UPPER

GASTROINTESTINAL
BLEEDING (UGIB)
AINIL FATIMA BINTI ZAINODIN
AHMAD ZHAFIR BIN ZULKIFLI
 UGIB : (Proximal to Ligament of Treitz)

Esophagus Stomach Duodenum

Clive R, Joanna B, Simon J.F, Essential surgery,5th Edition; Peptic Ulceration and related disorder, Churchill Livingstone; 294-307
 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
 Abdominal pain

NICE Clinical Guideline: Acute upper gastrointestinal bleeding: management, 2012

 UGIB : Risk Factor : Identify comorbids

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

NICE Clinical Guideline: Acute upper gastrointestinal bleeding: management, 2012

 UGIB

NON
VARICEAL
VARICEAL

NICE Clinical Guideline: Acute upper gastrointestinal bleeding: management, 2012

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
Malaysian CPG: Management of Variceal Upper GI Bleeding, 2003
 Damage Hepatocytes

Intrahepatic Fibrosis
Hardening of tissue +
Nodule formation

BLOCKAGE

Return blood to
systemic circulation
Gastroesophageal Varices

Portosystemic Venous • Rectum

collateral that can • Umbilicus
form any site • Retroperitoneum
J Am Acad Nurse Pract: Use of B-blocker therapy to prevent primary bleeding
• Distal esophagus
of rsophageal varices • Proximal stomach
OESOPHAGEAL VARICES

 HVPG (Hepatic Venous Pressure Gradient)

- Normal HVPG < 5 mmHg
- Varices HVPG >12 mmHg (cause bleeding)

Malaysian CPG: Management of Variceal Upper GI Bleeding, 2003

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

NICE Clinical Guideline: Acute upper gastrointestinal bleeding: management, 2012.

 PRIMARY PROPHYLAXIS
 OESOPHAGEAL VARICES
Grade I : Should not receive primary prophylaxis
But be screened for enlargement of varices every 1-2 years

Grade II & III with endoscopic red signs /Child’s C cirrhosis

should be treated

1) Pharmacological Therapy

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

Beta-blockers (reduce splanchnic circulation pressure)

2) Endoscopic Therapy

Endoscopic Variceal ligation (EVL)

Endoscopic sclerotherapy – injection of sclerosant

- Sodium tetradecyl sulphate (thrombovar)
- Ethanolamine oleate
Malaysian CPG: Management of Variceal Upper GI Bleeding, 2003
Malaysian CPG: Management of Variceal Upper GI Bleeding, 2003
 SCREENING
 Screening Endoscopy
 Patient with small varices on initial endoscopy should screened for
enlargement of varicess every 1-2 years .
Malaysian CPG: Management of Variceal Upper GI Bleeding, 2003

Variceal appearance on endoscopy :

• ("red signs"): red wale marks (longitudinal
red streaks on varices);
• cherry-red spots (red, discrete, flat spots
on varices);
• hematocystic spots (red, discrete, raised
spots);
• diffuse erythema
J Am Acad Nurse Pract: Use of B-blocker therapy to prevent primary bleeding of rsophageal varices
Management Acute Variceal Bleeding
• Correcting hypovolemic shock
• to restore hemodynamic stability
Resuscitation •
•
Keep HB ideally more than 7g/dL or HCT 24%
Avoid overTx  May ↑portal pressure 
exacerbate futher bleeding

• Iv Terlipressin/ Octreotide / Somatostation for

Pharmacotherapy 2-5 days to prevent early rebleeding.

( Vasoactive Terlipressin : 2mg bolus & 1mg every 6 hr (for 2-5 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.
Antibiotics • Incidence of sepsis ↑ almost 66% at two weeks.
• Infection high mortility & variceal re-bleeding.
3rd Generation cephalosporin (iv) or oral
quinolone (norfloxacin/ciprofloxacin)

Malaysian CPG: Management of Variceal Upper GI Bleeding, 2003

Management of Oesophageal Variceal
Bleeding

Endoscopic Variceal Ligation

Endoscopic Theraphy
•
(EVL)
• Endoscopic Sclerotheraphy
Temporary “bridge” for max 24hr
Ballon Tamponade
•
• 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

Malaysian CPG: Management of Variceal Upper GI Bleeding, 2003

Malaysian CPG: Management of Variceal Upper GI Bleeding, 2003
 Management of varices

J Am Acad Nurse Pract: Use of B-blocker therapy to prevent primary bleeding of rsophageal varices

EGD, esophogastroduodenoscopy; EVL, endoscopic variceal ligation.

Non Varieceal 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 branulla into
large peripheral veins
2. Give O2: NPO2, VM, HFM
3. Take bloods for IX: 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
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
 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 PU:
Therapeutics
• Mechanical
• Hemoclips
• Injection
• Injection therapy with diluted epinephrine
• Results in local tamponade and vasospasm
• Thermal
• Unipolar diathermy
• Thermal coagulation uses argon plasma coagulation (APC)
 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
 Clive R, Joanna B, Simon J.F, Essential surgery,5th Edition; Peptic
Ulceration and related disorder, ChurchillLivingstone; 294-307
 Malaysian CPG: Management of Variceal Upper GI Bleeding, 2003
 Kumar & Clark 3rd Edition ; Chapter 18 Oesophagus, Stomach and
Duodenum,Saunders; 280-292
 Gray’s Anatomy, 3rd Edition ; Venous Drainage 354-357