1.Dr. Balvir Singh Professor P. G. Deptt. Of medicine S.N. Medical College ,Agra

2. UGI BLEED It is defined as bleeding from gastrointestinal tract proximal to ligament of Trietz. It usually manifests as hematemesis or melena, and when severe, may even lead to hematochezia. Clinical guidelines are recommended to predict out -come, including rebleeding, and mortality. Stigmata of a recent hemorrhge are endoscopic finding that predict outcome. Endoscopy can provide the diagnosis,prognosis, and the potential for therapy. Medicine update 2013 API 3. Features Hemoptysis Haematemesis Definition Coughing out of blood Vomiting out of blood Symptoms Symptoms of pulmonary and CVS disease Symptoms of upper GI tract diseases Content & colour Mixed with sputum & bright red in colour Mixed with food particles & coffee-ground in colour Premonitory symptoms Cough, salty sensation in throat Nausea , vomiting, retching, abdominal discomfort. Melaena Does not occur Usually followed by melaena the next day Amount Relatively less Huge in amount Reaction Alkaline(Blue litmus remain unchanged) Acidic(Blue litmus remains unchanged 4. UGI BLEED Upper vs Lower GI bleeding = 5:1 Incidence: 170 patients/ 100,000 population /year(usa data). 40% due to peptic ulcer(Most common). 80% are self-limited. Pts on anti platelet therapy has two fold increase in bleed as compared to normal ones(annual UGI Bleed incidence-.13%). 20% of pts of moderate to high risk, who have recurrent bleeding (within 48-72 hrs) have poor prognosis. The mortality rate is 5% to 10% for severe UGI bleed. (Barkun A, Sabbah S, Enns R, et al:Am J Gastroenterol 2004; 99:1238-46) Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition :(Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013) 5. Clinical Features 1)Features due to blood loss : 1.Haemetemesis,malena or haematochezia , Hyperactive bowel sound. 2.H/O CLD presenting with shock. 3. H/O ESRD with sudden derange RFTs. 4. Features of co-morbid illnesses - IHD, COPD, CHF,SEPTICEMIA,PT ON VENTILLATORY SUPPORT. O/E: 1. Anemia 2.Orthostatic changes of BP and HR 3.Shock Other Clues -Raised BUN (Due to volume depletion and absorption of blood protein) 6. b ) Features due to underlying cause: Cause Features Peptic ulcer Epigastric burning pain Varices Vague right upper quadrant pain, fever, nausea, vomiting, ascites, edema. Features of hepatic failures Oesophagitis Heartburn, regurgitation, chest pain, dysphagia, odynophagia, and globus sensation. Mallory weiss tear Excessive retching,Vomiting, or coughing preceding hematemesis after alcohol intake. Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition 7. CAUSES OF SEVERE UGI BLEED Peptic ulcer 38 % Esophagitis 13 No cause found 8 Upper gastrointestinal tract tumor 7 Angioma 6 Mallory weis tear 4 Erosions 4 Dieulafoys lesion 2 Other 2 Variceal bleed Non variceal bleed Oesophageal varices & Gastric varices 16% Barkun A, Sabbah S, Enns R, et al Am J Gastroenterol 2004; 99:1238-46 8. Uncommon Causes of non variceal bleed (< 5%) Gastroesophageal reflux disease Trauma from foreign body Esophageal ulcer Cameron lesion Stress ulcer Drug induced erosions Angioma Watermelon stomach Portal hypertensive gastropathy Aorta-enteric Fistula Radiation telangiectasis/ Enteritis Benign tumours Malignant tumour Blue rubber bleb nevus syndrome Osler-Weber-Rendu syndrome Haemobilia Hemosuccus pancreatitis Infections(CMV,HSV) Stomal ulcer Zollinger-ellison syndrome :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013 9. DIAGNOSIS HISTORY EXAMINATION EMERGENCY ENDOSCOPY??? 10. History Helpful to find out the site and cause History suggestive of acid peptic disease Alcoholic liver diseases / chronic hepatitis / Cirrhosis History of anticoagulant / anti platelets / NSAIDS / Alcohol binge intake / steroids History of Coagulation disorder / Blood Dyscrasias History of Epistaxis or Hemoptysis to rule out the GI source of bleeding Patients of CVA, BURN, Sepsis, Head Trauma may have stress ulcers 11. ON EXAMINATION VITALS Pulse = Thready,BP = Orthostatic Hypotension SKIN changes Cirrhosis Palmer- erythema, spider angioma Bleeding diasthasis Purpura /Echymosis Coagulation Disorder Haemarthrosis, Muscle Hematoma ENT :- Look for clots (To rule out epistaxis P.N BLEED) P/A :- Liver , Spleen, Caput Medusa = Cirrhosis Epigastric Tenderness = APD/ Ulcer Respiratory, CVS, CNS For comorbid