1. Professor Altaf Talpur Surgical unit -3
UPPER GI BLEEDING
Professor Altaf Talpur
Surgical unit -3

2. Outline Introduction Treatment Aetiology Complications Presentation
Resuscitation
Diagnosis
History
Clinical examination
investigations
Treatment
Complications
Follow up
Prognosis
conclusion

3. Introduction Bleeding of GIT proximal to ligament of treitz.
Ligament of treitz- a fibromuscular band which extends from right crus of diaphragm to duodenojejunal flexure.

4. Presents as:
Haematemesis,, malena, hematochezia or occult blood.
Malena can present with loss of 50-60ml of blood.
May be acute or chronic
100 cases per 100,000 person per year.

5. Accounts for 3-5% of all hospitalizations
The incidence is 2- fold greater in males but death rate is similar in both sexes.
Overall mortality from acute bleeding is 20% .
Mortality & morbidity increases as age advances (>60 yrs)

6. Etiology of upper GI bleeding

7. Aetiology (Common causes)
Peptic ulcer disease
≥ 50% of cases
Duodenal ulcer
Gastric ulcer
Stomal ulcer

9. Aetiology (Common causes)
Erosive gastritis,
esophagitis, duodenitis
15-30% of cases
Common causative factors are:
ETOH [alcohol], ASA, NSAID’S,STEROIDS.

10. Erosive gastritis

11. Aetiology (Common causes)
Esophageal and gastric varices
10-20% of cases
caused by portal hypertension

12. Esophageal varices

13. Aetiology (Common causes)
Mallory- Weiss syndrome
5% of cases
Characterized by longitudinal mucosal tear in the cardioesophageal region.
Result from repeated vomitting or retching.
Common in male alcoholic patients

14. Mallory Weis Syndrome

15. Aetiology Less common Rare Oesophagitis Malignant gastric tumor
Benign gastric tumors
Oesophageal ulcer
Oesophageal tumors
A-V malformations
Rare
Duodenal tumous
Pancreatic tumors
Arterial aneurysm
Blood dyscrasia
Hereditary telangiectasia
Haemobilia

16. Malignancy In 3% of cases presentation is with upper GI bleeding
Gastric cancer
Oesophageal cancer

17. ESOPHAGEAL TUMORS

18. GASTRIC TUMORS

19. Clinical presentation
Chronic upper GI bleeding
Anemia.
Weakness.
Fatigueness.
Pt :looks pale.
Malena.
Occult blood positive.

20. Acute upper GI bleeding
Presents as emergency with hemetemesis or malena.
Hypovolaemia:
Mild: no significant hypovolaemia.
Moderate: hypovolaemia which responds to volume replacement.
Severe: hypovolaemia with continued active major bleeding making resuscitation difficult even with blood transfusions.
These patients are difficult to manage.
Patients will show all signs of shock.

21. Note: all patients should be examined for stigmata of CLD.
H/O drugs (NSAIDS).
H/O ulcers.
H/O alcohol abuse.

22. Resuscitation Initial management has 4 primary goals:
Quick assessment with attention to hemodynamic status
Appropriate resuscitation (ABC) & monitoring
Identify major source of bleeding
Specific therapeutic intervention.

23. Resuscitation (General measures)
Airway cleared of clot.
Oxygen inhalation.
Maintain IV line with at least 2 wide bore cannulae
Sample to blood bank for cross matching.
Class I + II hemorrhage replace with crystalloid.
Class III + IV hemorrhage replace with crystalloid & blood.
Pass NG tube for diagnostic & therapeutic purpose.
Catheterize the patient.
Sedation may be needed.

24. SEVERITY

25. Specific measures
If stable following resuscitation, proceed for upper GI endoscopy.
Endoscopy ideally done within 4-24 hrs.
If patient could not be stabilized, an emergency laparatomy may be necessary.

26. Diagnosis History of: Epigastric pain or retrosternal burning
hematemesis, melena, or hematochezia.
Vomiting, weight loss, alteration of bowel habits.
Aortic graft surgery
Use of ASA, NSAID’S, steroids, alcohol addiction

27. Diagnosis Physical examination
Vital signs may show hypotension & tachycardia.
Cool, clammy skin.
Petechiael hemorrhage & purpura seen in coagulopathy.
Signs of chronic liver disease.
Proper abdominal & rectal examination.

28. Investigations Upper GI endoscopy. Arteriography. Barium swallow
Ultrasound
Lab investigations

29. Endoscopy Most important investigation For diagnosis & intervention
Establishes diagnosis in 90% of patients
Can be repeated more than once.

