1. Upper GI bleeding
DDX
Local
esophagus
stomach
General
duodenum
-Haemophilia
-Leukemia
-Oesophageal varices-lesser curve gastric ulcers
erode left gastric A
-Oesophageal CA
-Erosive gastritis
-Reflux oesophagitis
Commom in alcoholic.
-Mallory-Weiss
syndrome
-Gastric CA
-gastric lymphoma
-complicated Duodenal
ulcer erode
gastroduodenal A
-Thrombocytopenia
-Anti-coagulant therapy
-Duodenitis
-Periampullary tumour
-Aorto-duodenal fistula
-gastric leiomyoma
-Dielafoy’s syndrome -rare
a)History taking ::
a)History taking
1-when?
-what is the color, the appearance of the vomited blood?
-redDark red? Brown? Black?
-coffee ground appearance(suggests more limited bleeding)?
-bright red (suggests moderate to severe bleeding)? & frothy?
-have u vomited blood only once/several times?
-has the bleeding been abrupt/massive?
2-have u passed black tarry stools with vomited blood(DDX : 90%UGIB or LGIB)?
-what is the color of the stool? Bright red(most are LGIB or massive UGIB)?
-have u had, bleeding from the nose? Bloody expectoration? A dental extraction?
-have u had >1 black, tarry stool within a 24-h period?

2. -for how long have the tarry stools persisted?
Help in DDX
3-Specific symptoms of most common causes of upper GI bleeding
●Peptic ulcer: Epigastric or right upper quadrant pain
●Esophageal ulcer: Odynophagia, gastroesophageal reflux, dysphagia
●Mallory-Weiss tear: Emesis, retching, or coughing prior to hematemesis
●Variceal hemorrhage or portal hypertensive gastropathy: Jaundice, weakness, fatigue, anorexia,
abdominal distention
●Malignancy: Dysphagia, early satiety, involuntary weight loss, cachexia
4- other symptoms and sign:
-retching & severe nonbloody vomiting?
-lightheadedness? Nausea? Thirst? Sweating?
Hypovolemic
shock
-faintness when lying down/when standing/syncope?
-following the haemorrhage did you have diarrhea?
-Symptoms that suggest the bleeding is severe include orthostatic dizziness, confusion, angina,
severe palpitations, and cold/clammy extremities.
# systemic review
5-Risk factors (drug and social ):
- aspirin or (NSAIDs)? anticoagulant or antiplatelet therapy? iron preparation(black stool)?
- age of the patient?
- what is your smoke/alcohol intake?
6-Past medical and surgical Hx:
- have there been similar episode in the past? When? Diagnosis?
- were u hospitalized on this occasion? Did u receive a transfusion?
-Potential bleeding sources suggested by a patient's past medical history include:
●Varices or portal hypertensive gastropathy in a patient with a history of liver disease or alcohol abuse
●Aorto-enteric fistula in a patient with a history of an abdominal aortic aneurysm or an aortic graft
●Angiodysplasia in a patient with renal disease, aortic stenosis, or hereditary hemorrhagic telangiectasia
●Peptic ulcer disease in a patient with a history of Helicobacter pylori, nonsteroidal anti-inflammatory drug
(NSAIDs) use, or smoking
●Malignancy in a patient with a history of smoking, alcohol abuse, or H. pylori infection

3. ●Marginal ulcers(ulcers at an anastomotic site) in a patient with a gastroenteric anastomosis
7-FHx: are there any other members of your family who have same conditions , intestinal
disease/bleeding tendency/peptic ulcer/liver disease, History of Malignancy?
b) Physical
b) Physical
examination:
examination:
Assessment of hemodynamic stability( Signs of hypovolemia ).
c)Management
c)Management
1 -Resuscitation and Risk Assessment
ِِ -Resuscitation and Risk Assessment
1
Resuscitate : crystalloid
and blood product if
indicated.
Assess
BASELINE
vitals
INVESTIGATION
(BP,HR,
orthostatic -FBC ( Hb, Wbc)
changes)
-liver function test –
cirrhosis
Endoscopy
(within 24 hrs)
-coagulation profile
-renal profile
-RBC morphology
-endoscopic variceal
injection with sclerosant
or banding.
Or sengstaken tube
Endoscopy
Immediate
2- other
2- other
INVESTIGATIONS
INVESTIGATIONS
Micro:chroni bleeding
Peptic Ulcer(PPI And if)
TTT:
Major SRH
somatostaten
and
vasopressure. Endoscopic
Treatment
+
Preceded
with ABx
Nitroglycerin
in CAD pt.
Failure
Other mangement :
unstable
Normo:acute bleeding
-OGDS
Varices
stable
Surgical
Minor SRH
Eradicate
H.pylori &
Risk
Reduction
No obvious cause
Minor
Bleed
Major
Bleed
Other
colonoscopy
or
angiography
CXR: aspiration
pneumonia; pleural
effusion, perforated
oesophagus.
-Erect and supine AX
ray:perforated viscus
and ileus.
CT scan and US:
-Liver disease.
-Cholecystitis with
haemorrhage.
-Pancreatitis with
haemorrhage and
pseudocyst.
-Aortoenteric fistulae.
Nuclear medicine
scans have been
used to identify areas
of active
haemorrhage.
Angiography: may
be useful if
endoscopy fails to
identify site of
bleeding.

4. Major SRH : (visible vessel, fresh clot)
RESUSCITATION in details:
 airway and oxygen
 Insert 2 large-bore (14-16G) IV cannulate take blood
 IV colloid - crossmatched.
 In a dire emergency, give O Rh-ve blood.
 haemodynamically stable.
 Correct clotting abnormalities
 Monitor
 Insert urinary catheter and monitor hourly urine output if shocked.
 Consider a CVP line to monitor CVP and guide fluid replacement.
 Organize a CXR, ECG, and check arterial blood gases in high-risk patient.
 Arrange an urgent endoscopy.
 Notify surgeon of all severe bleeds on admision.
INDICATION OF BLOOD TRANSFUSION :
1.Systolic BP < 110 mmHg
2.Postural hypotension
3.Pulse > 110/min
4.Haemoglobin <8g/dl
5.Angina or cardiovascular disease with a Haemoglobin <10g/dl .
UPPER GI BLEEDING RISK FACTORS FOR DEATH :
1. Advanced AGE
2. SHOCK on admission(pulse rate >100 beats/min; systolic blood pressure < 100mmHg)
3. COMORBIDITY (particularly hepatic or renal failure and disseminated malignancy)
4. Diagnosis (worst PROGNOSIS for advanced upper gastrointestinal malignancy)
5. ENDOSCOPIC FINDINGS (active, spurting haemorrhage from peptic ulcer; non-bleeding visible
vessel)
6. REBLEEDING (increases mortality 10 fold)