Upper Gi Bleeding

H
Maybe classified into:

◦ Upper GI bleeding (proximal to DJ flexure)
 Variceal bleeding
 Non-variceal bleeding
◦ Lower GI bleeding (distal to DJ flexure)
 Upper GI bleeding 4x more common than

lower GI bleeding
 Emergency resuscitation same for upper and

lower GI bleeds
Takes priority over determining the diagnosis/cause
 ABC (main focus is ‘C’)
 Oxygen: 15L Non-rebreath mask
 2 large bore cannulae into both ante-cubital fossae
 Take bloods at same time for FBC, U&E, LFT, Clotting, 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 derrangement
 NG tube and aspiration (will help differentiate upper from lower GI
bleed)
 Organise definitive treatment (endoscopic/radiological/surgical)
 RR, HR, and BP can be used to estimate
degree of blood loss/hypovolaemia
Class I Class II Class III Class IV
Volume Loss 0-750 750-1500 1500-2000 >2000
(ml)
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 >30 20-30 5-15 Anuric
(ml/hr)
Mental State Restless Anxious Anxious/ Confused/
confused lethargic
 Aim of history and examination is 3 fold
 1. Identify likely source – upper vs lower – and
potential cause
 2. Determine severity of bleeding
 3. Identify precipitants (e.g. Drugs)
◦ PC/HPC
 Duration, frequency, and volume of bleeding (indicate severity of bleeding)
 Nature of bleeding: will point to source
 Haematemesis (fresh or coffee ground)/melaena suggest upper GI bleed. (Note a very brisk upper GI bleed
can present with dark or bright red blood PR).
 PR Dark red blood suggests colon
 PR Bright red blood suggests rectum, anus
 If PR bleeding, is blood being passed alone or with bowel opening (if alone suggests heavier bleeding)
 If with bowel opening is blood mixed with the stool (colonic), coating the stool (colonic/rectal), in the toilet
water (anal), on wiping (anal)
 Ask about associated upper or lower GI symptoms that may point to underlying cause
 E.g. Upper abdominal pain/dyspeptic symptoms suggest upper GI cause such as peptic ulcer
 E.g. 2. lower abdo pain, bowel symptoms such as diarrhoea or a background of change in bowel habit
suggest lower GI cause e.g. Colitis, cancer
 Previous episodes of bleeding and cause
◦ PMH
 History of any diseases that can result in GI bleeding, e.g. Peptic ulcer disease, diverticular disease, liver
disease/cirrhosis
 Bleeding disorders e.g. haemophilia
◦ DH
 Anti-platelets or anti-coagulants can exacerbate bleeding
 NSAIDs and steroids may point to PUD
◦ SH
 Alcoholics at risk of liver disease and possible variceal bleeding as a result
 Smokers at risk of peptic ulcer disease
 Reduced level of consiousness
 Pale and clammy
 Cool peripheries
 Reduced CRT
 Tachcardic and thready pulse
 Hypotensive with narrow pulse pressure
 Tenderness on abdominal examination may point to
underlying cause e.g. Epigastric  peptic ulcer
 Stigmata of chronic liver disease (palmer erythema,
leukonychia, dupuytrens contracture, liver flap, jaundice,
spider naevi, gynacomastia, shifting dullness/ascites)
 Digital rectal examination may reveal melaena, dark red
blood, bright red blood
 Upper GI bleeding refers to bleeding from
oesophagus, stomach, duodenum (i.e.
Proximal to ligmanet of treitz)
 Bleeding from jejunum/ileum is not common

 Acute Upper GI bleeding presents as:
 Haematemesis (vomiting of fresh blood)
 Coffee ground vomit (partially digested blood)
 Melaena (black tarry stools PR)
 If bleeding very brisk and severe then can

present with red blood PR!
 If bleeding very slow and occult then can
present with iron deficiency anaemia

