Prepared by :

Inzar Yasin
Ammar Labib

Supervised by :
Dr. Abdulaziz Yousif Mansour
 INTRODUCTION
Acutegastrointestinal bleeding is a potentially life-threatening abdominal
emergency that remains a common cause of hospitalization.

Uppergastrointestinal bleeding (UGIB) is defined as bleeding derived

from a source proximal to the ligament of Treitz.

Can be categorized as either variceal or non-variceal. Variceal is a

complication of end stage liver disease. While non variceal bleeding
associated with peptic ulcer disease or other causes of UGIB.

UGIB is 4 times as common as bleeding from lower GIT, with a higher

incidence in male.
  Esophageal causes:
 Esophageal varices
 Esophagitis
 Esophageal cancer

CAUSE 

Esophageal ulcers
Mallory-Weiss tear

S  Gastric causes:

 Gastric ulcer
 Gastric cancer
 Gastritis
 Gastric varices
 Dieulafoy's lesions
  Duodenal causes:
 Duodenal ulcer
CAUS  Vascular malformation including
aorto-enteric fistulae
ES  Hematobilia, or bleeding from the
biliary tree
 Hemosuccus pancreaticus, or
bleeding from the pancreatic duct
 Severe superior mesenteric artery
syndrome
:SIGNS AND SYMPTOMS
 Hematemesis
 Melena
 Hematochezia
 Syncope
 Dyspepsia
 Epigastric pain
 Heartburn
 Diffuse abdominal pain
 Dysphagia
 Weight loss
 Jaundice
 :P RE SENTATION
1. H e m ateme sis : vomiting of blood ,could be: Digested blood
in the stomach(coffee-ground emesis t h a t indicate slower rate
of bleeding) or fresh/unaltered blood (gross blood and clots,
indicates rapid bleeding)

2. Melena: stool consisting of partially digested blood (black

tarry, semi solid, shiny and has a distinctive odor, when its
present it indicates t h a t blood h as been present in the GI
tract for a t least 14 h. The more proximal the bleeding site,
the more likely melena will occur.

3. H e m a t o c h e zi a usually represents a lower GI source of

bleeding, although a n upper GI lesion may bleed so briskly
t h a t blood does not remain in the bowel long enough for
melena to develop.
AP P ROAC
H
 History:

• Abdominal pain
• Haematamesis
• Haematochezia
• Melaena
• Features of blood loss: shock, syncope,
anemia
• Features of underlying cause: dyspepsia,
jaundice, weight loss
• Drug history: NSAIDs, Aspirin, corticosteroids,
anticoagulants, (SSRIs) particularly fluoxetine and
sertraline.

• History of epistaxis or hemoptysis to rule out the GI

source of bleeding.

• Pa s t medical :previous episodes of upper

gastrointestinal bleeding, diabetes mellitus;
coronary artery disease; chronic renal or liver
disease; or chronic obstructive pulmonary disease.

• Past surgical: previous abdominal surgery

APPROACH:
.CONT
 Examination :

• General examination and systemic

examinations

• VITALS:
Pulse = Thready pulse
BP = Orthostatic Hypotension

• SIGNS of shock:
Cold extremeties, Tachycardia, Hypotension
Chest pain, Confusion, Delirium, Oliguria, and etc.
• SKIN changes:
Cirrhosis – Palmer erythema, spider nevi
Bleeding disorders – P u r p u r a /Echymosis
Coagulation disorders – Haemarthrosis, Muscle
hematoma.

• Signs of dehydration (dry mucosa, sunken eyes, skin turgor

reduced).

• Signs of a tumour may be present (nodular liver, abdominal

mass, lymphadenopathy, and etc.

• DRE : fresh blood, occult blood, bloody diarrhea

• Respiratory, CVS, CNS  For comorbid diseases
 :LAB DIAGNOSIS
• CBC w i t h P l a t e l e t Count, a n d Differential
A complete blood count (CBC) is necessary to assess the
level of blood loss. CBC should be checked frequently(q4-6h)
during the first day.

