Approach to

Upper GI Bleed

Dr.Pankaj Ingale
Amravati Institute of Gastroenterology
Amravati. India
• Pre-endoscopic management Resuscitation
Risk stratification
• Pre-endoscopic pharmacological therapy
• Endoscopic management
• Management of continued or recurrent
bleeding
• Pharmacological therapy
• Post discharge management

•
 Definitions
• Upper GI bleed – arising
from the esophagus,
stomach, or proximal
duodenum
• Mid-intestinal bleed –
arising from distal
duodenum to ileocecal
valve
• Lower intestinal bleed –
arising from colon/rectum
 History
• Localizing symptoms
• History of prior GIB
• NSAID/aspirin use
• Liver disease/cirrhosis
• Vascular disease
• Aortic valvular disease
• Chronic renal failure
• Radiation exposure
• Family history of GIB
 Physical Examination
• Vital signs, orthostatics
• Abdominal tenderness
• Skin, oral examination
• Stigmata of liver disease
• Rectal examination
– Objective description of stool/blood
– Assess for mass, hemorrhoids
– No need for guaiac test
 Initial Assessment
• Always remember to assess A,B,C’s
• Assess degree of hypovolemic shock
 Resuscitation
• IV access: Two large bore peripheral Ivs

• Airway intubation :bleeding severely or altered

mental status

• Oxygen supplementation

• Send Lab sample

– Blood Group/Cross match
– CBC,Hct,RFT,LFT,PT/INR
– ECG
• Ryles Tube Insertion
– YES Vs NO

• RT Lavage
• ? Saline
• ?Tap Water
• ?Ice cold Saline
• ?Sucrafil lavage
 Resuscitation
• Volume Resuscitation
• Crystalloids Vs Colloids

• Use crystalloids first

• Goal
– SBP: 90–100 mmHg
– Heart rate :below 100 beats/ min
– CVP:1-5 mm Hg
– Diuresis: 40 ml/hr
 Resuscitation
• Need for blood transfusion
• 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%)
• Initial Hct can be misleading

bleed Time

40% IVFs
40% 20%
 Transfusion Strategy
• Randomized trial:
– 921 subjects with severe acute UGIB

– Restrictive (tx when Hgb<7; target 7-9) vs.

Liberal (tx when Hgb<9; target 9-11)

– Primary outcome: all cause mortality rate

within 45 days
NEJM 2013;368;11-21
 Restrictive Strategy Superior
Restrictive Liberal P value
Mortality rate 5% 9% 0.02
Rate of further 10% 16% 0.01
bleeding
Overall 40% 48% 0.02
complication rate

Benefit seen primarily in

Child A/B cirrhotics

NEJM 2013;368;11-21
 Resuscitation

• Packed RBC Vs Whole blood Assess degree of coagulopathy

Vitamin K – slow acting, long-

• Platelet Transfusion lived

FFP – fast acting, short lived

• Correct coagulopathy

• Recombinant factor VII

– improve hemostasis rates, but it does not improve
survival
 Risk Stratification
• Identify patients at high risk for adverse
outcomes
• Helps determine disposition (ICU vs. floor
vs. outpatient)
• May help guide appropriate timing of
endoscopy
 Rockall Scoring System
• Validated predictor of mortality in patients with
UGIB
• 2 components: clinical + endoscopic
Variable 0 1 2 3

Age <60 60-79 ≥ 80

Shock No Tachy- Hypotension-

SBP ≥ 100 SBP ≥ 100 SBP <100
P<100 P>100
Comorbidity No major Cardiac Renal failure,
failure, CAD, liver failure,
other major malignancy

Gut 1996;38:316
 Pre-endoscopic
Pharmacotherapy
• For suspected Non-Variceal UGIB

– IV PPI: 80 mg bolus, 8 mg/hr drip

– Rationale: suppress acid, facilitate clot formation
and stabilization
– Duration: at least until EGD, then based on
findings
 Pre-endoscopy PPI

