ON-VARICEAL UPPER GI HEMORRHAG

DVANCES IN DIAGNOSIS AND TREATM

EAKER IPSEET MISHRA

AIRPERSONS PROF. N. C. NATH

DR. A. MAJI

ACUTE GASTROINTESTINAL
HEMORRHAGE
UPPER GI HEMORRHAGE

NON-VARICEAL
BLEEDING

VARICEAL
BLEEDING

PEPTIC ULCER DISEASE 1. GASTRO-ESOPHAGEAL

MALLORY-WEISS TEARS
VARICES
GASTRITIS OR DUODENITIS
2. HYPERTENSIVE PORTAL
ESOPHAGITIS
GASTROPATHY
ARTERIOVENOUS
3. ISOLATED GASTRIC
VARICES
MALFORMATION
. TUMOURS

.
.
.
.
.

LOWER GI HEMORRHAGE

COLONIC
BLEEDING

1.
2.
3.
4.
5.
6.
7.
8.
9.

DIVERTICULAR DISEASE1.
ISCHEMIA
ANORECTAL DISEASE 2.
NEOPLASIA
INFECTIOUS COLITIS
3.
POST-POLYPECTOMY
4.
IBD
5.
ANGIODYSPLASIA
RADIATION COLITIS
6.
7.

SMALL INTESTINAL
BLEEDING

ANGIODYSPLASIA
S
EROSIONS,ULCER
S
CROHNS DISEASE
RADIATION
MECKELS
DIVERTICULUM
NEOPLASIA
AORTOENTERIC
FISTULAS

Upper GI bleeding refers to bleeding that arises from

the GI tract proximal to the ligament of Treitz; it
accounts for almost 80% of significant GI hemorrhage.
The nonvariceal causes account for approximately
80% of this bleeding, with peptic ulcer disease being
the most common.
In the remaining 20% of patients, most of whom have
cirrhosis, portal hypertension can lead to the
development of gastroesophageal varices, isolated
gastric varices, or hypertensive portal gastropathy.
Although patients with cirrhosis are at high risk of
developing variceal bleeding, nonvariceal sources
account for most upper GI bleeds,even in these
patients.

CAUSES
Cause of Bleeding

Relative Frequency(%)

Peptic Ulcer

30-50

Mallory Weiss tear

15-20

Gastritis/Duodenitis

10-15

Oesophagitis

5-10

Vascular Malformation

Tumours

Other (e.g. Aortoenteric fistula)

Emergency Resuscitation
Takes priority over determining the diagnosis/cause

ABC (main focus is C)

Oxygen: Non-rebreathing mask
2 large bore cannula into both ante-cubital fossa
Take bloods at same time for CBC, Urea/Crt, LFT,
BT/CT/PT, X match 6Units
Catheterise
IVF initially then blood as soon as available (depending on
urgency: O-, Group specific, fully X-matched)
Monitor response to resuscitation frequently (HR, BP, urine
output, level of consciousness, peripheral temperature, CRT)
Stop anti-coagulants and correct any clotting derangement
NG tube and aspiration (will help differentiate upper from lower
GI bleed)
Organise definitive treatment (endoscopic/radiological/surgical)

ESTIMATING DEGREE OF BLOOD

LOSS

RR, HR, BP, Urine output and Mental status

can be used to estimate degree of blood
loss/hypovolaemia
Class I

Class II

Class III

Class IV

Volume Loss 0-750

(ml)

750-1500

1500-2000

>2000

Loss (%)

0-15

15-30

30-40

>40

RR

14-20

20-30

30-40

>40

HR

<100

>100

>120

>140

BP

Unchanged

Unchanged

Reduced

Reduced

Urine
Output
(ml/hr)

>30

20-30

5-15

Anuric

Mental
State

Restless

Anxious

Anxious/con
fused

Confused/
lethargic

DIAGNOS
IS

ACUTE UPPER GI HEMORRHAGE

Upper GI Endoscopy or Esophagogastroduodenoscopy (EGD)

is the key to the diagnosis of Upper GI Hemorrhage.
Early EGD within 24 hrs results in identification of the lesion
- reduction in blood
transfusion
requirement
- decrease in need for
surgery
- shorter hospital stay
- estimation of risk of
subsequent or
persistent hemorrhage
Studies have shown that early EGD sooner than within 24 hrs
has no extra benefit due to increased risk and poor
visualization.
For improving visualization aggressive lavage of stomach
with room temp
normal saline
- single bolus injection of

DIAGNOSTIC ALGORITHM

REST CLASSIFICATION FOR ENDOSCOPIC

FINDINGS AND RE-BLEEDING RISK

Grade Ia

Grade IIb

Grade IIa

Grade IIc

Grade III

Radionuclide Scanning
Radionuclide scanning with 99mTclabeled RBC is the most
sensitive but least accurate method for localizing GI bleeding.
With this technique, the patients own red cells are labeled
and reinjected. The labeled blood is extravasated into the GI
tract lumen, creating a focus that can be detected
scintigraphically. Initially, images are obtained frequently and
then at 4-hour intervals, for up to 24 hours.
The RBC scan can detect bleeding as slow as 0.1 mL/min
and is reported to be more than 90% sensitive. Reported
accuracy of localization is in the range of only 40% to 60%
and it is particularly inaccurate for distinguishing right-sided
from left-sided colonic bleeding.
The RBC scan is not usually used as a definitive study before
surgery but instead as a guide to the usefulness of

