism, smoking
*Liver disease
*Vascular d/se
*Aortic valvular d/se
*Radiation exposure
*Localizing symptoms & family history
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 P/E
*Vital signs ,orthostatics;pulse rate & BP
*Pallor ,cold extremities
*skin,oral exam
*stigmata of liver d/se
*Adominal exam; GI-malignancy, ascites, cutaneous
signs of portal HTN.
*DRE
- objective description of stool
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- ascess for mass,hemorrhoids
Laboratory investigations
 CBC; Hgb,Hct,Pt count,WBC…
 Increase in BUN:Creatinine ratio:- The BUN-to-
creatinine ratio increases with UGIB. A ratio of
greater than 36 in a patient without renal
insufficiency is suggestive of UGIB.
 LFT

 Stool test for occult blood (Guaiac test)

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 Laboratory …
 Coagulation profile:
 A platelet count of less than 50 with active acute hemorrhage
requires a platelet transfusion and fresh frozen plasma
 The coagulopathy could be a marker for advanced liver
disease.
 The PT is used in calculating the Child-Pugh score
Prolongation of the PT based on an INR of more than 1.5 may
indicate moderate liver impairment.
 A fibrinogen level of less than 100 mg/dL also indicates
advanced liver disease with extremely poor synthetic function.

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 Upper GI-Endoscopy

 Establish the cause of bleed

(variceal Vs peptic ulceration)
 Enable endoscopic haemostatic intervention
 Identify stigmata of recent hemorrhage

 Pt should be hemodynamically stabilized & the stomach evacuated of clots

with large-bore lavage tube

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 Modified Forrest classification for UGIH

Class Endoscopic findings Re-bleeding

(bleeding stigmata) rate(%)
Ia Spurting arterial vessel 80-90
Ib Oozing hemorrhage 10-30
IIa Non-bleeding visible vessel 50-60
IIb Adherent clot 25-35
IIc Ulcer base with black spot sign 0-8
III Clean base
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0-12 34
Arteriography (celiac axis angiography)
 Endoscopy unavailable/non-revealing
 Angiodysplastic lesions & AVM can be diagnosed in the
absence of bleeding
 Contrast unlikely to be seen if bleeding <0.5ml/min

UGI-Barium radiography
 For chronic & intermittent bleeding
 Ulcer
 Mass lesion

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 Upper vs lower GIB

Bleeding Likelihood of Likelihood of

manifestation Upper GI-source Lower GI-source
Hematemesis Assured R/o

Melena Probable Possible

Hematochezia Unlikely Very likely

Blood streaked R/o Assured

stool
Occult blood in Possible Possible
stool
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 Part-3

Management of UGIB

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 Resuscitation
 Resuscitation of a hemodynamically unstable
patient begins with assessing and addressing
the ABCs (ie, airway, breathing, circulation) of
initial management.
.

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 Patients presenting with severe blood loss and
hemorrhagic shock present with mental status
changes and confusion. In such circumstances,
patients cannot protect their airway, especially when
hematemesis is present. In these cases, patients are at
an increased risk for aspiration, which is a potentially
avoidable complication that can significantly affect
morbidity and mortality. This situation must be
recognized early, and patients should be electively
intubated in a controlled setting
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 Intravenous access must be obtained. Bilateral,
16-gauge (minimum), upper extremity,
peripheral , short, large-bore, peripheral
intravenous lines are adequate for rapid fluid
infusion.
 crystalloid solutions may be used to attain
volume restoration prior to administering
blood products

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 degree of hypovolemic shock

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Resuscitation con’t
 Clinical monitoring
-Serial V/S, -Urine output
-Mental status, - Continuous EKG & Pulseoximetry
-Hct,

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 Resuscitation…

 Anticipate need for blood transfusion

 Threshold should be based on underlying condition,
hemodynamic status, markers of tissue hypoxia
 Should be administered if Hgb ≤ 7 g/dL
 1 U PRBC should raise Hgb by 1 (HCT by 3%)
 Remember that initial Hct can be misleading (Hct remains
the same with loss of whole blood, until re-equilibration
occurs

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 Resuscitation…
 Three categories of ‘resuscitative response’ have been
described:-
 I. Blood loss<20% - haemodynamic stability achieved
quickly at initial resuscitation
 II.Blood loss 20-40% - transient initial response, but
subsequent deterioration in indices
(ongoing hemorrhage or inadequate resuscitation)
 III.Non-responders – no response to initial fluid replacement
(sever Vol. depletion or rapid continuous bleeding)
variceal bleeding or aortoduodenal fistula

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 Treatment of Variceal bleeding
 Resuscitation
 Special considerations to correction of
reversible coagulopathy:-
 Vitamin-K
 Fresh frozen plasma
 Platelet transfusions

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 Treatment …
I.Pharmacologic therapy
1.Vasopressin –potent splanchnic vasoconstrictor
Controls hemorrhage in ~ 50% of pts
 Administration : IV bolus-20u/20min

continuous infusion 0.4u/min

 Adverse effects:–hypertention,bradycardia,decrease
in CO, coronary vasoconstriction
 Use be confined to ICU