diseses 12. Diagnostic Workup CBC Bleeding &Coagulation profile (BT, CT,PT, a PTT) Liver Function Test Complete S. Biochemistry Relevant lab test for underlying disease BLOOD INV. ENDOSCOPY RADIO-IMAGING Barium Meal F.T. Arteriography USG/ Doppler USG Radio nucleotide study (Tagged RBC scan) 13. RISK FACTORS AND RISK STRATIFICATION -To identify patients with nonvariceal UGI bleeding at greatest risk for mortality and rebleeding. -Pts may be categorised as low, intermediate and high risk Pre-endoscopy scoring systems Postendoscopy scoring system Blatchford Score: BP,BUN level, Hb, Heart rate , syncope, Melena ,liver disease , Heart failure Clinical Rockall Score: Patients age , shock & coexisting illnesses Artificial neural network score: 21 variables Complete Rockall Score: Clinical Rockall score + endoscopic findings. * Correlates well with mortality & risk of rebleeding. Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition 14. Blatchford scoring system( pre endoscopic assesment) Variables Points * SBP(mm Hg) 100-109 1 90-99 2 150 6 * Hb(men;g/dl) 12.0-12.9 1 10.0-11.9 3 100 1 Presentation with melena 1 Hepatic disease 2 Cardiac failure 2 Most patients need intervention if their score is 6 or higher. Blatchford O, Murray WR, Blatchford M: Lancet 2000; 356:1318-21. 15. ROCKALL SCORING SYSTEM Variable Points 0 1 2 3 Age(yr) 80 - Pulse rate 100 - - Systolic BP Normal >100 5) Intermediate (35) Low (02) Rockall TA, Logan RF, Devlin HB, Northfield TCGut 1996; 38:316-21. 17. Management as per risk 1- Low risk(0-2)-Usually 80 % of the pt recovers spontaneously with medical Tt( PPI)+ Hospitalisation for 24 hrs and may be discharge if uneventful. 2-Intermediate risk(3-5)- same Tt + Hospitilisation for atleast 72 hrs. 3- High risk(>5%)- Same Tt+ Hospitilisation in I.C.U. :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013 18. Objectives in Acute GI bleeding: Immediate Assessment Stabilization of hemodynamic status Identify the source of bleeding Stopping the active bleeding Treat the underlying Prevent recurrent bleeding 19. Management of UGIB GENERAL MEDICAL MANAGEMENT TYPE OF BLEEDING VARICEAL BLEEDING NON VARICEAL BLEEDING MEDICAL ENDOTHERAPY SURGICAL INERVENTION PRESSURE TECHNIQUES 20. ENDOSCOPIC MODALITIES AVAILABLE FOR THE MANAGEMENT OF U.G.I. BLEED INJECTION Adrenalin Fibrin glue Human Thrombin Sclerosants Alcohol THERMAL Heater Probe Bicap Probe Gold Probe Argon plasma coagulation Laser therapy MECHANICAL Haemoclips Banding Endoloops Staples Sutures Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition 21. NON VARICEAL BLEED Mt ENDOSCOPIC MANAGEMENT 1.INJ.EPINEPHRINE 2.HAEMOCLIPS 3.LOOP LIGATION 4.CAUTERY : MONOPOLAR BIPOLAR APC OTHERS 1.INTERVENTIONAL RADIOLOGICAL PROCEDURES 2.TRANS CATHETRAL ARTERIAL EMBOLISATION Ripoll C, Banares R, Beceiro I, et al 2004; 15:447-50 : 3.SURGICAL INTERVENTION WITH ENDOSCOPE WITHOUT ENDOSCOPE 22. AUGIB Rapid Assessment Monitor Hemodynamic Status Fluid Resuscitation Ryle;s tube for Gastric Lavage Self Limited Hemorrhage (80%) Continued bleeding (10-25%) Urgent endoscopy Recurrent Hemorrhage Elective Endoscopy (With in 24 48 hours) Definitive Therapy (If Necessary) Site not localized Localized Further Assessment (Extended EGD, Radio-isotope scan, Arteriography, Exploratory Laprotomy) Definitive Therapy 23. FLUID RESUSCITATION Vitals are monitored Assessment of severity of blood loss :- An orthostatic decrease of 20 mm Hg in systolic blood pressure or increases in the pulse of 20 beats / min. indicate 10% blood loss, if pt is pulsless and in shock- > 20% loss. Order hemoglobin, hematocrit, BUN, grouping and cross matching of blood. Insertion of central venous line may be beneficial to measure adequacy of fluid replacement and perfusion of vital organ . Monitor urine output. Fluid resuscitation is done by crystalloids such as normal saline or RL if hypoalbuminemia is detected use colloids. Placing the patient in trendelenburg position to maintaine cerebral blood flow. General Management :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013 24. General Management 1.Oxygen support to prevent hypoxia of tissues 2.IV route - Crystaloid solution/Colloids|blood. 3. Blood transfusion: maintain Hct at 30% in the elderly, esp. with comorbid deseases eg. CHF, CRF, IHD,COPD) 20-25% in younger pt 25-28% in portal HTN administration of vit k 4.In symptomatic thrombocytopenia (