1. Upper GI bleeding
University of Jordan

2. University of Jordan

3. University of Jordan

4. UPPER GI BLEEDING Signs and Symptoms
Hematemesis
Melena
Dizziness
Abd. Pain and symptoms of Peptic ulcer disease
Hx of NSAID’s use
Pallor
Hypotension
Orthostasis
Jaundice and other stigmatas of chronic liver diseases
University of Jordan

5. UPPER GI BLEEDING CAUSES
RARE CAUSES
Neoplasms
AVM/Ectasia
Dieulafoy’s
Stoma ulcers
Esophageal ulcers
Deodenitis
Hemobilia
Aorto-enteric fistulas
Unknown 5%
Rare 5% GU GU
20%
Varices DU
15%
Erosions
Mallory Weiss
Mallory
Weiss DU
Varices 5%
25%
Rare
Unknown
Erosions
25%
University of Jordan

6. UPPER GI BLEEDING Peptic Ulcer Disease
Defect in the GI mucosa extending through the muscularis mucosa.
Decreasing incidence.
Caused by imbalance between the aggressive and defensive factors.
University of Jordan

7. UPPER GI BLEEDING Peptic Ulcer Disease
Helicobacter Pylori
NSAID’s
Acid Hypersecretory state.
Antral G cell Hyperplasia
University of Jordan

8. UPPER GI BLEEDING Peptic Ulcer Disease
University of Jordan

9. UPPER GI BLEEDING Gastric Ulcers
University of Jordan

10. UPPER GI BLEEDING Duodenal Ulcers
University of Jordan

11. UPPER GI BLEEDING Mallory - Weiss
Laceration around the GE junction
Classical presentation as bleeding after episode of vomiting
Classical presentation found in 50% only
Self- limiting
University of Jordan

12. UPPER GI BLEEDING Dieulafoy’s
Massive And recurrent bleeding
Extramural artery present in the
Submucosa.
Most commonly in the gastric
Cardia, 6 cm from GE junction
High Mortality
Difficult to diagnose
University of Jordan

13. UPPER GI BLEEDING Hemobilia
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14. UPPER GI BLEEDING Hemobilia
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15. UPPER GI BLEEDING Vascular abnormalities
Portal HTN Gastropathy
Mosiac / Snake skin
Body or fundus
Antral Vascular Ectesia
Multiple punctuated lesions
PBC and CREST
University of Jordan

16. UPPER GI BLEEDING stress ulcers
Caused by Vagal hyperstimulation
and vascular hypoperfusion.
Body and fundus more affected
Multiple
Prophylaxis is indicated in critically
ill ICU patients
Curling Extensive burn
Cushing Head Injury
University of Jordan

17. UPPER GI BLEEDING ADVERSE PROGNOSTIC FACTORS
Diagnosis
Varices
Malignancy
Older age
Severe initial bleeding
Recurrence during hospitalization
Coincidental diseases
Endoscopic stigmata of recent bleeding
Need for emergency surgery
University of Jordan

18. UPPER GI BLEEDING MANAGEMENT
Resuscitation
Assessment
Endoscopy
Bleeding Stops Bleeding continues
Surgery or angiogram/ embolization
History
Physical
NG Tube
Labs
University of Jordan

19. UPPER GI BLEEDING MANAGEMENT
Most Have
NG Tube
Rectal Exam
Endoscopy
University of Jordan

20. UPPER GI BLEEDING MANAGEMENT
Most Have
NG Tube
Rectal Exam
Endoscopy
University of Jordan

21. UPPER GI BLEEDING IMPLICATIONS OF NG ASPIRATE
Active bleeding by endoscopy
Requires Surgery
Death
Clear
16 %
10 %
6 %
Coffee ground
30 %
13 %
Red blood
48 %
23 %
18 %
University of Jordan

22. UPPER GI BLEEDING IMPLICATION OF A CLEAR NG ASPIRATE
Endoscopic finding
Incidence ( % )
Duodenal Ulcers 30
Gastric Erosions 25
Gastric Ulcers 20
Doudenitis 7
Varices 4
Mallory Wiess 3
Others/ None 11
University of Jordan

23. UPPER GI BLEEDING MANAGEMENT
Most Have
NG Tube
Rectal Exam
Endoscopy
University of Jordan

24. UPPER GI BLEEDING MORTALITY: CORRELATION WITH STOOL AND NG COLOR
Stool color
Black
Red
Clear
5 %
7 %
Coffee ground
9 %
20 %
12 %
30 %
NG Aspirate
University of Jordan

