Approach to upper GIT bleeding (UGIB)

Approach to Upper GIT
Bleeding (UGIB)
Shaimaa Elkholy, M.D.
Cairo University, Egypt

5 Q??
• Who ??
• Why ??
• How ??
• When ??
• What ??
Shaimaa Elkholy, M.D. Cairo University

Agenda
• Definitions
• Epidemiology
• Aetiology
• Initial Evaluation
• General management
• Risk stratification
• Management of VGIB
• Management of NVGIB
• Take home message

Definitions:
UGIB : bleeding from GIT above ligament of trietz.

Definitions:
• Hematemsis: vomiting of blood or coffee-
ground like material suggests bleeding
proximal to the ligament of Treitz.
• Melena: black, tarry stools originates proximal
to the ligament of Treitz (90 %), or from the
small bowel or right colon.
• Hematochezia: red or maroon blood in the
stool is usually due to lower GI bleeding. It can
occur with massive upper GI bleeding.

Epidemiology :
• Acute (UGIB) is a GIT emergency with a
mortality of 4%-14% despite advances in
critical care monitoring and support.
• Spontaneous cessation of bleeding occurs in
85% of cases.
• UGIB in the UK ranges between 84-172 per
100,000 per year, causing 50-70,000 hospital
admissions per year.
• Major cases due to PUD.

• UGIB in the United States is 160 hospital admissions
per 100,000 population, which translates into more
than 400,000 per year.
• 80 to 90% have NVGIB mainly PUD.
• An increasing proportion related to the use of aspirin
/NSAIDs.
• PUD bleed is seen predominantly among the elderly,
68% > 60 years/ 27% > 80 years.
• Mortality remains high at 5-10%&medical costs for
the in-hospital care>$ 2 billion annually in US.
Epidemiology :

Aetiology of UGIB:
• Peptic ulcer disease — 55 %
• Oesphgealgasrtic varices — 14 %
• A-V malformations — 6 %
• Mallory-Weiss tears — 5 %
• Tumors and erosions — 4 %
• Dieulafoy's lesion — 1 %
• Others 11 % .

Other rare cases:
• Idiopathic angiomas
• Osler-Weber-Rendu syndrome
• Radiation-induced telangiectasia
• Traumatic or post-surgical
• Foreign body ingestion
• Post-surgical anastamosis
• Aortoenteric fistula
• Post gastric/duodenal polypectomy
• Hemobilia
• Hemosuccus pancreaticus

EGYPTIAN scenario:
• Variceal causes of bleeding were the most
common, representing 70.1% followed by
non-variceal causes (26.1%) and obscure
causes (3.8%).
• Gastric lesions were the most common causes
of non variceal bleeding.

VGIB:
• Variceal hemorrhage is the most common
fatal complication of cirrhosis.
• At the time of diagnosis:
30% of cirrhotic patients O.V.
90% after approximately 10 years.
• Bleeding ceases spontaneously in up to 40%

• Correlation to the severity of liver disease:
 Child–Pugh A patients: 40% have varices
 Child–Pugh C patients: 85% have varices
• Some patients may develop varices and hemorrhage
early in the course of the disease, even in the absence
of cirrhosis
• Patients with hepatitis C and bridging fibrosis: 16%
have esophageal varices
VGIB:

Prognosis:
• Bleeding O.V. occurs 30 % in
the 1st year after diagnosis.
• The mortality during the
attack:
 < 10% Child–Pugh grade A
 > 70% in advanced Child–
Pugh C cirrhotic stage.
• Bleeding O.V. mortality rate
20% at 6 weeks.
• The risk of re-bleeding is
high, reaching 80% within 1
year.
• High Portal venous pressure
> 20 mmHg :
 REBLEEDING : 1st week of
admission
 Failure to control bleeding
(83% vs. 29%)
 Higher 1-year mortality rate
(64% vs. 20%).

