by: be a good doctor

1. Upper GI Bleeding
Upper GI Bleeding
By: Khalid Ali Dirie
Department of medicine

2. Upper GI Bleeding
Overview
• Definitions
• Initial Patient Assessment
– ABC & Resuscitation
• Differential Diagnosis
• Identify the Source & Stop the Bleeding
– History & Physical
– Endoscopy & Potential Complications
– Other diagnostics tests
• Role of Surgery
• Prevention

3. Upper GI Bleeding
Definitions
• Upper GI Bleeding = proximal to ligament of
Treitz
• Hematemesis = vomiting blood
– This is diagnostic of upper GI bleeding
• Melena = passage of tarry or maroon stool
– Can be upper or lower (more commonly upper)
• Hematochezia = Bright red blood per rectum
– Usually characteristic of colonic hemorrhage

4. Upper GI Bleeding
Initial Patient Assessment
• Get to patient’s bedside, assess ABC
• Can the patient protect his airway?
– Does he need to be intubated?
• Is the patient hemodynamically unstable?
– Is he in hemorrhagic shock?
• 2 large bore IV, Bolus 2L fluids, Type &
Cross blood, send CBC & Coags
• Place patient on O2 & continuous monitor
• Place an NGT and lavage with NS
– To confirm if the bleeding source is upper GI

5. Upper GI Bleeding
Differential Diagnosis
• Peptic Ulcer Disease (PUD) >50% cases
• Gastritis / Duodenitis (15-30%)
– Subset due to NSAID use
• Varices from portal hypertension (10-20%)
• Mallory-Weiss tears at GE junction (5%)
• Esophagitis (3-5%)
• Malignancy (3%)
• Nasopharyngeal bleed – swallowed blood
• Other- Aortoenteric fistula, angiodysplasia,
Crohn’s disease, hemophilia,

6. Upper GI Bleeding
History & Physical
• History of prior ulcers, NSAID use, stress
• History of Helicobacter pylori & treatment
• Alcohol abuse
– Retching -> Mallory Weiss tear
– Alcoholic cirrhosis -> portal hypertension and
varices
• On Physical Exam, assess hydration
• Look for stigmata of cirrhosis & portal HTN

7. Upper GI Bleeding
Management – Acute UGI Bleed
• Once again, make sure pt is resuscitated
• If anemic and symptomatic, give blood
• Place NGT/lavage (helps for endoscopy)
• Perform Upper endoscopy (EGD)
– For ulcers: if visible clot, visible vessel, or active
bleeding, should cauterize/coagulate and inject
sclerosing agent
– For acute variceal bleeding: sclerotherapy +
somatostatin or endoscopic band ligation. If
fail/rebleed: surgical shunt. Balloon tamponade is an
emergency temporizing measure
• Start proton pump inhibitor (PPI) infusion

8. Upper GI Bleeding
Potential Complications
• Perforation of esophagus
• Aspiration
• Desaturation or respiratory distress
• Adverse reaction to conscious sedation
• ↑risk of complications with:
– Inadequate resuscitation or hypotension
– Comorbidities
• Consider elective intubation prior to EGD if
active bleeding, altered respiratory or
mental status

9. Upper GI Bleeding
Other Diagnostic Tests
• If bleeding is unresolved with endoscopy
or endoscopy is contraindicated
• 1. Angiography (Diagnostic & Therapeutic)
– Intra-arterial vasopressin
– Embolization
• 2. Tagged red blood cell (TRBC) scan
– Only diagnostic & usually for occult bleeding
– More sensitive than angiography
– Can detect bleeding rate of 0.1-0.5 mL/min

10. Upper GI Bleeding
Role of Surgery
• If medical and endoscopic therapy fail
• In the event that bleeding source is
unidentified -> exploratory laparotomy
• Recurrent bleeding peptic ulcers
– Anti-ulcer surgery (i.e. vagotomy/antrectomy,
or vagotomy/pyloroplasty, or selective vagot)

11. Upper GI Bleeding
Prevention
• After the acute situation is resolved,
educate patient on preventive measures
• Top 2 reasons for ulcers: Hpylori & NSAID
• 1. Testing for H.pylori (i.e. antral biopsy
during endoscopy)
• 2. Treat H.pylori (amoxicill, clarithromycin
x1wk plus PPI x4wk)
• 3. Reduce intake of NSAID

12. Upper GI Bleeding
Take Home Points
• Always, always perform ABC’s first &
resuscitate with two #16ga IV’s & isotonic
crystalloids (blood if pt doesn’t respond)
• NGT/lavage to confirm active bleeding
• Focused H&P looking for common
causes: ulcers, varices, “-itis”, Mallory-
Weiss, AVM
• Endoscopy is 1st
line for acute UGIB
– Don’t forget to start intravenous PPI infusion
• Endoscopy has associated complications
• Angio or surgery if still bleeding