1. Approach to Upper GIT Bleeding (UGIB)
Shaimaa Elkholy, M.D.
Cairo University, Egypt

2. Shaimaa Elkholy, M.D. Cairo University
5 Q??
Who ??
Why ??
How ??
When ??
What ??
Shaimaa Elkholy, M.D. Cairo University

3. Shaimaa Elkholy, M.D. Cairo University
Agenda
Definitions
Epidemiology
Aetiology
Initial Evaluation
General management
Risk stratification
Management of VGIB
Management of NVGIB
Take home message
Shaimaa Elkholy, M.D. Cairo University

4. Shaimaa Elkholy, M.D. Cairo University
Definitions:
UGIB : bleeding from GIT above ligament of trietz.
Shaimaa Elkholy, M.D. Cairo University

5. Shaimaa Elkholy, M.D. Cairo University
Definitions:
Hematemsis: vomiting of blood or coffee-ground like material suggests bleeding proximal to the ligament of Treitz.
Melena: black, tarry stools originates proximal to the ligament of Treitz (90 %), or from the small bowel or right colon.
Hematochezia: red or maroon blood in the stool is usually due to lower GI bleeding. It can occur with massive upper GI bleeding.
Shaimaa Elkholy, M.D. Cairo University

6. Shaimaa Elkholy, M.D. Cairo University
Epidemiology :
Acute (UGIB) is a GIT emergency with a mortality of 4%-14% despite advances in critical care monitoring and support.
Spontaneous cessation of bleeding occurs in 85% of cases.
UGIB in the UK ranges between per 100,000 per year, causing 50-70,000 hospital admissions per year.
Major cases due to PUD.
Shaimaa Elkholy, M.D. Cairo University

7. Shaimaa Elkholy, M.D. Cairo University
Epidemiology :
UGIB in the United States is 160 hospital admissions per 100,000 population, which translates into more than 400,000 per year.
80 to 90% have NVGIB mainly PUD.
An increasing proportion related to the use of aspirin /NSAIDs.
PUD bleed is seen predominantly among the elderly, 68% > 60 years/ 27% > 80 years.
Mortality remains high at 5-10%&medical costs for the in-hospital care>$ 2 billion annually in US.
Shaimaa Elkholy, M.D. Cairo University

8. Shaimaa Elkholy, M.D. Cairo University
Aetiology of UGIB:
Peptic ulcer disease — 55 %
Oesphgealgasrtic varices — 14 %
A-V malformations — 6 %
Mallory-Weiss tears — 5 %
Tumors and erosions — 4 %
Dieulafoy's lesion — 1 %
Others % .
Shaimaa Elkholy, M.D. Cairo University

9. Shaimaa Elkholy, M.D. Cairo University

10. Shaimaa Elkholy, M.D. Cairo University
Other rare cases:
Idiopathic angiomas
Osler-Weber-Rendu syndrome
Radiation-induced telangiectasia
Traumatic or post-surgical
Foreign body ingestion
Post-surgical anastamosis
Aortoenteric fistula
Post gastric/duodenal polypectomy
Hemobilia
Hemosuccus pancreaticus
Shaimaa Elkholy, M.D. Cairo University

11. Shaimaa Elkholy, M.D. Cairo University
EGYPTIAN scenario:
Variceal causes of bleeding were the most common, representing 70.1% followed by non-variceal causes (26.1%) and obscure causes (3.8%).
Gastric lesions were the most common causes of non variceal bleeding.
Shaimaa Elkholy, M.D. Cairo University

12. Shaimaa Elkholy, M.D. Cairo University
VGIB:
Variceal hemorrhage is the most common fatal complication of cirrhosis.
At the time of diagnosis:
30% of cirrhotic patients O.V.
90% after approximately 10 years.
Bleeding ceases spontaneously in up to 40%
Shaimaa Elkholy, M.D. Cairo University

13. Shaimaa Elkholy, M.D. Cairo University
VGIB:
Correlation to the severity of liver disease:
Child–Pugh A patients: 40% have varices
Child–Pugh C patients: 85% have varices
Some patients may develop varices and hemorrhage early in the course of the disease, even in the absence of cirrhosis
Patients with hepatitis C and bridging fibrosis: 16% have esophageal varices
Shaimaa Elkholy, M.D. Cairo University