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 Treatment …
 2.Somtostatin ( Octreotide )
 As efficacious as Endoscopic Rx for control of acute variceal
bleeding
 Fewer adverse effects than vasopressin

 Useful when Endoscopic Rx is unlikely to be effective

-failed chronic sclerotherapy

-gastric varices
-portal hypertensive gastropathy
Administration
 Somatostatin–IV bolus 250μg

 - infusion 250μg/hr for 2-4 days

 Octreotide –IV infusion 25-50μg/hr for 2-4 days

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 Treatment …
 3.Β-blockers
 Used only as primary prophylaxis
 Mechanisms:
-reduce portal venous inflow
-decrease CO
-direct splanchnic arterial vasoconstriction
 Propranolol/Nadololreduction in incidence
of hemorrhage
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 Treatment …
 II.Balloon tamponade
 Two commonly used tubes:- *
 Sengestaken-Blackmore tube*
 Minnesota tube
-Has a separate port for
aspiration of the esophagus
 It is a temporizing measure
 No survival benefit
 Initial hemostasis obtained
in 85%-89% of cases
 Rebleeding occurs in up to 65%
of cases
 Major complications reported in up to
20% of cases

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 Treatment …
Major complications Minor complications
Esophageal rupture -Nasopharyngeal bleeding
Tracheal rupture -Chest pain
Duodenal rupture -Balloon impaction and/or
Respiratory tract obstruction migration (nausea and
Aspiration vomiting)
Hemoptysis - necrosis
Tracheoesophageal fistula
Jejunal rupture
Thoracic lymph duct obstruction
Esophageal necrosis
Esophageal ulcer

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 III.Endoscopic therapy
 Indicated in all patients suspected of variceal
hemorrhage
 1.Injection sclerotherapy
 Is the initial treatment of choice
 Immediate control of bleeding
in 70% of cases
 Definitive control in
up to 95% with repeated sessions
 Well established therapeutic efficacy
-Improved rebleed rates
-Improved mortality rates

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 Endoscopic …
 Draw backs
-Multiple sessions to ablate variceal complex
-Esophageal ulceration & stricture
 2.Variceal ligation
-As effective as sclerotherapy
-Lower complication rates

READING ASSIGNMENT
 3.Thermal coagulation methods
 4.NdYAG non-contact laser ablation method

 5.Fibrin glue application

 6.Endoclip assisted hemostasis

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 IV.Surgical variceal therapy
Two general types of operations
 Non-shunt / esophagogastric devascularization
procedures
 Surgical decompression of the portal venous
system
 These are the definitive method of stopping acute
hemorrhage & preventing its recurrence

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 IV.Surgical variceal …

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 Non-selective portosystemic shunts

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 IV.Surgical variceal …
3.Transjugular intrahepatic portocaval shunt (
TIPS )
 The newest intervention
 Temporizing measure in pts
awaiting liver transplantation
 Relatively non-morbid
measurein high risk pts
 An expandable metal stent is
inserted under flouroscopic
guidance enabling bridging
b/n portal v. & hepatic v.

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 4.Hepatic transplantation
 Addresses the underlying liver disease in addition to providing
reliable portal decompression
 Not indicated for some of the more common causes of
variceal bleeding, such as schistosomiasis (normal liver
function) and active alcoholism (noncompliant).
 Not available to all patients
 Patients with variceal bleeding who are transplant candidates
include:-
 Nonalcoholic cirrhotics and
 Abstinent alcoholic cirrhotics with either limited hepatic
functional reserve (Child's Class C) or a poor quality of life
secondary to their disease (e.g., encephalopathy, fatigue, or
bone pain).

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 Algorithm

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 Peptic ulcer
I.Non- operative treatment
 Pharmacotherapy is ineffective

 Endoscopic haemostatic techniques

-injection therapy
-Electrocautery

 Angiographic embolization of the bleeding artery

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 Peptic ulcer …
II.Operative treatment
 Indication for operation
 Severe life-threatening hemorrhage not responsive to
resuscitative efforts
 Failure of medical therapy and endoscopic hemostasis with
persistent recurrent bleeding
 A coexisting reason for surgery such as perforation,
obstruction, or malignancy
 Prolonged bleeding with loss of 50% or more of the patient's
blood volume
 A second hospitalization for peptic ulcer hemorrhage

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 Peptic ulcer …
 The 3 most common operations performed for a
bleeding duodenal ulcer:-
 Truncal vagotomy and pyloroplasty with suture
ligation of the bleeding ulcer
 Truncal vagotomy and antrectomy with resection or
suture ligation of the bleeding ulcer
 Proximal (highly selective) gastric vagotomy with
duodenostomy and suture ligation of the bleeding
ulcer

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 Peptic ulcer …
 Operations for bleeding gastric ulcer
 Distal gastrectomy with gastroduodenostomy
 Distal gastrectomy with vagotomy (prepyloric or
pyloric channel)
 Vagotomy +Wide excision (prox. Stomach)
 Total gastrectomy (gastrinoma)

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