MANAGEMENT OF UPPER GI BLEED

BY
Dr. Sami Ullah Mumtaz
MBBS (KEMU), FCPS(MEDICINE)

Assistant Professor Medicine

North Medical Ward
KEMU/Mayo Hospital Lahore.

Final Year MBBS (Acute Care Medicine Module)

Date: 15-04-2020
Day: Wednesday
Time:8.45 am to 9.30am
Introduction
Upper GI bleeding (UGIB) is a common medical
emergency that is defined as bleeding anywhere from
esophagus to the duodenum where ligament of Treitz
is attached.
80% Cases are self limiting.
20% Require urgent therapy.
ETIOLOGY :

PEPTIC ULCERS. accounts for 40-50% cases, commonest
cause of UGIB worldwide .The Chronic
H.Pylori infection,dietry habits and use of NSAIDs &
steroids can cause leads to peptic ulcer.

ESOPHAGEAL VARICES.10-20%, can cause GI bleeding
due to portal hypertension & are usually related to a
chronic liver disease.

MALLORY-WEISS TEARS.5-10% Severe vomiting may
cause Mallory weiss tear, leading to GI bleeding. You can
have more than one Mallory-Weiss tear at a time.

ANGIODYSPLASIA. 7% These are abnormal or enlarged blood
vessels in GI tract that become fragile and bleed.

BENIGN TUMORS AND CANCER. 1% Both benign &
malignant tumors of esophagus & stomach may cause bleeding
by weakening the lining of the GI tract.

EROSIVE ESOPHAGITIS. 2-5% The most common is GERD
that leads to weakening of LES. Stomach acid reflux causes
sores and bleeding.

EROSIVE GASTRITIS. <5% Use of (NSAIDs) and other
medicines leads to gastric erosions & bleeding.

OTHERS RARE CAUSES: Hereditary talangectasias ,dieulafoy
gastric lesions,portal gastropathy,coagulopathy, aortoenteric
fistula, hemobilia, pancreatic malignancy,lymphoma,CKD &
pseudoaneurysm.
symptoms
Hematamesis bright red or coffee ground blood vomitting.
Malena black tarry, offensive stool that is difficult to flush(even if 50-
100ml bleed).
Hematochezia fresh blood in case of massive upper GI
bleed(>1000ml) due to rapid transit. seen in 5-10% cases.
Abdominal distention / epigastric pain (painless in variceal)
dizziness or faintness.
yellowish discoloration of skin & sclera.
shortness of breath.
feeling tired.
Generalized weakness.
drowsiness
Signs: depending upon cause
Hypotension
Postural drop
Tachycardia
Pallor
Jaundice
Spleenomegly & or hepatomegly
Fluid thrill or shifting dullness,
spider navi
Pedal edema
Small or no urine outut
 Glasgow-Blatchford Bleeding Score (GBS)
It is a screening tool used to evalute need of medical intervention such as a blood transfusion or endoscopic intervention in patient of UGIB.

scores of 6 or more were associated with a greater >50% need of an intervention.

Diagnosis
BASELINE INVESTIGATIONS

CBC, Hb,Platelets & leukocytes.

HCT decreased.
LFTS,albumin,GGT.
RFTS to see renal perfusion/function.
ECG
SPECIFIC LABS

BLOOD GROUP CROSS MATCH

PT/APTT/INR may be increased.
HBsAg, Anti HCV Screening
ULTRASOUND ABDOMEN to see liver, spleen,
ascities portal vein, kidney status.
Upper GI Endoscopy to see ulcer,erosions,varices or
portal hyppertension/gastropathy etc.& any
Intervention.
CT Chest abdomen with iv contrast if malignancy
suspected.
Treatment
O2 by nasal canula.
NPO-TFO.
Assess Haemodynamic status.
Pass 18 or 20-gauge double IV lines.
Rush IV fluids preferably 0.9% saline or Ringer lactate.
Transfuse whole blood as soon as avilable.
Transfuse platlets if less than 50,000/mcL.
FFPs if INR > 1.8.
Pass NG tube to avoid aspiration & to assess blood loss.
Pass Sengstaken blakemore tube if massive bleeding.
Pass Folys Cathetar to assess urine output.
Pass CV line if required.
Sengstaken Blakemore Tube
Acid Inhibitory Therapy: IV esomeprezole or
pantoprazole 80mg stat then 8mg/hour continuous
infusion for 3 days.
Prokinetics:Metocloperamide or erythromycin.
 Somatostatin analogue: Octreotide continuous iv
infusion 100mcg followed by 50-100mcg/hour for 3-5 days
if evidence of liver disease. Terlipression can also be
given.
Upper GI Endoscopy & intervention: while endoscopy
patient can have banding of varices, cautry, injection
epinephrine or sclerotherapy, endoclips, heater probes.
ENDOSCOPY INTERVENTION FOR PEPTIC ULCER
 Sclerotherapy, banding

Variceal bleed flow sheet

Antibiotics: for all patients of cirhosis.
Intra-arterial Embolization: can be used in ulcers,
angiomas or mallory weiss tears not responding to
endoscopy or unfit for surgery.
Transvenous intrahepatic portosystemic
shunts(TIPS): Hepatic vein & portal vein shunt can
effectively decrease portal pressure where other
interventions fail.
Surgery: in case of peptic ulcer if not responding to
any treatment.
 PROGNOSIS (ROCKALL SCORE)
Used to assess mortality risk for patients admitted with upper GI bleeding

A score less than 3 carries good prognosis while total score more than 8 carries
high risk of mortality
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ANY QUESTION AT : drsumumtaz@gmail.com