14. Shaimaa Elkholy, M.D. Cairo University
Prognosis:
Bleeding O.V. occurs 30 % in the 1st year after diagnosis.
The mortality during the attack:
< 10% Child–Pugh grade A
> 70% in advanced Child–Pugh C cirrhotic stage.
Bleeding O.V. mortality rate 20% at 6 weeks.
The risk of re-bleeding is high, reaching 80% within 1 year.
High Portal venous pressure > 20 mmHg :
REBLEEDING : 1st week of admission
Failure to control bleeding (83% vs. 29%)
Higher 1-year mortality rate (64% vs. 20%).
Shaimaa Elkholy, M.D. Cairo University

15. Shaimaa Elkholy, M.D. Cairo University

16. Varices Increase in Diameter Progressively
No varices
Small varices
Large varices
7-8%/year
7-8%/year
Merli et al. J Hepatol 2003;38:266
Shaimaa Elkholy, M.D. Cairo University

17. Shaimaa Elkholy, M.D. Cairo University
Grades of O.V.:
I. Dilated venes (< 5mm) still at the level of the surrounding tissue
II. Dilated, straight venes (> 5 mm) protruding into the esophageal lumen but not obstructing it
Shaimaa Elkholy, M.D. Cairo University

18. Shaimaa Elkholy, M.D. Cairo University
III. Large, tense and winding venes already obstructing the esophageal lumen considerably
IV. Near complete obstruction of the esophageal lumen with impending danger of hemorrhage (cherry red spots)
Shaimaa Elkholy, M.D. Cairo University

19. Shaimaa Elkholy, M.D. Cairo University
NVGIB :
Peptic ulcer disease:
The mortality associated with acute bleeding from a peptic ulcer remains high (5 to 10%).
4 risk factors:
H. pylori infection
NSAIDs
Stress
Gastric acid
Alcoholism
Shaimaa Elkholy, M.D. Cairo University

20. Shaimaa Elkholy, M.D. Cairo University
Bleeding PUD
FORREST - classification of upper gastrointestinal hemorrhage
Acute hemorrhage
Forrest IA
Active spurting hemorrhage
Forrest IB
Oozing hemorrhage
Signs of recent hemorrhage
Forrest IIA
Non-bleeding visible vessel
Forrest IIB
Adherent clot
Forrest IIC
Hematin on ulcer base
Lesions without active bleeding
Forrest III
Clean-base ulcers
Shaimaa Elkholy, M.D. Cairo University

21. Shaimaa Elkholy, M.D. Cairo University
Endoscopic Stigmata of Bleeding Peptic Ulcer, Classified as High Risk or Low Risk
Spurt blood (grade IA)
Ooze blood (grade IB)
Nonbleeding visible vessel (grade IIA)
Adherent clot (grade IIB)
Flat, pigmented spot (grade IIC)
Clean base (grade III)
Shaimaa Elkholy, M.D. Cairo University

22. Shaimaa Elkholy, M.D. Cairo University
DIEULAFOY'S LESION:
Dilated aberrant submucosal vessel which erodes the overlying epithelium in the absence of a primary ulcer.
It’s caliber 1 to 3 mm, 10-times the normal caliber of mucosal capillaries.
Usually on lesser curve below the cardia, may be found any where.
Shaimaa Elkholy, M.D. Cairo University

23. Shaimaa Elkholy, M.D. Cairo University
DIEULAFOY'S LESION:
unknown, but may be congenital.
Events triggering bleeding are also not well-understood(?? NSAIDs).
Male patients with comorbidities including cardiovascular disease, hypertension, CKD , diabetes, or alcohol abuse.
Bleeding is usually self limited but it may be severe.
Shaimaa Elkholy, M.D. Cairo University

24. Shaimaa Elkholy, M.D. Cairo University

25. Mallory-Weiss syndrome:
longitudinal mucosal lacerations s in the distal esophagus and proximal stomach, which are usually associated with forceful retching.
secondary to a sudden increase in intraabdominal pressure e.g. vomiting, straining or lifting, coughing, epileptic convulsions, hiccups under anesthesia, closed-chest massage, blunt abdominal injury.
Shaimaa Elkholy, M.D. Cairo University

26. Mallory-Weiss syndrome:
Precipitating factors:
hiatus hernia,
chronic alcoholism
increasing age
Shaimaa Elkholy, M.D. Cairo University

