UPPER GI BLEEDING Ayaz Chaudhary MD,FACP,FASGE,FAGA

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UPPER GI BLEEDINGAyaz ChaudharyMD,FACP,FASGE,FA
GA
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Upper GI Bleeding

• Diverse presentation
• Active/massive subacute/intermittent-occult
• 1 GI emergency
• Mortality

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Sign and Symptoms

• Hematemsis / Fresh blood / coffee ground.
• Melena.
• Hematochezia.
• Dizziness.
• Abdominal pain.

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History

• Prior episodes of GI Bleeding
• Concomitant Medical Conditions
• Medications
• Social History
• Surgical History,AAA

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Risk factors for poor outcome

• Age gt 60
• Severe comorbid conditions
• Inpatient hemorrhage
• Hypotension / shock
• Hematochezia / hematemesis
• Red nasogastric tube aspirate
• Transfusion gt 6 u RBC for single bleed
• Rebleed same lesion in house
• Severe coagulopathy or PLT disorder

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Physical Exam

• ORTHOSTATIC VITAL SIGNS
• Abd.examination.
• Stigmata of Liver disease.
• Rectal Exam.
• N/G Lavage.

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Diagnostic Procedure

• LABS (serial H/H, Plats, PT/PTT, BUN, Cr)
• EGD diagnostic and therapeutic.
• Bleeding scan.

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Approach to Active/MassiveGI Bleeder

• Assessment/Resuscitation
• Team Approach
• ICU Setting
• Early Diagnostic Endoscopy with Therapeutic
  Endoscopy where helpful

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TREATMENT

• Resuscitations
• Two large Caliba 18 Galage line or central venus
  access.
• High risk patients keep HCT30.
• Young and healthy HCT 20 ok.
• Correct coagulopathy and low Platelets,
• Access on going bleeding by reassessing heart
  rate,Blood pressure, N/G return or hematochezia,
  serial H/H
• Inadequate initial resusitation and failure to
  initiate therapy for unstable medical condition
  increases the complication if ever get EGD.

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Prior to Endoscopy

• Large bore orogastic lavage.
• Elective intubation.
• Use of prokinetic agents
• Both surgery and GI Physician should be involved.
• Somatostatin or its analog octerotide.
• Continue resuscitation
• Use of acid suppression.

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Endoscopy

• 80-90 Active/massive GI bleeding stops
  spontaneously
• Goal is to identify
• lesions continuing to bleed,
• lesions likely to bleed again
• To treat the lesions

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GI Bleeding treatment

• Peptic ulcer and others
• Variceal bleed

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Endoscopic treatment Peptic ulcer and other
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Peptic ulcer presentation
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Injection traetment
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Ulcer presentation
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Thermal Therapy
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Mechanical Therapy
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Ulcer

• Stigmata of Active or Recent Bleeding

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Clean base

• 33 total
• 3 rebleed

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Gray slough, red or black spot

• 14 total
• 7 rebleed

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Oozing ulcer with no stigmata

• 7 total
• 10 rebleed

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Adherent clot

• 10 total
• 33 rebleed

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Adherent clot
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Visible vessel

• 24 total
• 50 chance rebleed

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Endoscopic treatment for PUD
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Varices
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Esophageal Varices treatment

• Sclerotherapy
• Balloon Tamponade
• Banding
• TIPS

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Balloon Temponade
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Esophgeal banding
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TIPS procedure
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Varices

• Esophageal Vs Gastric
• Band Vs Injection
• ? Treat non-bleeding varices
• Balloon Tamponade
• Role of T.I.P. (Transjugular Intrahepatic
  Portosystemic Shunt)
• Portal Caval Shunt
• Octerotide
• Different site of bleeding

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Prognosis

• PUD 10 motility unchanged.
• Varices 50 motility.

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