1. UPPER GASTROINTESTINAL BLEEDING What Undergraduates should know ?
Prof SM Chandramohan
Prof and HOD
Department of Surgical Gastroenterology and
Center of Excellence for Upper GI Surgery
Madras Medical College and
Rajiv Gandhi Government General Hospital
Chennai

2. Can download this presentation from www.esoindia.org
Prof SM Chandramohan
Prof and HOD
Department of Surgical Gastroenterology and
Center of Excellence for Upper GI Surgery
Madras Medical College and
Rajiv Gandhi Government General Hospital
Chennai

6. DEFINITION CAUSES EVALUATION TREATMENT
PLAN OF THE TALK
CAUSES
EVALUATION
TREATMENT

7. DEFINITION CAUSES EVALUATION TREATMENT
PLAN OF THE TALK
CAUSES
MEDICAL
ENDOSCOPIC
SURGICAL
EVALUATION
TREATMENT

8. DEFINITION Any bleeding from The gastrointestinal Tract above the
Level of
ligament of Treitz
is upper GI Bleeding

9. DEFINITIONS Acute GI bleed Overt vs. occult < 3 days duration
hemodynamic instability
requires blood transfusion
Overt vs. occult
overt = visible blood (melena, bright red blood, coffee grounds)
occult = only detected by lab tests

11. COMMON CAUSES OF UGI BLEED%
Peptic Ulcer
38%
Varix
16%
Tumor 7%
MW Tear 4%
Erosions
Esophagitis
13%

12. NSAID
(1) the risk of gastric ulceration is increased to a greater extent than that of duodenal ulceration
(2) the risk of bleeding varies with the individual NSAID; for example, the relative risk of bleeding is greatest with piroxicam and less with ibuprofen
(3) the risk of bleeding is dose dependent
-age greater than 75 years,
-history of heart disease,
-history of peptic ulcer
- history of previous gastrointestinal bleeding
RISK FACTORS

13. A
AIRWAY B
BREATHING C
CIRCULATION

14. Examination
Tell tale signs…
Chronic Liver Disease
Portal Hypertension

18. Not to miss…….. Examination Haemodynamic stability
Signs of coagulation dysfunction
Signs of Liver cell failure PR

21. Bleeding PR

22. Resuscitate and Examine Simultaneously…….
As he comes………….
Resuscitate and Examine Simultaneously…….

23. Form a team………. Wide bore IV line…… preferably central line
(take samples at the same time)
Naso gastric tube
Urinary Catheter
ALERT OTHERS IN TEAM…….

24. Blood Sample for
Blood Group Haemogram including platelets Coagulation profile Liver function test Renal function Markers

25. Blood Sample
TRY NOT TO TAKE SAMPLES FREQUENTLY Except for serial evaluation

26. WHICH TUBE AND WHY?

27. Naso Gastric Tube or Senstaken tube?

28. ROLE OF NASOGASTRIC TUBE
10 % of UGIB presents as LGIB
Red blood vs coffee grounds
NGT clears the gastric field for endoscopic visualization
prevent aspiration of gastric content

30. Endoscopy
When to do?
What is Possible?
When not to do???

31. Endoscopy
One stop Shop
Diagnose
Assess
Treat
Reassess

32. ENDOSCOPIC EVALUATION
If Hemodynamically stable
Identify Bleeding site
Delineate cause
Allow endotherapy

35. ENDOSCOPIC MANAGEMENT
VARICEAL
NONVARICEAL

36. ENDOSCOPIC VARICEAL LIGATION
A rubber band is placed over the varix which
then undergoes thrombosis,sloughing,fibrosis.

40. ENDOSCOPIC SCLEROTHERAPY
Involves injecting a sclerosant
Intravariceal/perivariceal
Common sclerosants
Ethanolamine oleate
Absolute alcohol
Sodium morrhuate
Sodium tetradecyl
Hypertonic saline
Polidocanol

42. GLUE THERAPY Cyanoacrylate is a glue that is injected into
Gastric varices
Acts by forming a Cast over the varix on contact
with blood

44. Endoclip

45. DEFINITIVE MANAGEMENT OF NON VARICEAL BLEED
ULCERS IN
POSTERIOR WALL BULB-GDA
HIGH RISK
ULCER
FOR
BLEED
ULCERS IN THE HIGH LESSER CURVE - LGA
SRH/LARGE ULCER >2 cm

46. Non-Variceal - Modalities
Injection Therapy
(a) Adrenaline
(b) Sclerosants
Thermal Therapy
(a) Monopolar
(b) Bicap
(c) Heater Probe
(d) Argon Plasma Coagulation
(e) Laser
Mechanical Therapy
(a) Haemoclips
Endoscopic Management