27. Shaimaa Elkholy, M.D. Cairo University
GAVE & P.H.G:
Shaimaa Elkholy, M.D. Cairo University

28. Shaimaa Elkholy, M.D. Cairo University
Tumors:
Benign
Leiomyoma
Lipoma
Polyp (hyperplastic, adenomatous, hamartomatous)
Malignant
Adenocarcinoma
Mesenchymal neoplasm
Lymphoma
Kaposi's sarcoma
Carcinoid
Melanoma
Metastatic tumor
Shaimaa Elkholy, M.D. Cairo University

29. Pathway last updated: 22 February 2013
Copyright © NICE All rights reserved
Shaimaa Elkholy, M.D. Cairo University

30. Resuscitation and initial management:
Initial evaluation: “QUICK”
Triage.
General support.
Fluid resuscitation.
Blood transfusions.
Nasogastric lavage.
Shaimaa Elkholy, M.D. Cairo University

31. Shaimaa Elkholy, M.D. Cairo University
General management:
Triage:   “QUICK”
ICU admission
Hemodynamic instability (shock, orthostatic hypotension).
Active bleeding (manifested by hematemesis, bright red blood per nasogastric tube, or hematochezia).
Shaimaa Elkholy, M.D. Cairo University

32. Shaimaa Elkholy, M.D. Cairo University
General management:
Support :
oxygen by nasal cannula.
NPO.
Two large caliber (16-18 gauge) peripheral I.V. Catheters.
Central venous line if possible.
Pulmonary artery catheter should be considered in patients with hemodynamic instability or who need close monitoring during resuscitation. 
Elective endotracheal intubation in patients with ongoing hematemesis with altered respiratory or mental status.
Shaimaa Elkholy, M.D. Cairo University

33. Shaimaa Elkholy, M.D. Cairo University
General management:
Fluid resuscitation:
resuscitation and stabilization is essential prior to endoscopy
Patients with active bleeding should receive intravenous fluids (crystalloids or colloids)
while being typed and cross-matched for blood transfusion.
Patients at risk of fluid overload may require intensive monitoring with a pulmonary artery catheter.
Shaimaa Elkholy, M.D. Cairo University

34. Shaimaa Elkholy, M.D. Cairo University
General management:
Indications of blood transfusion:
Hb below 7mg/dl (low risk).
High risk patients (old or comorbid) 10mg/dl.
Active (fresh) bleeding & Hypovolemea even with normal HB.
Indications of platelet & FFP transfusion:
low platelet count (<50,000/microL) OR INR > 1.5.
life-threatening bleeding receiving antiplatelet or anti coagulation.
Patients receiving massive blood transfusion due to dilutional coagulopathy.
Over-transfuse patients with suspected variceal bleeding can precipitate worsening of bleeding (10 mg/dl).
Shaimaa Elkholy, M.D. Cairo University

35. Shaimaa Elkholy, M.D. Cairo University
General management:
Nasogastric lavage:
Its use before endoscopy in the ER remains controversial.
Benefits:
To confirm an UGI source of bleeding(can still miss up to 15%)
Prognostic index for identifying high-risk lesions as presence fresh red blood in the NGT aspirate.
May exclude false hematemsis.
To facilitate lavage of the upper GI tract to improve mucosal views at subsequent endoscopy.
Shaimaa Elkholy, M.D. Cairo University

36. Shaimaa Elkholy, M.D. Cairo University
Risk assessment:
Blatchford score at first assessment.
Rockall score after endoscopy.
Shaimaa Elkholy, M.D. Cairo University

37. Shaimaa Elkholy, M.D. Cairo University

38. Shaimaa Elkholy, M.D. Cairo University
ScoreLow risk defined as score of <=2
4.3% rebleeding
0.1% mortality
Shaimaa Elkholy, M.D. Cairo University

39. Medications (pre- endoscopy):
Acid suppression.
Prokinetics.
Somatostatin and its analogs in VUGIB.
 Antibiotics for patients with cirrhosis. 
Shaimaa Elkholy, M.D. Cairo University

40. Shaimaa Elkholy, M.D. Cairo University
Medications (pre- endoscopy):
Acid suppression:
starte empirically on an I.V. PPI &continued until confirmation of the cause of bleeding.
I.V. of a PPI significantly reduces the rate of rebleeding compared& hospital stay in comparison to H2 blockers.
80 mg bolus followed by 8 mg/hr infusion for 72 days then switched to oral.
Shaimaa Elkholy, M.D. Cairo University