Mesenteric Angiography
Selective angiography, using the superior or inferior
mesenteric arteries, can detect hemorrhage in the range of
0.5 to 1.0 mL/ min but is generally only used for the diagnosis
of ongoing hemorrhage.
It can be particularly useful in identifying the vascular
patterns of angiodysplasias. It may also be used for localizing
actively bleeding diverticula.
Catheter-directed vasopressin infusion can provide
temporary control of bleeding, permitting hemodynamic
stabilization, although as many as 50% of patients will
rebleed when the medication is discontinued. It can also be
used for embolization. Typically, such therapy is reserved for
patients whose underlying condition precludes surgical
therapy.

MANAGEMENT
Emergency resuscitation
Esophagoduodenoscopy urgent (within 24 hrs of admission)
Pharmacology
PPI (infusion) pH >6 stabilises clots and reduces risk of
re-bleeding following endoscopic
haemostasis
- PPI @ 8mg/hr is indictated.
Tranexamic acid (anti-fibrinolytic) maybe of benefit
(more studies needed)
If H pylori positive eradication therapy (only 60-70% of
patients with bleeding ulcer are H.pylori positive unlike
perforated ulcers)
Stop NSAIDs/aspirin/clopidogrel/warfarin/steroids/SSRIs if
safe to do so (risk:benefit analysis)

Endoscopic therapy
- Epinephrine injection (1 : 10,000) - to all four quadrants of the

lesion.
- Large-volume
injection (>13 mL)
gives better hemostasis
rebleeding rate;
practice is combination

- Associated with high

standard

therapy.
- Thermal energy - can be heater probes, monopolar or bipolar
electrocoagulation, or laser or argon plasma
coagulation (APC).
- The most commonly used
energy sources are electrocoagulation for
bleeding ulcers and APC for
superficial lesions.
- Hemoclips - studies have reported mixed results.
- may be particularly effective when dealing with a
spurting
vessel because they provide
immediate control of hemorrhage.

Endoscopic Injection

Ag Plasma Coagulation

Hemoclip

Angiographic techniques
- Are somewhat more generic and include selective
angiography with infusion of a vasoconstrictor, typically
vasopressin, or embolization.
-Embolic agents include temporary materials such as
gelatin sponge (Gelfoam; Pharmacia & Upjohn, Pfizer, New
York) and autologous clot or permanent devices such as
coils.
- There are few data comparing the efficacy of these
techniques.

Surgical therapy
- Approx. 10% of patients with bleeding ulcers still require surgery.
- Indications - Hemodynamic instability despite vigorous
resuscitation (>6 U transfusion)
- Failure of endoscopic techniques to arrest
hemorrhage
- Recurrent hemorrhage after initial stabilization (with
up
to two attempts at obtaining endoscopic
hemostasis) as
in >2cm ulcers, posterior
duodenal ulcers or gastric
ulcers
- Shock associated with recurrent hemorrhage
- Continued slow bleeding with a transfusion
requirement
>3 U /day

The first priority at operation should be control of the

hemorrhage. Once
this is accomplished, a decision must be made regarding the
need for a
definitive acid-reducing procedure.

Definitive surgical therapy

1. Duodenal Ulcer - longitudinal duodenotomy or
duodenopyloromyotomy
- Control initially with pressure and then direct suture ligation
with nonabsorbable suture.
- Four-quadrant suture ligation for anterior
ulcer.
- suture ligation of the vessel proximal and distal to
the ulcer, as
well as placement of a U stitch for
posterior ulcers eroding into
pancreaticoduodenal
or gastroduodenal artery
- pyloroplasty or antrectomy combined with
truncal vagotomy
2. Gastric ulcer - gastrotomy and suture ligation
- distal gastrectomy combined with resection of a
tongue of proximal
stomach to include the ulcer
- vagotomy and pyloroplasty combined with

3. Mallory-Weiss Tears - high gastrotomy and suturing of the

mucosal tear is

indicated if all other measures fail.

4. Stress Gastritis - vagotomy and pyloroplasty with

oversewing of the
hemorrhage or near-total
gastrectomy.
5. Dieulafoys Lesion gastrostomy with oversewing of ulcer or
partial
gastrectomy in patients in whom
the bleeding point is not
identified
6. Gastric Antral Vascular Ectasia Antrectomy for patients
failing endoscopic
therapy
7. Malignancy - surgical resection when a malignancy is
diagnosed.
- The extent of resection is dependent on the
specific lesion,
whether the resection is believed to be
curative or palliative
and the hemodynamic stablity

Risk stratification: ROCKALL SCORE

Identifies patients at risk of adverse outcome following acute upper GI

bleed
Variable

Score 0

Score 1

Score 2

Score 3

Age

<60

60-79

>80

Shock

Nil

HR >100

SBP <100

Comorbidity

Nil major

IHD/CCF/ma
jor
morbidity

Renal
failure/liver
failure

Diagnosis

Mallory
Weiss tear

All other
diagnoses

GI
malignancy

Endoscopic
Findings

None

Blood,
adherent
clot,
spurting
vessel

Score <3 carries good prognosis

Score >8 carries high risk of mortality

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