30. Arteriography
In pts who bleeds contineously & site can not be identified.
Has accuracy of 50-90%.
Accuracy is increased if there is active bleeding during investigation.
Demonstrates bleeding of ml/min
With technetium-labelled RBC, ml/min
Embolisation may be done at same time

31. Barium swallow / meal Used when endoscopy is not available
Double contrast study is ideal
May show varices, esophagitis, peptic ulcers, gastric tumors etc

32. Abdominal Ultrasound scan
To assess both liver architecture and portal circulation
More widely available than Arteriography
Should be performed before more invasive procedures

33. Lab Investigations CBC Electrolytes Glucose Coagulation studies
Liver function studies
Blood grouping and cross-match

34. Lab investigations CBC, urea/creatinine, S/Electrolytes, ABGs.
ed urea/ creatinine in upper GI bleeding.
Normal Hb in pts with active bleeding.
Iron deficiency anemia in chronic blood loss.

35. Treatment ( peptic ulcer disease)
At endoscopy
10ml epinephrine at ulcer base
Thermal treatment with bipolar diathermy
Laser photocoagulation
Rebleed is treated similarly
A second rebleed is treated by surgery

36. Post endoscopy treatment
Continuous intravenous infusion of Octretide (somatostatin analogue)
Proton pump inhibitors
H. pylori treatment may be required.

37. Surgery- PUD Surgical options are: Truncal vagotomy & drainage
Highly selective vagotomy
Partial gastrectomy

38. Surgery - PUD Indications for surgery are: Exsanguinating hemorrhage
Visible spurting arterial bleed
Concomitant perforation
Pts >60 yrs, who rebleed once or need 4 units at resuscitation or 8 units in 48 hrs
Younger pts requiring 8 units at initial resuscitation or 12 units in 48 hrs
Rare blood group

39. Treatment Gastric erosions / stress ulcers
Treatment of underlying cause
Intraluminal antacids
IV proton pump inhibitors
Bleeding usually subsides in hrs

40. Treatment Esophageal varices
1. Endoscopic sclerotherapy
Repeated at 3 weeks interval then 3 monthly until varices disappear
Some sclerosing agents are ethanolamine oleate, sodium morrhuate, 3% tetradecyl sulphate, absolute alcohal
2. Rubber band ligation
3. Vasoconstriction therapy (octreotide, vasopressin, propranolol)

41. Sclerotherapy of esophageal varices

42. Esophageal variceal Banding

43. 4. Balloon tamponade: if above measures fail
Modified Sengstaken- Blakemoore tube
Minnesota tube, Linton tube, Foley catheter
Balloon tamponade applied for 12 hrs
Stop bleeding in 80% of cases
Must be followed by surgery as bleeding is likely to recur after removal.

44. Balloon temponade

45. Surgery – esophageal varices
TIPS: in refractory bleed
Shunt established between portal vein & Rt or middle hepatic vein
Stapling transection of esophagus at CEJ
Distal splenorenal shunt
Portosystemic shunts
Spleenectomy in hypersplenism
Liver transplantation

46. Transjuglar intrahepatic portosystemic shunt [TIPS]_

47. Treatment Mallory- weiss Esophagitis Benign gastric tumors
observe
if persist, suture mucosal tear
Esophagitis
Observe
Benign gastric tumors
Excise
Dieulafoy’s lesion
Endoscopic electrocoagulation, sclerotherapy

48. Complications Of presenting problem Of resuscitative measures
Of underlying disease
Of treatment

49. Complications of massive hemorrhage
Hemorrhagic shock
Acute renal shut down
MODS
Death

50. Complications of resuscitation
Fluid overload
Pulmonary edema
CCF
Blood transfusion reaction
Cardiac arrest
Hypothermia
Esophageal perforation

51. Complications of underlying diseases
Rebleed in PUD & varices
Gastric outlet obstruction in PUD
Progressive CLD causing portal hypertension, ascites & coagulopathies

52. Complications of definitive surgery
PUD
Early & late dumping
gastric tumors
Iron deficiency anemia
Bypass procedures for portal hypertension
mucosal ulceration
Hepatic encephalopathy

53. Follow-up To monitor progress of non- surgical treatment
To prepare pts for elective definitive surgery
To look out for, and treat complications of surgery

54. Prognosis Depends upon ROCKALL scoring system this includes :
The state / time of presentation of pt
energetic resuscitation
underlying disease
Co morbidities

55. ROCKALL SCORING SYSTEM

56. Adverse prognostic factors

57. Conclusion
Upper GI bleeding is not uncommon & may be life threatening.
Prompt intervention could be life saving.
It require multidisciplinary approach.
Definitive treatment depends upon the final diagnosis.

58. THANK YOU