• H e m o g l o b i n Value, Ty pe a n d Cro ssma tch Blo o d

The patient should be crossmatched for 2-6 units, based on

the rate of active bleeding.The hemoglobin level should be
monitored serially in order to follow the trend. An unstable
Hb level may signify ongoing hemorrhage requiring further
intervention.
• LFT- to detect underlying liver disease

• RFT- to detect underlying renal disease

• Calci um level- to detect hyperparathyroidism

and in monitoring calcium in patients receiving
multiple transfusions of citrated blood

• Gastrin level
• The BUN-to- c r e a t i n i n e ratio increases with upper
gastrointestinal bleeding (UGIB). A ratio of greater t h a n
36 in a patient without renal insufficiency is suggestive of
UGIB.

• The patient's prothrombin time (PT), activated partial

thromboplastin time, and International Normalized Ratio
(INR) should be checked to document the presence of a
coagulopathy
• Prolongation of the PT based on a n INR of more t h a n
1.5 may indicate moderate liver impairment.

• A fibrinogen level of less t h a n 100 mg/dL also indicates

advanced liver disease with extremely poor synthetic
function
 :ENDOSCOPY
• Initial diagnostic examination for all patients
presumed to have UGIB

• Endoscopy should be performed immediately after

endotracheal intubation (if indicated), hemodynamic
stabilization, and adequate monitoring in a n
intensive care unit (ICU) setting have been achieved.
:IMAGING

• CHEST X-RAY-Chest radiographs should be

ordered to exclude aspiration pneumonia, effusion,
and esophageal perforation.

• Abdominal X-RAY- erect and supine films should

be ordered to exclude perforated viscous and ileus.
• C o m p u t e d t o m o g r a p h y (CT) s c a n n i n g a n d
u l t r a s o n o g r a p h y may be indicated for the
evaluation of liver disease with cirrhosis,
cholecystitis with hemorrhage, pancreatitis with
pseudocyst and hemorrhage, aortoenteric fistula,
and other unusual causes of upper GI hemorrhage.

• N u c l e a r m e d i c i n e s c a n s may be useful in
determining the area of active hemorrhage
ANGIOGRAPHY
:
 Angiography may be useful if bleeding
persists and endoscopy fails to identify a
bleeding site.

 Angiography along with transcatheter arterial

embolization (TAE) should be considered for
all patients with a known source of arterial
UGIB t h a t does not respond to endoscopic
management, with active bleeding and a
negative endoscopy.

 Incases of aortoenteric fistula, angiography

requires active bleeding (1 mL/min) to be
diagnostic.
NASOGASTRIC LAVAGE

A nasogastric tube is a n important diagnostic

tool.

 Thisprocedure may confirm recent bleeding

(coffee ground appearance), possible active
bleeding (red blood in the aspirate t h a t does
not clear), or a lack of blood in the stomach
(active bleeding less likely but does not
exclude a n upper GI lesion).
BENEFITS OF LAVAGE :

1. Better visualization during endoscopy

2. Give crude estimation of rapidity of bleeding
3. Prevent the development of Porto systemic
encephalopathy in cirrhosis
4. Increases P H of stomach, an d hence, decreases clot
desolation due to gastric acid dilution
5. Tube placement can reduce the patient's need to vomit

 During gastric lavage use saline an d not use large

volume of to avoid water intoxication.

 Gastric lavage should be done in alert an d cooperative

patient to avoid bronco-pulmonary aspiration
S EVERITY
ROCKALL SCORE
RISK CATEGORY

 Rockall’s score>8=High risk of death

 Rockall’s score<3=excellent prognosis

MAN AGEMENT
Pr i or i t ie s are:
1. Stabilize the patient: protect airway, restore
circulation.
2. Identify the source of bleeding.
3. Definitive treatment of the cause .