• Reduces the proportion

of patients with high
risk endoscopic
stigmata (“downstages”
lesion)
• Decreases need for
endoscopic therapy
High risk Low risk
• Has not been shown to
reduce rebleeding, Endoscopic treatment required:
surgery, or mortality Omeprazole – 19% (23% of PUD)
Placebo – 28% (37% of PUD)
rates
N Engl J Med 2007;356:1631
 Pre-endoscopic
Pharmacotherapy
• For suspected Variceal UGIB
• Antibiotic prophylaxis: reduces bacterial
infections, variceal rebleeding, and death
• vasopressin, somatostatin, terlipressin, and
octreotide
 Upper GI Bleed

Do all Upper GI bleeders need Endoscopy?

YES

When?
 2 AM …

Is emergency endoscopy necessary?

Upper GI Bleed – Timing of Endoscopy

• Emergency Endoscopy < 6 hrs

• Early Endoscopy 6 – 24 hrs

• Elective Endoscopy < 48 hrs

• Balance benefits & drawbacks

 Upper GI Bleed

Advantages of early endoscopy

• Identify source of bleeding
• Predict rebleeding
• Secure hemostasis
• Triage low risk patients
Identify active bleeders and vessels that
J Clin Gastroenterol 1996;
warrant treatment Gastrointest Endosc 1999;
Ann Intern Med 2010;
Early Endoscopy in High Risk patients

• Reduce rebleeding

• Reduce surgery

• Reduce hospital stay

 Pre Endoscopic Preparations

• Blood pressure: systolic BP >70 mmHg

• Unconscious patients should be intubated
• A vasoactive drug should be initiated
• An injectable proton pump inhibitor
• Routine use of sedation is not
recommended
 ENDOSCOPY
1. Non Variceal Upper GI Bleed

2. Variceal Upper GI Bleed

Upper GI Bleed

1 Variceal Bleed

a) Cirrhosis of liver

b) EHPVO

c) NCPF

2 Non variceal Bleed

 Variceal Bleed

Varices exist in…

– 40% compensated ,80% Childs C cirrhosis

– Increased risk of bleeding of up to 15% p.a.

– 40-50% stop spontaneously

– Mortality at 6 week is about 20%,33%at 1year

– Recurrent bleeding 60% -1year

 Variceal Bleeding
Risk of bleeding higher with
a) Large varices – Grade III / IV > Grade I / II
b) Red Wale sign
c) Child Turcotte Score – C>B>A

NIEC/ Beppu
 Variceal Bleeding
Modes of therapy

Drugs Endoscopic
Therapy

Surgery TIPSS
 Variceal Bleed

• Primary prophylaxis

• Active bleed

• Secondary prophylaxis

• Recurrent bleed (non responder)

 Variceal Hemorrhage
Primary Prophylaxis

Drug Therapy - Beta Blockers

-Nitrates

Disadvantages
• Variable response

• Contraindications

• ? Response in Childs C

• Life long ? compliance

Does endoscopy have a role
in primary prophylaxis ?
 Primary Prophylaxis
EVL vs Propranolol
Propranolol EVL
44 45
Bleed (8.5 + 2.4 Mo) 11 (25.6%) 4 (9.5%)
Probability of bleeding
(Kaplan-Meir) 43% 15%
Bleeding 12 4
Mortality due to bleed 4/5 3/5
Variceal Rec. - 9 (21.4%)

Sarin SK et al NEJM 1999

 Variceal Bleed

Endoscopic Variceal Band Ligation

 Variceal Bleed

Complications Of Endoscopic Sclerotherapy

Regional
Local
– Ulcers  Mediastinitis
– Bleeding  Perforation
– Stricture
– Esophageal dysmotility  Pleural effusion
– Odynophagia  Increased risk of bleeding
– Laceration from portal gastropathy
Systemic
– Sepsis
– Aspiration pneumonia
– Hypoxia
– Spontaneous bacterial
peritonitis
– Portal vein thrombosis
 Variceal Bleed