Cause of Bleeding Relative Frequency
Peptic Ulcer 44
Oesophagitis 28
Gastritis/erosions 26
Duodenitis 15
Varices 13
Portal hypertensive 7
gastropathy
Malignancy 5
Mallory Weiss tear 5
Vascular Malformation 3
Other (e.g. Aortoenteric rare
fistula)
 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 -
Co-morbidity Nil major - IHD/CCF/major Renal

morbidity failure/liver
failure
Diagnosis Mallory Weiss All other GI malignancy -

tear diagnoses
Endoscopic None - Blood, adherent -

Findings clot, spurting
Score <3 carries good prognosis

vessel

 Score >8 carries high risk of mortality
 Emergency resuscitation as already described
 Endoscopy
 Urgent OGD (within 24hrs) – diagnostic and therepeutic
 Treatment administered if active bleeding, visible vessel, adherent blood
clot
 Treatment options include injection (adrenaline), coagulation, clipping
 If re-bleeds then arrange urgent repeat OGD
 Pharmacology
 PPI (infusion) – pH >6 stabilises clots and reduces risk of re-bleeding
following endoscopic haemostasis
 Tranexamic acid (anti-fibrinolytic) – maybe of benefit (more studies
needed)
 If H pylori positive then for eradication therapy
 Stop NSAIDs/aspirin/clopidogrel/warfarin/steroids if safe to do so
(risk:benefit analysis)
 Surgery
 Reserved for patients with failed medical management
(ongoing bleeding despite 2x OGD)
 Nature of operation depends on cause of bleeding
(most commonly performed in context of bleeding
peptic ulcer: DU>GU)
 E.g. Under-running of ulcer (bleeding DU), wedge
excision of bleeding lesion (e.g. GU), partial/total
gastrectomy (malignancy)
 Suspect if upper GI bleed in patient with history of chronic
liver disease/cirrhosis or stigmata on clinical examination
 Liver Cirrhosis results in portal hypertension and
development of porto-systemic anastamosis (opening or
dilatation of pre-existing vascular channels connecting portal
and systemic circulations)
 Sites of porto-systemic anastamosis include:
 Oesophagus (P= eosophageal branch of L gastric v, S= oesophageal branch of
azygous v)
 Umbilicus (P= para-umbilical v, S= infeior epigastric v)
 Retroperitoneal (P= right/middle/left colic v, S= renal/supra-renal/gonadal v)
 Rectal (P= superior rectal v, S= middle/inferior rectal v)
 Furthermore, clotting derrangement in those with chronic
liver disease can worsen bleeding
 Emergency resuscitation as already described
 Drugs
 Somatostatin/octreotide – vasoconstricts splanchnic circulation and reduces pressure in portal
system
 Terlipressin – vasoconstricts splanchnic circulation and reduces pressure in portal system
 Propanolol – used only in context of primary prevention (in those found to have varices to
reduce risk of first bleed)
 Endoscopy
 Band ligation
 Injection sclerotherapy
 Balloon tamponade – sengstaken-blakemore tube
 Rarely used now and usually only as temporary measure if failed endoscopic management
 Radiological procedure – used if failed medical/endoscopic Mx
 Selective catheterisation and embolisation of vessels feeding the varices
 TIPSS procedure: transjugular intrahepatic porto-systemic shunt
 shunt between hepatic vein and portal vein branch to reduce portal pressure and bleeding from varices):
performed if failed medical and endoscopic management
 Can worsen hepatic encephalopathy
 Surgical
 Surgical porto-systemic shunts (often spleno-renal)
 Liver transplantation (patients often given TIPP/surgical shunt whilst awaiting this)
TIPSS
Sengstaken-Blakemore Tube
Surgical porto-systemic shunt (spleno-renal shunt)
 Prognosis closely related to severity of underlying chronic
liver disease (Childs-Pugh grading)
 Child-Pugh classification grades severity of liver disease into
A,B,C based on degree of ascites, encephalopathy, bilirubin,
albumin, INR
 Mortality 32% Childs A, 46% Childs B, 79% Childs C

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H

Maybe classified into:

 Upper GI bleeding 4x more common than

 Emergency resuscitation same for upper and

 Bleeding from jejunum/ileum is not common

 If bleeding very brisk and severe then can

present with iron deficiency anaemia

Age <60 60-79 >80 -

Shock Nil HR >100 SBP <100 -

Co-morbidity Nil major - IHD/CCF/major Renal

Diagnosis Mallory Weiss All other GI malignancy -

Endoscopic None - Blood, adherent -

Score <3 carries good prognosis

 Mortality 32% Childs A, 46% Childs B, 79% Childs C

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