R e s u s c i t a t i o n a n d initial m a n a g e m e n t
 Protect airway: position the patient on side
 IV access: use 1-2 large bore cannula
 Take blood for: Hb, PCV, PT and cross match
 Restore the circulation: if pts
haemodynamically stable give N.S. infusion,
if not give colloid 500ml/1hr and then
crystalloid and continue until blood is
o Transfuse blood for:

o Obvious massive blood loss

o Hematocrit < 25% with active bleeding
o Symptoms due to low hematocrit and hemoglobin

o Platelet transfusions should be offered to patients

who are actively bleeding an d have a platelet count
of <50000.

o Fresh frozen plasma should be used for patients

who have either a fibrinogen level of less t h a n 1
g/litre, or (INR) greater t h a n 1.5 times normal.

o Over-transfusion may be as damaging as under-

transfusion .
 Monitor urine output.

 Watch for signs of fluid overload (raised JVP, pul.

edema, peripheral edema)

 Commence IV PPI, omeprazole 80 mg iv followed

by 8mg/hr for 72 hrs.

 Keep the pt nill by mouth for the endoscopy

TREATMENT OF VARICEAL BLEEDING

 Terlipressin,
t r e atment should be stopped after
definitive homeostasis has been achieved, or after
five days, unless there is another indication for its
use.

 Prophylactic antibiotic therapy

 Balloontamponade should be considered as a

temporary salvage treatment for uncontrolled
variceal haemorrhage
B LEED ING
1. Oesophageal varices:
 B a n d ligation
 S t e n t insertion is effective for
selected patients
 Transjugular intrahepatic portosystemic shunts
(TIPS) should be considered if bleeding from
oesophageal varices is not controlled by band ligation.

2. Gastric varices:
 Endoscopic injection of N-butyl-2-cyanoacrylate
should be used.
 TIPS should be offered if bleeding from gastric varices
is not controlled by endoscopic injection of N-butyl-2-
cyanoacrylate
TREATMENT OF NON-VARICEAL
BLEEDING
Endoscopy is now the method of choice for controlling active
peptic-ulcer related UGIB.

Endoscopic therapy should only be delivered to actively

bleeding lesions, non-bleeding visible vessels and, when
technically possible, to ulcers with a n adherent blood clot.

 Blackor red spots or a clean ulcer base with oozing do not

merit endoscopic intervention since these lesions have a n
excellent prognosis without intervention.

Adrenaline (epinephrine) should not be used as monotherapy

for the endoscopic treatmen t of non-variceal UGIB
TREATMENT OF NON-VARICEAL
BLEEDING
For the endoscopic treatmen t of non-variceal UGIB, one of
the following should be used:

1. A mechanical method (clips) with or without adrenaline

(epinephrine)

2. Thermal coagulation with adrenaline (epinephrine)

3. Fibrin or thrombin with adrenaline (epinephrine)

Interventional radiology should be offered to unstable

patients who re-bleed after endoscopic treatment. Refer
urgently for surgery if interventional radiology is not
immediately available.
SU RGERY

1. Persistent hypotension

2. Failure of medical t r eatment or endoscopic

homeostasis

3. Coexisting condition ( perforation, obstruction,

malignancy)

4. Transfusion requirement (4 units in 24 hr)

5. Recurrent hospitalizations
TYPES OF OPERATIONS

Th e ch oice of opera t ion depends on t h e sit e a n d

the bleeding lesions:

1. Duodenal ulcers are treated by under-running

with or without pyloro-plasty.

2. Gastric ulcers treated by under-running (take a

biopsy to exclude carcinoma).

3. Local excision or partial gastrectomy will be

required.
COMPLICAT
IONS
Can arise from treatments administered for
example:

 Endoscopy:

1. Aspiration pneumonia
2. Perforation
3. Complications from coagulation, laser
treatments

 Surgery:

1. Ileus
2. Sepsis
3. Wound problems
PREVENTION
 The most important factor to consider is
t r e atme nt for H. pylori infection.

 1st line therapy PPT

( omeprazole, lansoprazole, pantoprazole) +
two of these three AB
( clarithromycin, amoxicillin, metronidazole)

 2nd line therapy - PPT

- bismuth
- m etr onida zole
- tetracycline
For 7 days
:RESOURCES

1. MacLeod's clinical examination 12th edition

2. Davidson’s principle and practice of

medicine th21 edition

3. Oxford handbook of emergency medicine

4. Upper GIT bleeding
h t t p://www.pat ient .co.u k/doct or

5. www.medscape.com