1. Acute upper gastrointestinal Bleeding
Prof.Dr.Khalid Al-Khazraji
MBCHB , MD, CABM , FRCP , FACP
Baghdad medical college

2. Epidemiology The most common gastrointestinal emergency.
Overall incidence is approximately 100 hospitalizations per adults per year.
The incidence among men is approximately double than that among women.
Rate increases markedly with age.
Mortality rate is 5-12%

3. Clinical features The two cardinal features are: -
1- Haematemesis: bloody vomitus ; either fresh & bright red or older and “coffee-ground” in character.
2- Melaena: Passage of black, tarry, foul-smelling stools.
Following a bleed from the upper GI tract, unaltered
blood can appear per rectum, but the bleeding must
be massive and is almost always accompanied by
shock.
The passage of dark blood and clots without
shock is always due to lower GI bleeding.

4. Aetiology Common causes: - Other uncommon causes:
1- Peptic ulcer %
2- Gastric erosions %
3- Esophagitis (usually with hiatus hernia). 5%
4-Varices. 5-15%
5- Vascular malformation. 2%
6- Mallory - weiss tears. 5%
7- Cancer of stomach or esophagus. 5%
Other uncommon causes:
1-Hereditary telangiectasia (osler-weber-rendu syndrome).
2-Pseudoxanthoma elasticum.
3-Blood dyscrasias.
4-Dieulafoy gastric vascular abnormality.
5-Portal gastropathy
6-Aortic graft surgery with fistula.

5. Causes:

6. Clinical Assessment -Haematemesis is red with clots when bleeding is
profuse, or black (coffee grounds) when less
severe.
Intravascular volume depletion
Hypotension
Syncope
-Symptoms of anaemia suggest chronic bleeding.
- Approximately 85% of patients stop bleeding
spontaneously within 48 hours.
- Factors affects the risk of rebleeding and death:-
1- age
2- evidence of co-morbidity
3- shock
4- endoscopic diagnosis
5- ulcer with active bleeding
6- clinical signs of chronic liver disease

7. Calculate after endoscopy
Rockall Score
Parameter 1 2 3
Age
<60
60-79
≥80
Shock
None
HR >100
SBP <100
Co-morbidity
Nil
CCF, IHD , major comorbidity
Renal / liver failure
Metastatic cancer
Calculate after endoscopy
Diagnosis
M-W tears, or normal
All other diagnoses
GI malignancy
Evidence of Bleed
Blood in stomach
Adherent clot Visible or spurting vessel
Final score
0 - 11

8. Management Immediate Management
The goals of management: First the patient’s hemodynamic
status must rapidly assessed & resuscitative measures
initiated. Only then should next steps in management be
undertaken: determine the source of hemorrhage, stop the
Bleeding and prevent recurrent rebleeding.
Immediate Management
1- History and examination. Note co-morbidity.
2- Monitor pulse and BP half-hourly.
3- Take blood for: Hb, electrolytes, urea, liver biochemistry, coagulation screen, group and cross-match.
4- IV access (2 large-bore i.v cannulae). Central line if brisk bleed.
5- Give blood transfusion/colloid if necessary.
Indications for blood transfusions are:
A- shock
B- Hb less than 10 g/dL.
6-Oxygen
7- Urgent Endoscopy in shocked patients / liver disease.
8- Continue to Monitor Pulse and BP.
9- Re-endoscope for continued bleeding / hypovolemia.
10- surgery if bleeding persist.

9. Indication for urgent endoscopy :
1-large initial bleed
2-patients with resting hypotension or orthostatic change
3-repeated hematemesis or bloody nasogastric .
4-requiring blood transfusions

10. Endoscopy: can detect the cause of bleeding in
80% or more of cases.
At first endoscopy:
Varices treated with banding, or sclerosing.
Bleeding ulcer treated with two haemostatic
Methods ( injection with adrenaline ,& thermal
Coagulation). Or by endoscopic clipping
- Take antral biopsy for H. pylori.
Drug therapy
After diagnosis at endoscopy; give IV omeprazole 80
mg followed by 8 mg/h 72 hours to all ulcer patients as
it reduces the rebleeding rates and the need for surgery.
H2-receptor antagonists are of no value.

12. Atlas
DU with clot
Therapy with Argon photocoagulation of vessels of DU

13. Mallory weiss syndrome

14. Variceal banding

15. Thank You
2016