Small varices Large varicesNo varices
7-8%/year 7-8%/year
Varices Increase in Diameter Progressively
Merli et al. J Hepatol 2003;38:266
VARICES INCREASE IN DIAMETER PROGRESSIVELY

I. Dilated venes (< 5mm) still at the level of the surrounding
tissue
II. Dilated, straight venes (> 5 mm) protruding into the
esophageal lumen but not obstructing it
Grades of O.V.:

III. Large, tense and winding venes already obstructing the
esophageal lumen considerably
IV. Near complete obstruction of the esophageal lumen with
impending danger of hemorrhage (cherry red spots)

NVGIB :
Peptic ulcer disease:
• The mortality associated with acute bleeding
from a peptic ulcer remains high (5 to 10%).
• 4 risk factors:
H. pylori infection
NSAIDs
Stress
Gastric acid
Alcoholism

FORREST - classification of upper gastrointestinal hemorrhage
Acute hemorrhage
Forrest IA Active spurting hemorrhage
Forrest IB Oozing hemorrhage
Signs of recent hemorrhage
Forrest IIA Non-bleeding visible vessel
Forrest IIB Adherent clot
Forrest IIC Hematin on ulcer base
Lesions without active bleeding
Forrest III Clean-base ulcers
Bleeding PUD

Endoscopic Stigmata of Bleeding Peptic Ulcer, Classified as High Risk or Low Risk
Spurt blood (grade IA) Ooze blood (grade IB) Nonbleeding visible
vessel (grade IIA)
Adherent clot (grade IIB) Flat, pigmented spot
(grade IIC)
Clean base (grade III)

DIEULAFOY'S LESION:
• Dilated aberrant submucosal vessel
which erodes the overlying
epithelium in the absence of a
primary ulcer.
• It’s caliber 1 to 3 mm, 10-times
the normal caliber of mucosal
capillaries.
• Usually on lesser curve below the
cardia, may be found any where.

DIEULAFOY'S LESION:
• unknown, but may be congenital.
• Events triggering bleeding are also not well-
understood(?? NSAIDs).
• Male patients with comorbidities including
cardiovascular disease, hypertension, CKD ,
diabetes, or alcohol abuse.
• Bleeding is usually self limited but it may be
severe.

Mallory-Weiss syndrome:
• longitudinal mucosal lacerations
s in the distal esophagus and
proximal stomach, which are
usually associated with forceful
retching.
• secondary to a sudden increase
in intraabdominal pressure e.g.
vomiting, straining or lifting,
coughing, epileptic convulsions,
hiccups under anesthesia,
closed-chest massage, blunt
abdominal injury.

• Precipitating
factors:
hiatus hernia,
chronic alcoholism
increasing age
Mallory-Weiss syndrome:

GAVE & P.H.G:

Tumors:
Benign
Leiomyoma
Lipoma
Polyp (hyperplastic, adenomatous,
hamartomatous)
Malignant
Adenocarcinoma
Mesenchymal neoplasm
Lymphoma
Kaposi's sarcoma
Carcinoid
Melanoma
Metastatic tumor Shaimaa Elkholy, M.D. Cairo University

Pathway last updated: 22 February 2013
Copyright © NICE 2013. All rights reserved

Resuscitation and initial management:
Initial evaluation: “QUICK”
 Triage.
 General support.
 Fluid resuscitation.
 Blood transfusions.
 Nasogastric lavage.

General management:
• Triage: “QUICK”
ICU admission
Hemodynamic instability (shock, orthostatic
hypotension).
Active bleeding (manifested by hematemesis,
bright red blood per nasogastric tube, or
hematochezia).

General management:
• Support :
 oxygen by nasal cannula.
 NPO.
 Two large caliber (16-18 gauge) peripheral I.V.
Catheters.
 Central venous line if possible.
 Pulmonary artery catheter should be considered in
patients with hemodynamic instability or who need
close monitoring during resuscitation.
 Elective endotracheal intubation in patients with
ongoing hematemesis with altered respiratory or
mental status.

General management:
• Fluid resuscitation:
resuscitation and stabilization is essential prior to
endoscopy
Patients with active bleeding should receive
intravenous fluids (crystalloids or colloids)
while being typed and cross-matched for blood
transfusion.
Patients at risk of fluid overload may require
intensive monitoring with a pulmonary artery
catheter.

General management:
• Indications of blood transfusion:
• Hb below 7mg/dl (low risk).
• High risk patients (old or comorbid) 10mg/dl.
• Active (fresh) bleeding & Hypovolemea even with normal HB.
• Indications of platelet & FFP transfusion:
• low platelet count (<50,000/microL) OR INR > 1.5.
• life-threatening bleeding receiving antiplatelet or anti coagulation.
• Patients receiving massive blood transfusion due to dilutional
coagulopathy.
• Over-transfuse patients with suspected variceal bleeding can precipitate
worsening of bleeding (10 mg/dl).