Comparision of EVL And EST

ESTT EVL
E S
an
Technique r th Variable Standard
t e
Control of active bleedinget >90% >90%
L B
Session required More Less
EV
Serious complication Common Rare
Recurrence of varices Infrequent Common
Effects on survival No effect May improve
Primary prophylaxis No good Comparable to
-blocker
Endoloop

Sung J. Gastrointest Endosc. 1998

 Variceal Bleeding
Therapy for acute variceal bleeding
• Pharmacotherapy

• Tamponade

• Endotherapy - EVL / EST

Drugs In Acute Variceal Bleeding

• Vasopressin

• Octreotide

• Somatostatin

• Terlipressin
 Acute Variceal Bleeding
Balloon Tamponade - S B Tube
Recurrent Variceal Bleeding

Modes of therapy
• TIPSS

• Surgery
 Acute Variceal Bleeding
Transjugular Intrahepatic Porto Systemic Shunt – TIPSS
Is there a place for Surgery?
1970s  1990s

Changing Concepts
Changing Hands
 Esophago – Gastric Varices

Surgery
• Selective Shunts
• Non selective shunts
• Devascularization
 Active variceal bleed

Use of covered stents (Ella stent)

• Covered metal stents used to control acute
variceal bleed
• Extracted after 48 to 72 hrs
• Limited experience but good response
Gastric varices
Fundal varices
 Gastric Varices

Use of glue-cynoacrylate
polymerizes on contact with blood
 Variceal Bleed
Summary
Primary B Blockers ,EVL
prophylaxis

Pharmaco therapy ,SB tube ,

Active bleed
EVL ,EST ,Stent.

Secondary β-blockers (non-selective) indefinitely

prophylaxis
EVL
TIPSS / Shunt surgery
Recurrent bleed

Fundal Varices Glue / BRTO

 Non – Variceal Bleed

• 90% of GI bleeds are from the upper GI tract

• 50-60% of upper GI bleeds are due to peptic ulcers

• Mortality varies between 6-10% despite all advances

• 2 large meta analysis have shown definite benefit of

endotherapy

Sachs 1990, Cook et al 1992

 Non – Variceal Bleed

Etiology

Common Uncommon Iatrogenic

Duodenal ulcer Dieulafoys

Gastric ulcer AVM / GAVE

Erosions Hemobilia

Mallory-Weiss Hemosuccus

Esophagitis Aorto-Duodenal fistula

Neoplastic
 Non – Variceal Bleed

• Grading of bleeding peptic ulcers and therapy

• Newer modalities for haemostasis

• Significance of expertise

• Early endoscopy

• Relook endoscopy

• Role of surgery

• Drugs and bleeding peptic ulcer

 Bleeding Peptic Ulcers

Forrest Classification of stigmata of hemorrhage

1A Active bleeding-Spurting

1B Active bleeding-Oozing

IIA Visible vessel

IIB Adherent clot

IIC Flat spot

III Clean base

Forrest et al Lancet 1974

 Non – Variceal Bleed

Do all bleeding peptic ulcers need endotherapy

NO
 Stigmata of Bleeding
Prevalence and Risks of Re-bleeding

100

80

60

40

20

0
Spurter NBVV Clot Dot Clean base
 Bleeding Peptic Ulcers

Stigmata of hemorrhage Rebleed rate Surgery Mortality

Clean Base 5% ( 0 -10 ) 0.5% 2%

Flat spot 10% (0 – 13) 6% 3%

Adherent clot 22% (14 – 36 ) 10% 7%

Visible vessel 43% ( 0 – 81 ) 34% 11%

Active Bleeding 55% (17 – 100 ) 35% 11%

Laine & Peterson 1994

Bleeding Peptic Ulcers
Active Bleed
 Bleeding Peptic Ulcers

Active Bleed

Therapy

• Injection 1-10,000 adrenaline – 10 – 15cc

• Followed by thermal method (Gold probe, BICAP or

Heater probe) or Hemoclip

• Combination therapy better than individual technique

• Rebleed rate reduced from 55% - 25%

Lin et al Gut 1999
Jensen et al 1994
Epinephrine works by
Volume tamponade
Which one to select
 py
r a
h e
o t
on
m
a n
th
r
tte
b e
n
tio
n a
b i
o m
C
 Cold snare removal Exposed vessel

