MANAGEMENT OF UPPER GI BLEEDING M K ALAM MS; FRCSEd.

MANAGEMENT OF

UPPER GI BLEEDING

M K ALAM MS; FRCSEd

ILOsAt the end of this presentation students will be able to: 

Define upper GI haemorrhage.

Describe the resuscitative measures.

Enumerate the causes of upper GI bleeding.

Describe the symptoms & signs of UGI bleeding.

Describe diagnostic work up.

Describe the non-surgical management and

indications for surgical intervention.

Introduction

• UGIB is defined as bleeding derived from a

source proximal to the ligament of Treitz.

UGIB

• A potentially life-threatening emergency.

• A common cause of hospitalization

• More common in male.

• 4 times more common than lower GI bleeding.

• Mortality 6-10%

Mortality in UGIB

• Comorbid illness (72%) rather than actual

bleeding, is the major cause of death.

• Comorbid illness- 51% of patients.

• Rebleeding or continued bleeding- associated

with increased mortality

Causes of UGIB

• Peptic ulcer disease (duodenal & gastric ulcer)

• Oesophageal varices (portal hypertension)

• Mallory-Weiss syndrome- mucosal tears of the esophagus.

• Erosive gastritis /esophagitis.

• Dieulafoy lesion.

• Gastric cancer.

• Ulcerated gastric stromal tumor (GIST)

• Aortoenteric fistula- erosion of the aortic graft into the bowel.

• Angiodysplasia- dilated, thin-walled vessels appearing as cherry spots

Pathophysiology

• Arterial hemorrhage- ulcer disease, mucosal tears

as in Mallory-Weiss syndrome.

• Low-pressure venous hemorrhage, as in

telangiectasias.

• Variceal hemorrhage is due to elevated portal

pressure (>12 mmHg) transmitted to esophageal and

gastric varices and resulting in rupture of varices.

Mucosal ulceration can be a bleeding source.

Peptic ulcer disease (PUD)

• The most common cause of UGIB.

• High-risk for PUD: Alcohol abuse, chronic renal failure, and/or

nonsteroidal anti-inflammatory drug (NSAID) use.

• Duodenal ulcers are more common than gastric ulcers

• Ulcer burrows deeper into the mucosa, causes weakening and

necrosis of the arterial wall, leading to a pseudoaneurysm. The

weakened wall ruptures, producing hemorrhage.

• Approximately in 80% bleeding from PUD stops spontaneously.

Bleeding Prepyloric ulcer

Oesophageal Varices• Portal hypertension leads to portosystemic shunting.

• Leads to the development of varices in the lower oesophagus

and gastric fundus

• Elevated portal pressure transmitted to esophageal / gastric

varices resulting in rupture of varices.

• Mucosal ulceration can be a bleeding source.

• Normal portal pressure 5-15 cm of H₂O

• Bleeders- usually > 25 cm of H₂O

• 20 % may have peptic ulcer or gastritis

Causes of portal hypertension

• Pre-hepatic: Congenital atresia of PV, PV thrombosis, Compression of PV (tumours)

• Intrahepatic: Pre-sinusoidal- Schistosomiasis Sinusoidal- Cirrhosis

• Post-hepatic (Post-sinusoidal): Budd-Chiari syndrome,

Constrictive pericarditis

Bleeding Oesophageal Varices

Bleeding Oesophageal Varix

Mallory-Weiss syndrome

• Mallory-Weiss tears -15% of acute upper UGIB

• Mucosal laceration- result of forceful vomiting

• 80-90%- tear along the lesser curve of the stomach just

distal to the gastro-esophageal junction

Mallory-Weiss syndrome

Acute stress gastritis

• Seen in shock, multiple trauma, acute respiratory distress syndrome, systemic respiratory distress syndrome, acute renal failure, and sepsis patients.

• Predisposing conditions alter local mucosal protective barriers, such as mucus, bicarbonate, blood flow, and prostaglandin synthesis.

• Disruption of balance of these factors results in diffuse gastric mucosal erosions.

• The principal mechanisms- decreased splanchnic mucosal blood flow and altered gastric luminal acidity.

Acute stress gastritis

Dieulafoy lesion

• A vascular malformation of the proximal stomach.

• 2-5% of acute UGIB episodes.

• Endoscopic appearance: large ulcerated submucosal vessel.

• Bleeding can be massive and brisk.

• Vessel rupture occurs in the setting of chr. gastritis

• Alcohol use is associated with the Dieulafoy lesion.

• Mostly- men in their third to tenth decade.