25. UPPER GI BLEEDING MANAGEMENT
Most Have
NG Tube
Rectal Exam
Endoscopy
University of Jordan

26. UPPER GI BLEEDING INFLUENCE OF DIAGNOSIS ON OUTCOME
% Rebleeding
% Dying
Varices 60 30
Gastric Cancer 50 14
Gastric ulcers 28 6
Duodenal ulcers 24 4
Gastric erosions 15 7
Mallory Weiss 2
No diagnosis
2.5
0.4
University of Jordan

27. UPPER GI BLEEDING MANAGEMENT: Endoscopic Therapy
Prevalance
Mortality
Rebleeding rate without endoscopic therapy
Rebleeding rate with endoscopic therapy
Clean base 34 2 3
<3
Flat spot(s) 16 5 7
Clot 15 9 22
Nonbleeding visible vessel 17 11 43 23
Active bleeding 18 12 55 25
University of Jordan

28. UPPER GI BLEEDING
University of Jordan

29. UPPER GI BLEEDING
University of Jordan

30. UPPER GI BLEEDING
University of Jordan

31. UPPER GI BLEEDING
University of Jordan

32. UPPER GI BLEEDING MANAGEMENT:H2 Blockers
University of Jordan

33. UPPER GI BLEEDING MANAGEMENT: Proton Pump Inhibitors
10 studies had been published on the use of PPIs for upper GI bleeding since 1990.
Proven benefit in controlling bleeding when 80 mg bolus of Omeprazole followed by infusion for total of 160 mg/day.
Preventing rebleeding when Omeprazole orally at 40 mg twice daily.
University of Jordan

34. UPPER GI BLEEDING BLEEDING ESOPHAGEAL VARICEAL
Dilated tortuous veins of
the lower and mid
esophagus.
Secondary to portal HTN
30% mortality after the
first episode.
60% Rebleeding rate
University of Jordan

35. UPPER GI BLEEDING Esophageal Varices: Predictors of severity
High Hepatic Gradient
>12 mmHg
Degree of Cirrhosis
(Child Classification )
Size of Varices
Larger > smaller
Endoscopic Appearance
Cherry red spots
Red wale
University of Jordan

36. UPPER GI BLEEDING Esophageal Varices: Significance of hepatic gradient
University of Jordan

37. UPPER GI BLEEDING Esophageal Varices: Influence of endoscopic appearance
University of Jordan

38. UPPER GI BLEEDING Esophageal Varices: Influence of degree of Cirrhosis1 2 3
Bilirubin ( mg/dl)
<2.0
2-3
>3.0
INR
<1.7
>2.3
Albumin (mg/dl)
> 3.5
<2.8
Encephalopathy
None
I-II
III-IV
Ascites
Slight
Moderate
Tense
University of Jordan

39. UPPER GI BLEEDING Esophageal Varices: Influence of degree of Cirrhosis
A < 7 points
B 7-9 points
C >10 points
University of Jordan

40. UPPER GI BLEEDING Esophageal Varices: Relation of size to bleeding
University of Jordan

41. UPPER GI BLEEDING Esophageal Varices: Active Bleeding
University of Jordan

42. UPPER GI BLEEDING Esophageal Varices: Management
Assessment / Resuscitation
Pharmacological Therapy
Somatostatin or Octreotide
Vassopressin and Nitroglycerine
Endoscopy for diagnosis and therapy
Variceal Banding
Sclerotherapy
Balloon Temponade
University of Jordan

43. UPPER GI BLEEDING Esophageal Varices: Vassopressin
Splanchnic vasoconstriction and decrease portal blood flow
Controls bleeding in 50%.
High side effects profile with 50% develops chest pain while on treatment.
Nitroglycerin decreases CP but cause hypotension.
U/min Infusion
University of Jordan

44. UPPER GI BLEEDING Esophageal Varices: Somatostatin and Octreotide
Decrease portal pressure and collateral blood flow.
Equivalent to sclerotherpy in controlling bleeding.
More effective than Vassopressin with less side effects.
Used as initial therapy
University of Jordan

45. UPPER GI BLEEDING Esophageal Varices: Endoscopic banding
Bleeding control in 90%.
Rebleeding rate reduced to 30%.
Comparing to sclerotherapy
Less rebleeding
Lower mortality
Less complications
Fewer treatment sessions
University of Jordan

46. UPPER GI BLEEDING Esophageal Varices: TIPS
Technical success in 90%
Control of bleeding in > 90%
Immediate procedural complications around 10%.
Late complications
Encephalopathy 20-30%
Heart failure 40%
University of Jordan

47. University of Jordan

48. University of Jordan