41. Medications (pre- endoscopy):
Prokinetics: erythromycin & metchlopromide.
Somatostatin, or its analog  Octreotide splanchnic vasoconstriction and decreased portal inflow
50 mcg bolus followed by a continuous infusion of 50 mcg per hour and is continued for 3-5 days.
Shaimaa Elkholy, M.D. Cairo University

42. Medications (pre- endoscopy):
Antibiotics for patients with cirrhosis:
The AASLD guidelines : (max.7 days)
Oral norfloxacin (400 mg twice daily) or intravenous ciprofloxacin
In patients with advanced cirrhosis, I.V. ceftriaxone (1 g/day) & with a high prevalence of quinolone-resistant organisms.
Shaimaa Elkholy, M.D. Cairo University

43. Shaimaa Elkholy, M.D. Cairo University
:Timing of endoscopy
Patients with UGIB should generally undergo endoscopy within 24 h of admission, following resuscitative efforts to optimize hemodynamic parameters and other medical problems
Shaimaa Elkholy, M.D. Cairo University

44. Shaimaa Elkholy, M.D. Cairo University
Timing of endoscopy
Patients who are hemodynamically stable and without serious comorbidities:
Endoscopy as soon as possible in a non-emergent setting to identify the substantial proportion of patients with low-risk endoscopic findings who can be safely discharged
Shaimaa Elkholy, M.D. Cairo University

45. Shaimaa Elkholy, M.D. Cairo University
Timing of endoscopy
Patients with higher risk clinical features endoscopy within 12 h may be considered to potentially improve clinical outcomes
Shaimaa Elkholy, M.D. Cairo University

46. Endoscopic management VUGIB:
EIS
( endoscopic injection sclerotherapy)
Sclerosing materials : ethanolamin oleate(E/O) cyanoacrylate (H/A).
Local complications :
Ulceration
Bleeding
stricture formation
portal hypertensive gastropathy
Regional complications
esophageal perforation and mediastinitis.
Systemic complications
sepsis and aspiration with ventilation perfusion mismatch and hypoxemia
Shaimaa Elkholy, M.D. Cairo University

47. Endoscopic management VUGIB:
Video 1
Video 2
Video 3
Shaimaa Elkholy, M.D. Cairo University

48. Endoscopic management VUGIB:
EVL: endoscopic variceal ligation
Less complications e.g. ulcers, stricture (rare).
Less sessions.
Shaimaa Elkholy, M.D. Cairo University

49. Endoscopic management NVUGIB:
Endoscopic therapy should be provided to patients with Forrest grade IA, IB, or IIA.
Endoscopic therapy may be considered for patients with an adherent clot resistant to vigorous irrigation.
Endoscopic therapy should not be provided to patients who have an ulcer with a clean base or a flat pigmented spot (Forrest grade IIC, or III).
Shaimaa Elkholy, M.D. Cairo University

50. Shaimaa Elkholy, M.D. Cairo University
Endoscopic Stigmata of Bleeding Peptic Ulcer, Classified as High Risk or Low Risk
Spurt blood (grade IA)
Ooze blood (grade IB)
Nonbleeding visible vessel (grade IIA)
Adherent clot (grade IIB)
Flat, pigmented spot (grade IIC)
Clean base (grade III)
Shaimaa Elkholy, M.D. Cairo University

51. Endoscopic management NVUGIB:
Mechanical method (for example, clips) with or without adrenaline
Thermal coagulation with adrenaline
Fibrin or thrombin with adrenaline
No single method of endoscopic thermal coaptive therapy is superior to another
Shaimaa Elkholy, M.D. Cairo University

52. Shaimaa Elkholy, M.D. Cairo University
Take home messeges
Patient with UGIB is critically ill patient with different presentations.
PUD is the commonest cause world wide.
VUGIB is commonest cause in Egypt.
Stepped approach to UGIB has to be known.
Resuscitation is essential prior to endoscopy.
Indications of blood , platelets & FFP transfusion differs from one patient to another.
Target HB differs according to the patient.
Risk assessment is essential in those patients by different scoring systems.
Forrest classification is essential to determine the line of management.
EVL is much preferred than injection sclerotherapy.
Shaimaa Elkholy, M.D. Cairo University

53. Shaimaa Elkholy, M.D. Cairo University
Thank you
Shaimaa ELKHOLY
Thank you
Shaimaa Elkholy, M.D. Cairo University