Management of Acute Upper GI

Bleed
Dr Niladri Banerjee
 Terms
• Upper GI Bleed
• Obscure bleeding
• Occult bleeding
• Overt bleeding
– Melena
– Hematemesis
– Hematochezia
General Approach to patients with acute GI
bleed
Initial assessment and
resuscitation

History and
examination

Localise bleeding

Initiate
therapy
 Initial Assessment
• ABC assessment
• To assess magnitude of bleeding
– Degree of shock
– Haematocrit
– Elderly vs young
• Lab evaluation
• Resuscitation
– RL, MTP
 History and Physical Exam
• Symptoms assessment
• Medications
• Previous Surgery
• Head to toe examination
 Risk stratification
Blatchford score and Rockall score
• Blatchford score: includes
– BUN
– Hb
– SBP
– Pulse
– Presence of melena, syncope, hepatic or cardiac
dysfunction
Localise Bleeding
 Treatment

Closely monitor airway, clinical status, vital signs, cardiac rhythm, urine output, nasogastric output
(if nasogastric tube in place)

Do NOT give patient anything by mouth

Establish two large bore IV lines (16 gauge or larger)

Provide supplemental oxygen (goal oxygen saturation ≥94% for patients without COPD)

Treat hypotension initially with rapid, bolus infusions of isotonic crystalloid (eg, 500 to 1000 mL per
bolus; use smaller boluses and lower total volumes for patients with compromised cardiac function)
Transfusion:
For severe, ongoing bleeding, immediately transfuse blood products in 1:1:1 ration of RBCs,
plasma, and platelets, as for trauma patients
For hemodynamic instability despite crystalloid resuscitation, transfuse 1 to 2 units RBCs
For hemoglobin <8 g/dL (80 g/L) in high-risk patients (eg, older adult, coronary artery disease),
transfuse 1 unit RBCs and reassess the patient's clinical condition

For hemoglobin <7 g/dL (70 g/L) in low-risk patients, transfuse 1 units RBCs and reassess the
patient's clinical condition
Avoid over-transfusion with possible variceal bleeding

Give plasma for coagulopathy or after transfusing four units of RBCs; give platelets for
thrombocytopenia (platelets <50,000) or platelet dysfunction (eg, chronic aspirin therapy) or after
transfusing four units of RBCs
Obtain immediate consultation with gastroenterologist; obtain surgical and interventional
radiology consultation for any large-scale bleeding ¶
Pharmacotherapy for all patients with suspected or known severe bleeding:
Give a proton pump inhibitor
Evidence of active bleeding (eg, hematemesis, hemodynamic instability), give esomeprazole or
pantoprazole, 80 mg IV
No evidence of active bleeding, give esomeprazole or pantoprazole, 40 mg IV
Endoscopy delayed beyond 12 hours, give second dose of esomeprazole or pantoprazole, 40 mg
IV
Pharmacotherapy for known or suspected esophagogastric variceal bleeding and/or cirrhosis:
•Give somatostatin or an analogue (eg, octreotide 50 mcg IV bolus followed by 50 mcg/hour
continuous IV infusion)
•Give an IV antibiotic (eg, ceftriaxone or fluoroquinolone)
 Common causes of UGIB
Non-variceal bleeding Portal hypertensive bleeding
• Gastric and duodenal ulcers • Gastroesophageal varices
(30%-40%) (>90%)
• Gastritis and duodenitis • Hypertensive portal
(20%) gastropathy (<5%)
• Esophagitis (5%-10%) • Isolated gastric varices
• Mallory-Weiss tears (5%- (rare)
10%)
• Arteriovenous
malformations (2%)
• Tumors (5%)
Role of early endoscopy??
Forrest Classification
Non-variceal UGIB
 Algorithm for the diagnosis and
management of non- variceal UGIB
 PUD
• MC- 40% of all cases
• Ulcer penetrates GDA or left gastric artery
• T/T: EGD within 24 hour, PPI
– Endoscopic treatment based on Forrest
classification
– 25%- need repeat endoscopic treatment
– 60-70% are H.pylori positive
– Stop ulcerogenic medications
• Endoscopic T/t:
– Epinephrine (>13 ml)
– Elctrocoagulation
– Laser or APC
– Hemoclips
• 2nd attempt endoscopic T/t- 75% vs 25%
• Surgical management
– Duodenal ulcer vs Gastric ulcer
 Indications of Surgery in Gastrointestinal
Hemorrhage
• Hemodynamic instability despite vigorous
resuscitation (>6 unit transfusion)
• Failure of endoscopic technique to arrest
hemorrhage
• Recurrent hemorrhage after initial stabilisation(2
attempts to at obtaining endoscopic hemostasis)
• Shock a/w recurrent hemorrhage
• Continued slow bleeding with a transfusion
requirement exceeding >3 units/day
 Mallory-Weiss tears
• Binge drinking
• Mucosal and sub-mucosal tears
• UGIE
• Most: self limiting within 72 hours
• Local endoscopic t/t, angiographic
embolisation, gelatin sponge
 Stress gastritis
• Multiple superficial erosions
• Ischaemia d/t hypoperfusion
• Endoscopic therapy
• Acid suppressive therapy : medical/ surgical
 Esophagitis
• GERD
• Usually superficial mucosal ulceration
• Occult bleeding
• R/o medications, radiation, Crohn’s
• T/t: acid suppressive therapy
 Dieulafoy lesion
• Vascular malformation within 6 cm of GEJ
• 1-3 mm vessels- at sub-mucosa
• T/t: endoscopic t/t if fails angiographic coil
embolisation
• Last resort: partial gastrectomy
 GAVE
• Watermelon stomach d/t multiple dilated
venules
• Antrum
• Continued occult bleed
• TOC: APC
• Last resort: antrectomy
 Malignancy
• C/f: chronic anemia or hemoccult-positive
stool
• GIST
• Endoscopic t/t good to control bleed but
rebleeding chances are higher
• Surgical resection or palliative resection
 Aortoenteric fistula
• Post graft-enteric erosion: 1% of aortic graft
• Median interval is 3 years
• Pseudoaneurysm with fistulisation
• Sentinel bleed massive and fatal bleed
• D3 or D4
• Therapy: ligation of graft proximal to the graft,
removal of infected prosthesis, and extra-
anatomic bypass
• Duodenum-primarily repaired
 Hemobilia
• Post trauma, iatrogenic, hepatic neoplasm
• Triad: hemorrhage, right upper quadrant pain
and jaundice
• UGIE: blood at the ampulla
• CT angio and embolisation
 Hemosuccus pancreaticus
• Bleeding from the pancreatic duct
• Splenic artery erosion: pancreatic pseudocyst
• Abdominal pain, hematochezia
• TOC: DP
 Iatrogenic bleeding
• Hemobilia
• Endoscopic sphincterotomy
• Percutaneous trans-hepatic procedures
• Percutaneous endoscopic gastrostomy
 Suggestions
• Very-low-risk patients (e.g., Glasgow-
Blatchford score: 0–1) - may be discharged
with outpatient follow-up
• For patients hospitalized with overt UGIB:
– red blood cell transfusion at a threshold of 7 g/dL
– Erythromycin infusion is suggested before
endoscopy
– endoscopy is suggested within 24 hours of
presentation
• Endoscopic therapy for:
– Forrest Ia, Ib and Iia
• Endoscopic therapy includes:
– bipolar electrocoagulation
– heater probe, and
– absolute ethanol injection
• Clips, argon plasma coagulation, and soft
monopolar electrocoagulation: low to very
quality evidence
• Hemostatic powder spray TC-325 is suggested
for actively bleeding ulcers
• PPI therapy:
– high-dose proton pump inhibitor therapy is
recommended continuously or intermittently for 3
days, followed by twice-daily oral proton pump
inhibitor for the first 2 weeks of therapy after
endoscopy.
• Repeat endoscopy is suggested for recurrent
bleeding
• If endoscopic therapy fails- transcatheter
embolization is suggested
Bleeding due to Portal Hypertension
Algorithm for diagnosis and management
of UGIB d/t PHTN

