1. Management of acute upper GI haemorrhage

2. Causes Peptic ulcer 35-50% Gastroduodenal erosions 8-15%
Oesophagitis %
Varices %
Mallory Weiss tear %
Upper GI malignancies %
Vascular malformations %
Rare %

3. Initial resuscitation
Two large bore cannulae and take sample
Normal saline 1-2 lt fall of pulse/improved BP/adq urine
Plasma expander if still shocked
Blood transfusion - haematemesis/shock
- Hb <10

4. Severity of bleed
Current clinical scoring system( Rockall) for risk of re-bleed or death involves OGD
So definition of mild/mod/severe remains a matter of clinical judgement

5. Mild to moderate bleed Pulse/BP normal Hb >10
Insignificant comorbidity
Mostly <60 yrs
General ward
Allowed fluid if stable
BP/pulse hourly
Monitor urine volm
Endoscopy next available list
Early discharge

6. Excellent prognosis if no SRH/varices/malignancy
Continued
Excellent prognosis if no SRH/varices/malignancy
Subsequent management
May include H.Pylori eradication
Use of acid suppressing treatment
Advice concerning NSAIDs

7. Severe bleed Pulse>100 SBP < 100 Hb < 10
Significant comorbidity
Mostly >60 yrs
Preferably HDU
Hrly BP/pulse/ urine volm
Fasted
Urgent endoscopy after resuscitation

8. Endoscopy in acute upper GI haemorrhage
Semi-elective in minor and urgent in major bleed
Only after initial resuscitation
Best done in endoscopy unit
But out of hours ,operating theatre with full resus. Equipment and anaesthetist may be better option
Only expert endoscopists
Consider ET tube to prevent aspiration

9. Endoscopic finding & subsequent management
No SRH : general ward
Varices : VBL/VScl
Ulcer with SRH : endoscopic haemostasis adrenaline inj
2.heat application
3.mechanical clips

10. Drug therpy for non-variceal principally ulcer bleed
Evidence suggests following successful endoscopic treatment in patient presenting with major ulcer bleed high dose omeprazole stabilizes clot and prevents rebleed
omeprazole 80mg iv stat followed by 8mg per hour infusion for upto 72 hrs

11. After endoscopy Close monitor to identify rebleed
If stable after 6hrs allow light diet ( no data suggesting prolong fasting necessary)
Repeat endoscopy
If active rebleed
If concern re optimal initial therapy (after hrs)

12. Surgical intervention
If endoscopic therapy unsuccessful
In rebleed it is advisable to repeat endoscopy to confirm bleed and also try offer one more time of endoscopic therapy before considering surgery if it was initially successful
In massive rebleed sometimes surgical intervention is needed straightway if initial OGD was unfavourable

13. Surgical options Duodenal ulcers Gastric ulcers
Under running ±ligation of gastroduodenal/rt gastroepiploic arteries
Gastrectomy to include the ulcer with Billroth I or II reconstruction
Gastric ulcers
Excised
Parial gastrectomy
Under running if elderly with poor condition

14. Follow up For ulcer bleeds standard ulcer healing treatment
In most cases this also involves H.Pylori eradication
Ulcer associated with NSAID -stop drug or choose the least damaging one
Re-endoscope GU in 6wks to ensure healing. Not necessary for DU.

15. Additional points for variceal haemorrhage
For no varix on initial endoscopy repeat 3yrly
For grade 1 varix yearly F/U
Primary prophylaxis with propranolol (80-160mg) for all grade 2/3 oesophageal varices
If unsuitable for ppnl, VBL is next option
ISMN

16. Acute management of variceal haemorrhage
Antiobiotic prophylaxis for all patients ciprofloxacin 500mg BD for a week
VBL is method of choice for OV
VScl if above difficult or unavailable
If endoscopy unavailable vasoconstrictor therapy or balloon tamponade with Sengstaken tube while more definitive therapy is arranged

17. continued
Pharmacological therapy is with two major classes of drugs –vasopressin or its analogue terlipressin (glypressin) and somatostatin or its analogue octreotide
Terlipressin is given as 2mg iv bolus followed by 1-2mg every 4-6 hrs for up to 72hrs

18. OV BLEED
Controlled – banding eradication programme. One band /wk. F/U at 3& 6 month and then yearly
Uncontrolled –balloon tamponade until further endoscopic treatment/ TIPSS/surgical intervention
Choice of TIPSS or surgical intervention such as oesophageal transection depends on centre’s preference

19. GV bleed If IGV initial sclerotherapy with butyl-cyanoacrylate
If unsuccessful balloon tamponade prior to more definitive treatment

20. Secondary prophylaxis of variceal haemorrhage
banding eradication programme
TIPSS
Portocaval shunt surgery

21. Thank you