Contents

• Overview of GI bleeding
• UGIB
• LGIB
• Approach to a patient with GI bleeding
• GIB from obscure source
• summary

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Overview
• GIB is bleeding that originates from virtually any part of the GIT including liver, pancreas,…
• Presents in 5 different ways
1.HEMATEMESIS
- Vomiting of bright red blood or “coffee ground” appearance
- Caused by bleeding from upper GI tract
- This is diagnostic of upper GI bleeding.

2.MELENA
- Is the passage of black, tarry and foul smelling stool
- Generally suggests bleeding from the upper GI tract – 90%
- Distal bowel or right colon—particularly if transit is slow
- Blood has been present in the GI tract for at least 14 h(and as long as3-5 days)

2
…cont’d

3.HEMATOCHEZIA
- passage of bright red or maroon blood from the rectum
- Although this typically reflects a distal colonic source , if the
magnitude is significant even upper GI bleeding may produce
hematochezia.

4.SYMPTOMS OF BLOOD LOSS OR ANEMIA

Such as light headedness, syncope, angina or dyspnea

3
…cont’d

5.Occult GI bleeding- is the absence of GI bleeding by a fecal occult blood

test or the presence of Iron deficiency.
-It is not apparent to the patient until symptoms of anemia occurs.
 Obscure GI bleeding- persistent or recurrent bleeding for which no
source has been identified by routine endoscopy and contrast x-ray
studies.
-It may be overt(melana, hematechesia)or occult(Iron deficiency
anemia

4
…cont’d

• Mostly active GIB stops spontaneously allowing elective evaluation

• However, in up to 15% cases it may persist requiring emergent resuscitation,
evaluation and Rx.
• 5-10% cases which are hospitalized require operative intervention
• Overall MR remains to be higher than 5% despite improvements in Rx

5
…cont’d

• Generally classified into 2 by the Lgt of Trietz found at the level of duodenojejunal
junction
-UGIB(80%)
-LGIB(20%)

6
Upper GI bleeding
 Definition
• Upper gastrointestinal bleeding refers to bleeding that arises
from the gastro intestinal tract proximal to the ligament of
treitz.
• Acute gastrointestinal bleeding is potentially life threatening
abdominal emergency that remains a common cause of
hospitalization.
• It accounts for nearly 80% of significant gastrointestinal
hemorrhage.
• The incidence of UGIB is approximately 100cases/100,000
population.

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 • It is a major cause of morbidity and mortality.
• Some risk factors associated with increased mortality: Increased age,
male sex, cardiovascular disease, DM, renal disease, oral
anticoagulant use.
• The overall mortality rate of UGIB is approximately 10%
• It is best localized by EGD…but in we may not localize in 1-2%of the
cases due to…
- excessive blood impairing visualization of the mucosal surface
- Aggressive lavage of the stomach with room temperature
normal saline solution before the procedure can be helpful.

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 ETIOLOGY

• The causes of upper gastrointestinal bleeding can be broadly

classified in to two major categories
1-Non Variceal causes
2-Bleeding related to portal hypertension
- The Non Variceal causes account for 80% of such bleeding ,
whereas 20% of the cases are caused by portal hypertension.

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 Differential Diagnosis of upper GI
bleeding

Non variceal Bleeding(80%) Variceal Bleeding(20%)

PUD (30-50%) Gastro esophageal Varices (>90%)

Mallory weiss syndrome (15-20%) Hypertensive Portal gastropathy(<5%)

Gastritis or duodenitis (10-15%) Isolated gastric varices (rare)

Esophagitis (5-10%)

Vessels malformation(5%)
-Dieulafoys lesion
-Angiodysplasia

Tumors (2%)

Others (5%)
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Peptic Ulcer Disease
• Ulcers
- Defintion - A breach in the mucosa of the alimentary tract that extends through
the muscularis mucosa into the submucosa or deeper.
• Peptic Ulcers
- Defintion - Chronic, most often solitary, lesions that occur in any portion of the GI
tract exposed to the aggressive action of acid/peptic juices.

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Etiology
H.pylori infection
 NSAIDS-reduce PGS synthesis
Stress-alter mucosal protectivebarrier
Gastric acid

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Pathogenesis

An imbalance between gastroduodenal mucosal defence

mechansims and the damaging forces of gastric acid and
pepsin

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•  Damaging forces • Defense mechanism
Gastric acidity surface mucus secretion
 Peptic enzymes bicarbonate secretion
mucosal blood flow
epithelial regenerative capacity –
 elaboration of prostaglandins

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06/28/2023 17
Clinical features
Epigastric pain (gnawing, burning or aching)
- The pain tends to be worse at night and occurs usually 1 to 3 hours after meals
  Nausea, Vomiting, Bloating, Weight loss
 Pain relieved by alkalis or food
With penetrating pains it is referred to the back
  Iron deficiency anemia (with hemorrhage, perforation)

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Complications
 Bleeding
  Perforation
  Obstruction from edema or scarring
  Malignant transformation
- Malignant transformation does not occur with duodenal ulcers and is extremely
rare with gastric ulcers
  Chronic gastritis is universal among patients with peptic ulcer disease