• Can occur anywhere along the GI tract

Dieulafoy lesion

GIST (gastrointestinal stromal tumour)

• Mesenchymal tumour, submucosal lesions

• 50-60%- stomach

• 20-30%- small intestine

• 10%- rectum

• Benign or malignant (positive for c-Kit oncogene)

• Pacemaker cells in smooth muscle

• Asymptomatic, bleeding or obstruction

Bleeding GIST of the stomach

Gastric carcinoma

• Common- chronic blood loss (anaemia)

• Haematemesis- uncommon

Gastric carcinoma

NSAID in UGIB

• Cause gastric and duodenal ulcers by inhibiting

cyclooxygenase - ↓ mucosal prostaglandin

synthesis- results in impaired mucosal defenses.

• Daily NSAID: 40-fold increase in gastric ulcer &

8-fold increase in duodenal ulcer creation.

Symptoms and signs

• Hematemesis• Melena• Hematochezia • Syncope• Dyspepsia• Epigastric pain• Heartburn• Diffuse abdominal pain• Dysphagia• Weight loss• Jaundice

Initial workup

• Vital signs: Pulse, BP

• CBC: WBC with differential, platelet

• Hemoglobin level

• Coagulation profile (PT, PTT, INR)

• Type and crossmatch blood

• U & E, LFTs

• Nasogastric lavage

Diagnosis

• Nasogastric lavage

• Endoscopy

• Chest radiography

• Gastrin level

• Angiography (persistent bleeding, source not identified by endoscopy)

• CT scan & ultrasonography: Liver disease with cirrhosis Pancreatitis with pseudocyst and hemorrhage Aortoenteric fistula

Management- Resuscitation

• Airway + O₂

• Two peripheral IV lines

• X-match, CBC, u/e, coagulation profile, LFTs

• Crystalloid solution (RL)- 3:1 ratio

• NG tube: Gastric wash, monitor bleeding, prevent aspiration.

• Foley catheter- evaluation of urinary output.

• Endoscopic hemostatic therapy.

• Peptic ulcer patients: 80 mg IV PPI.

Endoscopic hemostatic therapy in bleeding peptic ulcers

• Endoscopy: Diagnose + control of bleeding.

• Injection of 1:10,000 adrenaline

• Heater-probe coagulation

• Laser or bipolar electrode coagulation

• Clips or bands

Bleeding peptic ulcer

Recurrent bleeding

• A minority - recurrent bleeding after endoscopic therapy

• Risk factors for rebleeding: Age>60 years,

Presence of shock upon admission,

Coagulopathy,

Active pulsatile bleeding,

Presence of cardiovascular disease.

• H pylori infection- recurrent bleeding is extremely low.

Indications for surgery in bleeding peptic ulcers

• Life-threatening bleeding not responding to resuscitation.

• Failure of endoscopic hemostasis or recurrent bleeding

• Prolonged bleeding, with loss of 50% or more of the

patient's blood volume

• A second hospitalization for peptic ulcer bleeding.

• A coexisting perforation or obstruction.

• Failure of medical therapy

Management of recurrent bleeding

• Re-endoscopy to achieve hemostasis.• Surgical management: • Duodenal ulcer:

A) Duodenotomy+ under-run with suture + anti- ulcer medications. B) (?) Duodenotomy+ under-run with suture + anti-ulcer surgery- pyloroplasty+ bilateral truncal vagotomy

• Gastric ulcer:Young & fit- wedge excision of ulcer.

Old & unfit- Under-run the bleeding point+ biopsy

Benign ulcer: Anti-ulcer medical treatment.

Malignant ulcer: Staging the disease, surgery if indicated.

Acute variceal bleeding- management

• Octreotide infusion- lowers portal pressure

• Endoscopic banding

• Endoscopic injection sclerotherapy

• Balloon tamponade

• TIPPS (Transjugular intrahepatic portosystemic shunting)

• SURGERY: • Gastro-oesophageal devascularization + stapled oesophageal transection

• Liver transplantation

Sengstaken-Blakemore Tube

TIPPS

Band ligation of OV

Endoscopic sclerotherapy for OV

Prognosis• Risk factors associated with:

Increased mortality, recurrent bleeding, the need for endoscopic hemostasis, or surgery :

• Age >60 years• Severe comorbidity• Active bleeding (witnessed hematemesis, blood in nasogastric tube,

fresh blood per rectum)

• Hypotension• Blood transfusion ≥ 6 units• Inpatient at time of bleed• Severe coagulopathy

Management of uncommon causes of UGI bleeding

• Conservative/ endoscopic management:

Mallory-Weiss syndrome-

Erosive gastritis /esophagitis.

Dieulafoy lesion.

• Surgical management after stabilization and diagnosis:

Gastric cancer.

Ulcerated gastric stromal tumor (GIST)

Thank you!