MANAGEMENT

OF
UPPER GI BLEEDING

M K ALAM MS; FRCSEd

 ILOs
At the end of this presentation students will be able to: 
 Define upper GI haemorrhage.
 Describe the resuscitative measures.
 Enumerate the causes of upper GI bleeding.
 Describe the symptoms & signs of UGI bleeding.
 Describe diagnostic work up.
 Describe the non-surgical management and
indications for surgical intervention.
 Introduction
• UGIB is defined as bleeding derived from a
source proximal to the ligament of Treitz (D J flexure)
 UGIB

• A potentially life-threatening emergency.

• A common cause of hospitalization

• More common in male.

• 4 times more common than lower GI bleeding.
• Mortality 6-10%
 Mortality in UGIB

• Comorbid illness (72%) rather than actual

bleeding, is the major cause of death.
• Comorbid illness- 51% of patients.
• Rebleeding or continued bleeding- associated
with increased mortality
 Causes of UGIB

• Peptic ulcer disease (duodenal & gastric ulcer)

• Oesophageal varices (portal hypertension)
• Mallory-Weiss syndrome- mucosal tears of the esophagus.
• Erosive gastritis /esophagitis.
• Dieulafoy lesion.
• Gastric cancer.
• Ulcerated gastric stromal tumor (GIST)

• Aortoenteric fistula- erosion of the aortic graft into the bowel.

• Angiodysplasia- dilated, thin-walled vessels appearing as cherry spots

 Sources of bleeding

• Arterial hemorrhage- ulcer disease, mucosal tears as in

Mallory-Weiss syndrome.

• Low-pressure venous hemorrhage, as in telangiectasias.

• Variceal hemorrhage is due to elevated portal pressure

(>12 mmHg) transmitted to esophageal and gastric
varices and resulting in rupture of varices. Mucosal
ulceration can be a bleeding source.
 Peptic ulcer disease (PUD)

• The most common cause of UGIB.

• High-risk for PUD: H pylori, alcohol abuse, chronic renal failure,
and/or nonsteroidal anti-inflammatory drug (NSAID) use.
• Duodenal ulcers are more common than gastric ulcers
• Ulcer burrows deeper into the mucosa, causes weakening and
necrosis of the arterial wall, leading to a pseudoaneurysm. The
weakened wall ruptures, producing hemorrhage.
• Approximately 80% bleeding from PUD stops spontaneously.
 NSAID in UGIB

• Cause gastric and duodenal ulcers by inhibiting

cyclooxygenase - ↓ mucosal prostaglandin
synthesis- results in impaired mucosal defenses.

• Daily NSAID: 40-fold increase in gastric ulcer &

8-fold increase in duodenal ulcer creation.
Bleeding Prepyloric ulcer
 Oesophageal Varices
• Portal hypertension leads to portosystemic shunting.
• Development of varices- lower oesophagus and gastric fundus
• Elevated portal pressure transmitted to esophageal / gastric
varices resulting in rupture of varices.
• Mucosal ulceration can be a bleeding source.
• Normal portal pressure 5-15 cm of H₂O

• Bleeders- usually > 25 cm of H₂O

• 20 % may have peptic ulcer or gastritis
 Causes of portal hypertension

• Pre-hepatic:
Congenital atresia of PV,
PV thrombosis,
Compression of PV (tumours)

• Intrahepatic:
Pre-sinusoidal- Schistosomiasis
Sinusoidal- Cirrhosis
• Post-hepatic (Post-sinusoidal):
Budd-Chiari syndrome,
Constrictive pericarditis
Bleeding Oesophageal Varices
Bleeding Oesophageal Varix
 Mallory-Weiss syndrome

• Mallory-Weiss tears -15% of acute upper UGIB

• Mucosal laceration- result of forceful vomiting

• 80-90%- tear along the lesser curve of the stomach just

distal to the gastro-esophageal junction
Mallory-Weiss syndrome
 Acute stress gastritis

• Seen in shock, multiple trauma, acute respiratory

distress syndrome, systemic respiratory distress
syndrome, acute renal failure, and sepsis patients.
• Predisposing conditions alter local mucosal
protective barriers, such as mucus, bicarbonate, blood
flow, and prostaglandin synthesis.
• Disruption of balance of these factors results in diffuse
gastric mucosal erosions.
• The principal mechanisms- decreased splanchnic
mucosal blood flow and altered gastric luminal acidity.
Acute stress gastritis
 Dieulafoy lesion

• A vascular malformation of the proximal stomach.

• 2-5% of acute UGIB episodes.

• Endoscopic appearance: large ulcerated submucosal vessel.

• Bleeding can be massive and brisk.