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 Forrest Classification of Endoscopic Findings
and Rebleeding Risks in PUD
Rebleeding risk classification
High Grade Ia:Active, pulsatile
bleeding
High Grade Ib: Active, nonpulsatile
bleeding
High Grade IIa: Nonbleeding visible
vessel
Intermediate Grade IIb: Adherent clot

Low Grade IIc: Ulcer with black spot

Low Grade III: Clean, nonbleeding

ulcer bed

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 Management
• If the patient is not bleeding and at low risk of rebleeding…we
should manage the underlying cause
H. pylori-triple therapy
NSAID&alcohol –stopping
Stress-histamine H2 blockers
Gastric acid..PPI
• Medical…start PPI for pt. with bleeding pud
• Endoscopic therapy is recommended in cases of active bleeding as well
as a visible vessel (Forrest I to IIa).
- epinephrine injection,
-heater probes and coagulation
- Clipping at ulcer site to constrict or
compress
• adherent clot (Forrest IIb), the clot is removed and the underlying lesion
evaluated.
• Surgical treatment – for patients at high risk of failed endoscopic
therapy.
-10% of patients with pud need surgical intervention
Mallory Weiss syndrome
• Longitudinal tear at GEJ due to repeated
vomiting,retching,vigirious coughing.
• common in alcoholic patients
• Dx by history and 90% of bleeding are self
limited
• Recurrent bleeding is uncommon
TX: needed if protracted
• Resuscitation
• Local Endoscopic therapy with
injection(epinephrine or cauterization
therapy), angiographic embolization,
endoscopic clipping
• If this fails high gastrotomy and suturing of
the mucosal tear may be needed.
• Avoid alcohol
Gastritis
• Inflammation of the lining of stomach.an important risk factors
include…..NSAIDs, stress, alcohol, infection.
• Clinical presentation-burning epigastric pain with hematemesis.
• Dx : endoscopically cxzed by the appearance of multiple superficial
erosion of the entire stomach.
Ng tube decompression-saline lavage & remove any pooled blood.
Mgt : of underlying cause to prevent risk of rebleeding.
 stop NSAIDs,alcohol
Decrease the acid(H2 antagonists,PPIand
sucralfates)
If failed, Vasopressin Or octretoid to through the left gastric artery.
Surgical Tx - Vagotomy and pyloroplasty
Esophagitis
• Defintion - Inflammation of esophageal mucosa Caused by:
• chemical, physical, biologic agents
• 1. Reflux esophagitis
Reflux of gastric contents into the lower esophagus
• 2. infectious and chemical
 Ingestion of mucosal irritants
 Cytotoxic anticancer therapy
 Viral infection – HSV, CMV.
 Fungal infection- candidiasis, mucormycosis
Esophagus infection most often occurs in immunosuppressed
 Uremia in renal failure
Mgt
Acid suppressive therapy.
Give antibiotic for infections.
Endoscopic control of the hemorrhage.
Operation is seldomly necessary
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Variceal bleeding
•They are complications of portal hypertension.
•Are almost always emergencies causing hemodynamic shock &
multi organ failure
•They can involve…the esophagus, stomach and the rectum.
•High risk of rebleeding, need for transfusion & increased
mortality
•Regardless of the cause of the increased portal pressure, the
resistance to portal blood flow leads to the development of 4
well-recognized collateral vascular systems, ie ,
the esophageal submucosal venous plexus,
the cardiac vein of the stomach,
the retroperitoneal-umbilical system, and
the hemorrhoidal system.
 Hypertensive portal gastropathy
• Mucosa is affected by increased portal pressure
• Snake skin appearance
• Cherry red spot
• Diffuse hemorrhage
• Unlike variceal hemorrhage, bleeding from PGP is not amenable to
endoscopic treatment because of the diffuse nature of the mucosal
abnormalities.
• pharmacologic therapies aimed at reducing portal venous pressure are
indicated. If pharmacologic therapy fails to control acute bleeding, TIPS is
considered
 Isolated gastric varices - they are rare

Tx : Endoscopic injection of histoacryl

…cont’d

General Resuscitation
Air way protection
Correct coagulopathy
Drug Therapy
Endoscopic Tx
 sclerotherapy using ethanolamine
oleate or butyl cyanoacrylate
 Banding
Esophageal balloon tamponade(Sengstaken-
Balkemore tube)
reserved for patients with massive
hemorrhage to permit more definitive
therapies.
Mgt

• Trans jugular intrahepatic portosystemic shunts(TIPS)

Immediate complication
I. perforation of liver capsule with fatal intraperitoneal haemorrhage
II. Post procedure encephalopathy

Late complication
I. Stenosis of the shunt and recurrence of variceal bleeding
Complications of Variceal bleeding
• The complications of variceal bleeding are due to either the bleeding itself
or the procedures used to control bleeding.
• Bleeding-related complications include vascular collapse and hypotension,
encephalopathy, aspiration, and subacute bacterial peritonitis.

Prevention of Variceal bleeding

• Treating the underlying cause of bleeding varices
• Treating liver diseases earlier
• prophlactic b-blockers
Dx : Endoscopy
Tx : 50% stop spontaneously
- Medical Tx (vassopressin,octretoid)
- Endoscopic:(sclerotherapy with ethanolamine&)band ligation
- TIPS for failed medical and endoscopic therapy
- propranolol….to prevent rebleeding.

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