47. Bleeding Peptic Ulcer - Stigmata
Forrest
Classification
1a – Spurting vessel
1b – Oozing from a vessel
2 – Clot in the ulcer base
3 – Ulcer without bleed
Endoscopic Management

51. SECOND LOOK ENDOSCOPY It is repeat endoscopy 24 hours after initial
Endoscopic hemostasis
INDICATIONS
1 Incomplete first endoscopic examination due
to blood obscuring the field
2 Patients with clinically significant rebleeding

52. WHEN TO CALL IT AS
FAILED ENDOTHERAPY?

53. SURGICAL MANAGEMENT OF UGI BLEEDING
The Need
Only in Select Situations

54. Role of Surgery
5-10% of UGI Bleed
Mortality
3% to 14%

56. TV Vs H.PYLORI Eradication
40% to 70% of patients with a bleeding duodenal ulcers- positive for H. pylori

57. Bleeding Gastric Ulcer
Simple excision alone -rebleed in 20% of patients
10% incidence of malignancy

58. Surgical options- Variceal bleeding
Shunt Or Devascularisation

59. Less Common Causes of UGIB

60. Managed with 1 Hemoclips 2 MPEC Probes 3 PPI
MALLORY WEISS TEARS
Managed with
1 Hemoclips
2 MPEC Probes
3 PPI

61. Mallory-Weiss Tears
Angiographic embolization – in cases of failed endoscopic therapy
High gastrotomy and suturing of the mucosal tear – failure of all methodes

62. DIEULAFOY’S LESION large submucosal artery
that protrudes through mucosa
at the gastric fundus.
bleeding can be massive
Endoscopic Doppler USG can
help localize
Endoscopic hemostasis -injection therapy , Thermal probe, clips.

63. Dieulafouy’s lesion

64. DIEULAFOY'S LESION
Failed endoscopic therapy - angiographic coil embolization
Surgical intervention - prior endoscopic tattooing
Gastrotomy - bleeding source can be oversewn
Partial gastrectomy - the bleeding point not identified

65. GASTRIC ANTRAL VASCULAR ECTASIA-GAVE
rows of ectatic mucosalVessels(WATERMELON STOMACH)
most patients present with persistent, iron deficiency anemia from continued occult blood loss.
It is managed with
1 APC-argon Plasma coagulation
2 MPEC
Multiple sessions may be needed to eradicate
the lesions.

66. PPPRE APC
PPPOST APC

69. Gastric Antral Vascular Ectasia
Endoscopic therapy - successful in up to 90% of patients
Failure of endoscopic therapy - antrectomy

70. SEVERE PORTAL HYPERTENSIVE GASTROPATHY
May present with acute or
chronic bleed.
No role for endoscopic
management.
Managed with B Blockers, TIPS,
Surgical Porto Caval shunt,
Liver transplantation.

71. HEMOBILIA The diagnosis can be confirmed By Side viewing Scopy
Ongoing or Recurrent bleed is
Treated with angioembolization
CAUSES-HEMOBILIA
Liver trauma
Liver biopsy
ERCP/PTC/TIPS
HCC, CHOLANGIOCARCINOMA
Biliary parasite infestations

72. HEMOSUCCUS PANCREATICUS
The diagnosis can be made
by Side viewing scopy
Management is by
angioembolization
CAUSES-HEMOSUCCUS PANCREATICUS
Acute pancreatitis/chronic pancreatitis
Pancreatic pseudocyst
Pancreatic cancer
ERCP manipulation of PD
Rupture of splenic artery pseudoaneurysm into PD

73. ANGIOEMBOLIZATION

74. STRESS GASTRITIS Surgery - rarely indicated
Vagotomy and pyloroplasty, with oversewing of the hemorrhage, or near-total gastrectomy - mortality rates as high as 60%

75. Malignancy
Endoscopic therapy - successful in controlling hemorrhage, the rebleeding rate is high
Standard cancer operations - indicated when possible
Palliative wedge resections – to control bleed

76. Aortoenteric Fistula Ligation of the aorta proximal to the graft
Removal of the infected prosthesis
Extra-anatomic bypass
Defect in the duodenum - small and can be repaired primarily
Typically, patients with bleeding from an aortoenteric fistula will present first with a “sentinel bleed.”

77. MORTALITY
7% to 10%.
The mortality has decreased only minimally during the last 30 years, despite the introduction of endoscopic therapy that reduces the rate of rebleeding.
increasing percentage of UGIB occurring in the elderly
frequent use of antiplatelet medications or anticoagulants
frequent comorbid conditions.

78. Conclusion