UPPER

GASTROINTESTINAL
BLEEDING (UGIB)
DR. AINIL FATIMA BINTI ZAINODIN
DR. AHMAD ZHAFIR BIN ZULKIFLI

SUPERVISED BY:
DR. MOHD FADHIL BIN DATO HJ AHMAD NAZLAN
UGIB : (Proximal to Ligament of Treitz)

Esophagus Stomach Duodenum

 UGIB : CLINICAL
PRESENTATION
 Aim – to get diagnosis, to find causes, to elicit complications
 Hematemesis :Red Blood, “Cofee- ground”
 Malena : Black, Tarry, Foul smelling stool
 Sx of Anemia
 Occult GI Bleeding : + Iron Deficiency
 Abdominal pain
UGIB : Risk Factor

 Causes
 PMh(x) : CLD, Hep B/C , H. Pylori infection,
previous PUD, Dyspepsia
 Drug history : NSAIDS, aspirin, steroid
 Alcohol, smoking
 Trauma
 Constitutional symptoms
 UGIB

NON
VARICEAL
VARICEAL
CONTENT

 ANATOMY(HEPATIC PORTAL VEIN TRIBUTE)

 GASTROESOPHAGEAL VARICEAL
 PRIMARY PROPHYLAXIS
 SCREENING
 MANAGEMENT OF ACUTE VARICEAL
BLEEDING
 MANAGEMNT OF OESOPHAGEAL VARICEAL
BLEEDING
 GASTRIC
VARICEAL ESOPHAGEAL
VARICEAL

Gastroesophageal variceal
INTRODUCTION

 Gastroesophageal variceal bleeding accounts for 10-

30% of UGIB
 Major cause of death in patients with cirrhosis
 Variceal bleeding accounts for 6.4% of UGIB in
Malaysia.
 Etiology of cirrhosis in Malaysia is mainly due to
chronic infection hepatitis B or alcoholic liver
disease
OESOPHAGEAL VARICES

 HVPG (Hepatic Venous Pressure Gradient) - Normal HVPG < 5

mmHg
- Varices HVPG >12 mmHg (cause bleeding)
Grade:

 1: Small, straight varices

 2: Enlarged, tortuous varices that occupy less than
one-third of the lumen
 3: Large, coil-shaped varices that occupy more than
one-third of the lumen
 PRIMARY PROPHYLAXIS
 OESOPHAGEAL VARICES

1) Pharmacological Therapy

Non- selective B-adrenergic antagonist ( eg: Propanolol)

Beta-blockers (reduce splanchnic circulation pressure)

2) Endoscopic Therapy

Endoscopic Variceal ligation (EVL)

Endoscopic sclerotherapy – injection of sclerosant

- Sodium tetradecyl sulphate (thrombovar)
- Ethanolamine oleate
 SCREENING

 Screening Endoscopy
 Patient with small varices on initial endoscopy should screened for
enlargement of varicess every 1-2 years .
Management Acute Variceal Bleeding
• Correcting hypovolemic shock
• to restore hemodynamic stability
• Keep HB ideally more than 7g/dL or HCT 24%
Resuscitation • Avoid overTx  May ↑portal pressure  exacerbate
futher bleeding

• Iv Terlipressin/ Octreotide / Somatostation for 2-5

Pharmacotherapy days to prevent early rebleeding.
Terlipressin : 2mg bolus & 1mg every 6 hr (for 2-5
( Vasoactive days)
Somatostatin : 250mcg bolus followed by 250mcg/
Theraphy) hr infusion (for 5 days)
Octreotide : 50mcg bolus followed by 50mcg/hr
(for 5 days)

• Bacterial infection seen in 20% of cirrhotics presenting

with UGIB within 48 hrs.
• Incidence of sepsis ↑ almost 66% at two weeks.
Antibiotics • Infection high mortility & variceal re-bleeding.

3rd Generation cephalosporin (iv) or oral

quinolone (norfloxacin/ciprofloxacin)
Management of Oesophageal Variceal
Bleeding

Endoscopic Variceal Ligation

Endoscopic Theraphy
•
(EVL)
• Endoscopic Sclerotheraphy
• Temporary “bridge” for max

Ballon Tamponade •
24hr
Consider if not available
facilities for endoscopy
• TIPS is indicated as a rescue
TIPS TRANSJUGULAR INTRAHEPATIC
PORTOSYSTEMIC SHUNTS therapy for uncontrolled
variceal bleeding after
combine pharmacological &
Surgical Therapy endoscopic therapy

• Oesophageal Transection
• Portosystemic shunts
• Liver Transplant
Non Variceal UGIB
 ETIOLOGY BY ANATOMIC CLASSIFICATION

ESOPHAGUS STOMACH DUODENUM

Oesophageal ulcer Gastric ulcer Duodenal ulcer

Mallory-Weiss tear Gastric erosion Aorta-duodenal fistula
Reflux oesophagitis Dieulafoy’s lesion Polyps
Barret’s ulcer Gastric cancer Ampullary/pancreas cancer
Cameron ulcer

The mostcommon cause for non variceal UGIB is

peptic ulcer disease.
Epidemiology

 Male:Female – 2:1
 Incidence of UGIB: 72 per 10,0000
population, peaked around the 4th to 6th
decade. [Med J Mal. 2001]
 Mortality rate: 10.2% but increased
substantially with age
 Inpatients who developed UGIB has 5x
higher mortality than those came from ED
admission for UGIB.
 Clinical presentations