1.Cold snare the clot

2.Expose the underlying lesion
3.Treat the underlying pathology
 Bleeding Peptic Ulcers
Flat spot /Clean based ulcer

• No endoscopic treatment

• Wash – exclude other

stigmata

• Biopsy – H.Pylori

• Same day discharge

Hsu et al 1990, Jensen 1999

 Peptic Ulcer Bleeding

Forrest I Forrest II a/b Forrest IIc, III

IV PPI IV PPI Oral PPI

Endo Rx Endo Rx No Endo Rx

Recurrent bleeding

Repeat
Surgery
Endo Rx
 Nonvariceal UGIB –
Post-endoscopy management
• Patients with low risk ulcers can be fed
promptly, put on oral PPI therapy.

• Patients with ulcers requiring endoscopic

therapy should receive PPI iv x 72 hours
– Significantly reduces 30 day rebleeding rate vs
placebo (6.7% vs. 22.5%)

N Engl J Med 2000;343:310

Arch Intern Med 2010;170:751
 Non – Variceal Bleed

• Grading of bleeding peptic ulcers and therapy

• Newer modalities for haemostasis

• Significance of expertise

• Early Endoscopy

• Relook Endoscopy

• Role of surgery

• Drugs and bleeding peptic ulcer

 Clips

Hayashi 1975
Soehendra

Olympus Boston Scientific Wilson Cook

QuickClip Resolution Triclip
 Clips

Dieulafoy lesion
Clips
Band Ligation

Dieulafoy lesion
 Band Ligation

Limited data
• Dieulafoy’s
• AV malformations
• Mallory-Weiss tear
• Post-polypectomy bleed
• Ulcers
Limitations of technique
• inability to capture fibrotic/tangential lesions
 Argon Plasma Coagulation

Gastric Antral Vascular Ectasia

 Non – Variceal Bleed

 Grading of bleeding peptic ulcers and therapy

 Newer modalities for haemostasis

 Significance of expertise

 Early endoscopy

 Relook endoscopy

 Role of surgery

 Drugs and bleeding peptic ulcer

 Non – Variceal Bleed

• Grading of bleeding peptic ulcers and therapy

• Newer modalities for haemostasis

• Significance of expertise

• Early endoscopy

• Relook endoscopy

• Role of surgery

• Drugs and bleeding peptic ulcer

 Second Look Endoscopy
Definition & Timing

Scheduled endoscopy <24 hrs of an index

endoscopy

Useful in selected cases – high risk

patient,unsatisfactory initial endotherapy
 Non – Variceal Bleed

 Grading of bleeding peptic ulcers and therapy

 Newer modalities for haemostasis

 Significance of expertise

 Early endoscopy

 Relook endoscopy

 Role of surgery

 Drugs and bleeding peptic ulcer

Non variceal bleed-Role of surgery

• Surgery indicated in limited cases.

• 6.5% in the RUGBE series.

• 27% needed surgery –Hongkong.

Barkun A Am.J.Gastroenterology 2001

Lau JY NEJM 1999.
Angio+embolisation
Angio+Embolisation
 Non – Variceal Bleed

 Grading of bleeding peptic ulcers and therapy

 Newer modalities for haemostasis

 Significance of expertise

 Early endoscopy

 Relook endoscopy

 Role of surgery

 Drugs and bleeding peptic ulcer

 Rationale for Acid Suppression

• In vitro studies have shown that high intragastric pH (> 6.0)

facilitates platelet aggregation & stabilizes the clot

• Acid suppression therapy may decrease rebleed and need for

surgery
 Non variceal bleed- Role of drugs

• H2 RA are not recommended for management of upper

G.I.bleed.