General management:
• Nasogastric lavage:
• Its use before endoscopy in the ER remains
controversial.
• Benefits:
 To confirm an UGI source of bleeding(can still miss up
to 15%)
 Prognostic index for identifying high-risk lesions as
presence fresh red blood in the NGT aspirate.
 May exclude false hematemsis.
 To facilitate lavage of the upper GI tract to improve
mucosal views at subsequent endoscopy.

Risk assessment:
• Blatchford score at first assessment.
• Rockall score after endoscopy.

ScoreLow risk
defined as score
of <=2
4.3% rebleeding
0.1% mortality

Medications (pre- endoscopy):
• Acid suppression.
• Prokinetics.
• Somatostatin and its analogs in VUGIB.
• Antibiotics for patients with cirrhosis.

• Acid suppression:
• starte empirically on an I.V. PPI &continued
until confirmation of the cause of bleeding.
• I.V. of a PPI significantly reduces the rate of
rebleeding compared& hospital stay in
comparison to H2 blockers.
• 80 mg bolus followed by 8 mg/hr infusion for
72 days then switched to oral.

• Prokinetics: erythromycin & metchlopromide.
• Somatostatin, or its analog Octreotide
splanchnic vasoconstriction and decreased
portal inflow
50 mcg bolus followed by a continuous
infusion of 50 mcg per hour and is continued
for 3-5 days.

• Antibiotics for patients with cirrhosis:
• The AASLD guidelines : (max.7 days)
Oral norfloxacin (400 mg twice daily) or
intravenous ciprofloxacin
In patients with advanced cirrhosis,
I.V. ceftriaxone (1 g/day) & with a high
prevalence of quinolone-resistant organisms.

:Timing of endoscopy
• Patients with UGIB should generally undergo
endoscopy within 24 h of admission, following
resuscitative efforts to optimize hemodynamic
parameters and other medical problems

Timing of endoscopy
• Patients who are hemodynamically stable and
without serious comorbidities:
Endoscopy as soon as possible in a non-emergent
setting to identify the substantial proportion of
patients with low-risk endoscopic findings who can
be safely discharged

Timing of endoscopy
• Patients with higher risk clinical features endoscopy
within 12 h may be considered to potentially improve
clinical outcomes

Endoscopic management VUGIB:
• EIS
( endoscopic injection
sclerotherapy)
 Sclerosing materials :
ethanolamin oleate(E/O)
cyanoacrylate (H/A).
• Local complications :
 Ulceration
 Bleeding
 stricture formation
 portal hypertensive gastropathy
• Regional complications
 esophageal perforation and
mediastinitis.
• Systemic complications
 sepsis and aspiration with
ventilation perfusion mismatch and
hypoxemia

Video 1
Video 2
Video 3

• EVL:
endoscopic
variceal
ligation
• Less
complications
e.g. ulcers,
stricture
(rare).
• Less sessions.

• Endoscopic therapy should be provided to patients with
Forrest grade IA, IB, or IIA.
• Endoscopic therapy may be considered for patients with an
adherent clot resistant to vigorous irrigation.
• Endoscopic therapy should not be provided to patients who
have an ulcer with a clean base or a flat pigmented spot
(Forrest grade IIC, or III).
Endoscopic management NVUGIB:

• Mechanical method (for example, clips) with
or without adrenaline
• Thermal coagulation with adrenaline
• Fibrin or thrombin with adrenaline
• No single method of endoscopic thermal
coaptive therapy is superior to another
Endoscopic management NVUGIB:

Take home messeges
• Patient with UGIB is critically ill patient with different
presentations.
• PUD is the commonest cause world wide.
• VUGIB is commonest cause in Egypt.
• Stepped approach to UGIB has to be known.
• Resuscitation is essential prior to endoscopy.
• Indications of blood , platelets & FFP transfusion differs from one
patient to another.
• Target HB differs according to the patient.
• Risk assessment is essential in those patients by different scoring
systems.
• Forrest classification is essential to determine the line of
management.
• EVL is much preferred than injection sclerotherapy.

Thank you

Approach to upper GIT bleeding (UGIB)

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