Coffee ground
Maelena Hemetemesis
vomitus

• Haematochezia
• Anemia with or without
evidence of visible blood
loss
Patient assessment

 History:
• Bleeding from where? How much patient
has bled?
• Risk factor: NSAID, blood thinning agents,
traditional meds, alcohol, PUD, hepatitis
 Physical examination:
• General examination
• PR: “fresh” vs “stale” malena
Resus, resus, resus! (ABC)

 Aim to stabilize hemodynamic status

1. Insert at least 2 large bore branula into
large peripheral veins
2. Give supportive O2: NPO2, VM, HFM
3. Take bloods: FBC, RP, LFT, COAG, BG,
GXM/GSH
4. Fluid resus with crystalloids or packed cell
5. Correct coagulopathy
6. Monitoring: Ryles tube*, CVP, CBD, strict
I/O
Resus, resus, resus! (ABC)
 Start PPI
 Consider intubation when:
• severe uncontrollable bleeding
• encephalopathic
• inability to maintain O2 saturation adequately
• to prevent aspiration
 ICU bed and facilities should be made
available
 Close monitoring in ward
 Once patient stable -> OGDS within 24H if
indicated
When to transfuse blood or blood
products?
 Why transfuse?
 To restore blood volume, BP and to correct anemia to
maintain oxygen carrying capacity
 Indication for packed cell transfusion:
1. Systolic BP < 110 mmHg
2. Postural hypotension
3. Pulse > 110/min
4. Hb <7g/dl
5. Angina or cardiovascular disease with a hb <10g/dl
 Maintain Hb ~10g/dL
 Transfuse platelet if patient actively bleeding and PLT count
is <50,000/mm3
 Give FFP if PT is at least 1.5x higher than control value
 When to scope?

 Offer endoscopy to unstable patients with severe

acute UGIB immediately after resuscitation.
 Offer endoscopy within 24 hours of admission to all
other patients with UGIB
Source: NICE Clinical Guideline: Acute upper gastrointestinal bleeding: management,
2012.
 Oesophago Gastro Duodeno Scopy
(OGDS)
Indication:
 Diagnostic
 Therapeutic

Complications (1 in 1000):
 Aspiration pneumonia
 Bleeding
 Perforation
 Cardiopulmonary problems
 Risk scoring: The Rockall score

A score of 2 or less is associated with a low risk of further

bleeding or death.
 Forrest classification for bleeding peptic ulcer:

Source: Jain V, Agarwal P N, Singh R, Mishra A, Chugh A, Meena M. Management of Upper Gastrointestinal
Bleed. MAMC J Med Sci 2015;1:69-79
Forrest classification for bleeding peptic ulcer:
Therapeutics procedure during OGDS
• Mechanical
• Hemoclips
• Injection
• Injection therapy with diluted epinephrine
• Results in local tamponade and vasospasm
• Thermal
• Unipolar diathermy
• Thermal coagulation uses argon plasma coagulation (APC)
Impact of nasogastric tube insertion on outcomes
in acute GI bleeding.
Huang ES, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel BM
Gastrointest Endosc. 2011 Nov;74(5):971-80. Epub 2011 Jul 7.
Retrospective analysis. A total of 632 patients admitted with GI bleeding.

RESULTS: Patients receiving NGT were more likely to take nonsteroidal anti-
inflammatory drugs and be admitted to intensive care, but less likely to have
metastatic disease or tachycardia, be taking warfarin, or present on
weekdays. After propensity matching, NGT did not affect mortality (odds ratio
[OR]0.84; 95% confidence interval [CI], 0.37-1.92), length of hospital stay (7.3
vs 8.1 days, P = .57), surgery (OR 1.51; 95% CI, 0.42-5.43), or transfusions (3.2
vs 3.0 units, P = .94). However, NGT was associated with earlier time to
endoscopy (hazard ratio 1.49; 95% CI, 1.09-2.04), and bloody aspirates were
associated high-risk lesions (OR 2.69; 95% CI, 1.08-6.73).

CONCLUSIONS: Performing NGT is associated with the earlier

performance of endoscopy, but does not affect clinical
outcomes. Performing NGL at initial triage may promote more
timely process of care, but further studies will be needed to
confirm these findings.
References:

 Malaysian CPG: Management of Acute Non Variceal

Upper GI Bleeding, 2003.
 NICE Clinical Guideline: Acute upper gastrointestinal
bleeding: management, 2012.
 Jain V, Agarwal P N, Singh R, Mishra A, Chugh A, Meena
M. Management of Upper Gastrointestinal Bleed. MAMC
J Med Sci 2015;1:69-79
 Approach to acute upper gastrointestinal bleeding in
adults, UpToDate 2017.
 Huang ES, Karsan S, Kanwal F, Singh I, Makhani M,
Spiegel BM: Gastrointest Endosc. 2011 Nov;74(5):971-
80. Epub 2011 Jul 7.
THANK YOU!

 Special thanks to our mentor Dr Mohd Fadhil in

guiding us to prepare this slide.
 Alas, thank you all for lending your precious time to
listen to our presentation. Your presence are greatly
appreciated!