• inconsistent

• marginal benefits

• PPI better

• Somatostatin/Octreotide – little to recommend use of these in

nonvariceal upper G.I. bleed.

Bardou et al Gastroenterology 2003.

 Non variceal bleed –Role of drugs

IV omeprazole – 80mg bolus followed by 8mg /hr for 72hrs.

• Decrease rebleed
• Decreased incidence of surgery
• No effect on mortality

Can be used pre endoscopic therapy

Was used in combination with endotherapy

Lau JY NEJM 2000

 Adjuvant iv PPI improves Outcome
1.0

Omeprazole

Probability of No Recurrent Bleeding

.8
Placebo

.6
Hazard Ratio=4.8

.4

Epinephrine injection + 3.2mm

heater probe treatment .2

OR .0
0 5 10 15 20 25 30
Epinephrine injection + 3.2mm No. at Risk
Omeprazole
120 115 113 113 113 113 112
120 94 93 93 93 93 93
heater probe treatment + Placebo

Omeprazole 80mg+ 8mg/h for

72h Versus Placebo
Lau JY. N Engl J Med. 2000;343:310–316
 IV PPI Reduces Rebleeding
from Ulcer after Endoscopic
Therapy
25 * P<0.001
rebleeding rate (%)

20
Accumulative

15
20 21.6 22.5
10
*
*
5 *
5.8 6.6
4
0
72 hours 7 days 30 days
Omeprazole Placebo
Lau et al. NEJM 2000
IV PPI Reduces Need Of Endoscopic Re-rx And
Transfusion

Omeprazole Placebo Omeprazole Placebo

25 P<0.001 4 P= 0.04
20

Median units
3
Percentage
of patients

15
20.8 2
10
3.5
2.7
1
5
5
0 0
Endoscopic Transfusion
retreatment
 IV PPI May Reduce
Surgery And Mortality
Omeprazole Placebo

10% P= 0.12

8% P= 0.14
Percentage
of patients

6%
10
4% 7.5

2% 4.1
2.5
0%
Surgery 30 day mortality
 Non variceal bleed –Role of drugs

• PPI’s are not a replacement for endotherapy.

• I.V PPI’s for high risk stigmata

• Oral PPI’s for low risk stigmata.

Sung JJ et al Ann Int Med 2003

 Non variceal bleed-Role of H.pylori

• H.pylori therapy indicated in all ulcers after control of

initial bleed.

• Rebleed rates - 28.6% without H.pylori treatment.

- 0% after triple therapy.

Graham et’ al Scand. J. Gastroenterology1993.

 NSAID & Aspirin
• COX-2 selective NSAID plus a PPI offers
the best available upper GI protection

• Among patients receiving clopidogrel and

aspirin as dual treatment, prophylactic use
of a PPI reduces the risk of adverse GI
events
 Ten commandments of NV bleed

1.Is early endoscopy necessary?

Endoscopy within 24 hrs would be OK
2.Mono or combined endoscopic therapy?
Don’t use injection alone
3.Thermal or clip?
Equally good
4.What to do with clot?
Remove it and treat underlying vessel
 Ten commandments of NV bleed

5.Pre-endoscopy PPI?
Will reduce need for endoscopic therapy
6.IV PPI is necessary?
It is a sin not to use it
7.Routine second-look endoscopy?
Not recommended
8.Surgery still needed?
Yes.in selected cases
 Ten commandments of NV bleed

9.How to reduce mortality?

Support of cardiopulmonary status &

resuscitation is important

10.Should we stop anti-platelet agents?

Balance the risk and benefit

Therapy for Non Variceal Bleed

???

Medical + Endo Therapy

Combination Endo Therapy

Single Endo Therapy

Medical therapy
Thank you