Variceal bleeding suspected based on history

ABC’s and resuscitation
Start octreotide and vasopressin infusion
Variceal bleeding confirmed on EGD
EBL (or sclerotherapy)
Bleeding stopped
 Bleeding stopped
yes

• Octreotide/vasopressin for 3-5 days

• Complete 7 days of antibiotics
• Repeat endoscopic banding every 10-14 days
until elliminated
 Bleeding stopped
No

• Balloon tamponade
• Consider TIPS or surgical shunt if TIPS fails or
not available
• Varices: dilated sub mucosal veins in response
to portal hypertension
• Overlying mucosa becomes tenuous
• Portal hypertensive gastropathy
• Have increase risk of re-bleeding and need for
transfusion
• hepatic functional reserve-CP score
• T/t- control acute bleeding and take care of re
bleeding
 Management
• Hyperaldosteronism
• Underlying sepsis rebleeding 7 day
emperical antibiotic course
• medical, endoscopic and surgical mangement
 Medical management
• Vasopressin combined with nitroglycerin and
somatostatin or its analogue
• Terlipressin
 Endoscopic management
• Early EGD within 15 hours
• Sclerotherapy , banding
• Gastric varices – not effectively controlled with
endoscopic techniques
• Sengstaken Blakemore Tube- 2 balloons and 4
lumens
• 50%- hemorrhage recurs with deflation of balloon
• 20-30% a/w complications-aspiration pneumonia
and esophageal tears
 TIPS
• Kept between HV and PV
• Stent is made up of PTFE
• Complications:
– Capsule rupture with intraperitoneal hemorrhage
– Encephalopathy, shunt thrombosis- within 1
month
– Shunt stenosis- within 1 year
– Ascitis gets resolved
 C/I
Absolute C/I Relative C/I
• Right heart failure • Portal vein thrombosis
• Polycystic liver disease • Encephalopathy
• Hepatopulmonary • Liver tumors
syndrome
• Portopulmonary
hypertension
 Surgical shunts
Non-selective shunts Selective shunts
• End to side poto caval • Warrens shunt
• Side to side porto caval • Inokuchi shunt
• Interposition graft
• TIPS
• Linton shunt
 C/I to shunt operations
• Splenic vein thrombosis
• SMV thrombosis
• Splanchnic vein thrombosis

• In these cases shunt operation is not possible-

devascularisation operations
 Devascularisation operations
Sugiura operation
• Ligation of veins near esophagus
• Vagotomy
• Pyloroplasty
• Esophageal transection and anastomosis
• splenectomy
Last resort: Liver Transplantation
 Prevent rebleeding
• Apprximately 70%- have rebleed within 2
months
• Risk is highest within first few hours to days
after the first episode
• Endoscopic band ligation repeated every 10-
14 days until all varices are eradicated
Thank you