• Vessel rupture occurs in the setting of chronic gastritis
• Alcohol use is associated with the Dieulafoy lesion.
• Mostly- men in their third to tenth decade.
• Can occur anywhere along the GI tract
Dieulafoy lesion
 GIST (gastrointestinal stromal tumour)
• Mesenchymal tumour, submucosal lesions

• 50-60%- stomach

• 20-30%- small intestine

• 10%- rectum
• Benign or malignant (positive for c-Kit oncogene)

• Pacemaker cells in smooth muscle

• Asymptomatic, bleeding or obstruction
Bleeding GIST of the stomach
 Gastric carcinoma

• Common- chronic blood loss (anaemia)

• Haematemesis- uncommon
Gastric carcinoma
 Symptoms and signs

• Hematemesis
• Melena
• Hematochezia
• Syncope
• Dyspepsia
• Epigastric pain
• Heartburn
• Diffuse abdominal pain
• Dysphagia
• Weight loss
• Jaundice
 Initial workup

• Vital signs: Pulse, BP

• CBC: WBC with differential, platelet

• Hemoglobin level

• Coagulation profile (PT, PTT, INR)

• Type and crossmatch blood

• U & E, LFTs

• Nasogastric lavage
 Diagnosis
• Nasogastric lavage

• Endoscopy
• Chest radiography

• Gastrin level (Gastrinoma)

• Angiography (persistent bleeding, source not identified by endoscopy)
• CT scan & ultrasonography:
 Liver disease with cirrhosis
 Pancreatitis with pseudocyst and hemorrhage
 Aortoenteric fistula
 Management: Resuscitation
• Airway + O₂

• Two peripheral IV lines

• X-match, CBC, u/e, coagulation profile, LFTs

• Crystalloid solution (RL)- 3:1 ratio

• NG tube: Gastric wash, monitor bleeding, prevent aspiration.

• Foley catheter- evaluation of urinary output.

• Peptic ulcer patients: 80 mg IV PPI.

• Endoscopic hemostatic therapy.
 Endoscopic hemostatic therapy
Bleeding peptic ulcers

• Endoscopy: Diagnose + control of bleeding.

• Injection of 1:10,000 adrenaline

• Heater-probe coagulation

• Laser or bipolar electrode coagulation

• Clips or bands
Bleeding peptic ulcer
 Recurrent bleeding in PUD

• A minority - recurrent bleeding after endoscopic therapy

• Risk factors for rebleeding:

Age>60 years,
Presence of shock upon admission,
Coagulopathy,
Active pulsatile bleeding,
Presence of cardiovascular disease.

• H pylori infection- recurrent bleeding is extremely low.

 Indications for surgery in bleeding peptic ulcers

• Life-threatening bleeding not responding to resuscitation.

• Failure of endoscopic hemostasis or recurrent bleeding
• Prolonged bleeding, with loss of 50% or more of the
patient's blood volume
• A second hospitalization for peptic ulcer bleeding.
• A coexisting perforation or obstruction.
• Failure of medical therapy
 Management of recurrent bleeding
• Re-endoscopy to achieve hemostasis.
• Surgical management:
• Duodenal ulcer:
A) Duodenotomy+ under-run with suture + anti- ulcer medications.
B) (?) Duodenotomy+ under-run with suture + anti-ulcer surgery-
pyloroplasty+ bilateral truncal vagotomy
• Gastric ulcer:
Young & fit- wedge excision of ulcer.
Old & unfit- Under-run the bleeding point+ biopsy
Benign ulcer: Anti-ulcer medical treatment.
Malignant ulcer: Staging the disease, surgery if indicated.
 Acute variceal bleeding- management

• Octreotide infusion- lowers portal pressure

• Endoscopic banding
• Endoscopic injection sclerotherapy
• Balloon tamponade

• TIPPS (Transjugular intrahepatic portosystemic shunting)

• SURGERY:

• Gastro-oesophageal devascularization + stapled oesophageal transection

• Liver transplantation
Sengstaken-Blakemore Tube
TIPPS
Band ligation of OV
Endoscopic sclerotherapy for OV
 Prognosis
Risk factors for: Increased mortality, recurrent bleeding, the
need for endoscopic hemostasis, or surgery :

• Age >60 years

• Severe comorbidity
• Active bleeding (witnessed hematemesis, blood in nasogastric
tube, fresh blood per rectum)
• Hypotension
• Blood transfusion ≥ 6 units
• Inpatient at time of bleed
• Severe coagulopathy
Management of uncommon causes of UGI bleeding

• Conservative/ endoscopic management:

Mallory-Weiss syndrome-

Erosive gastritis /esophagitis.

Dieulafoy lesion.

• Surgical management after stabilization & diagnosis:

Gastric cancer.

Ulcerated gastric stromal tumor (GIST)

Thank you!