1. UPPER GASTROINTESTINAL BLEEDING
G.C. Sturniolo
Nicoletta Merlini
Dipartimento di
Scienze Chirurgiche e Gastroenterologiche
Sezione di Gastroenterologia

2. ACUTE UPPER GI BLEEDING
INCIDENCE:
50 to 150 cases per 105 per year
In UK
hospital admission
each year
Palmer, PMJ 2004

3. AUGIB ETIOLOGY Peptic ulcer disease Oesophageal/gastric varices
Mallory-Weiss tear
Oesophagitis
Duodenitis/gastritis/erosions
Vascular (Angiodysplasia, Dieulafoy)
Tumours
Aortoenteric fistula

4. ACUTE UPPER GI BLEEDING
Adapted from
Palmer, PMJ 2004

5. MORTALITY Mortality % 4153 upper GI bleeding Rockall, BMJ 1995 > 90
21-30
31-40
41-50
51-60
61-70
71-80
81-90
Rockall, BMJ 1995

6. and mortality related to the source of bleeding
MORTALITY in UGIB
Hospital mortality
and mortality related to the source of bleeding
in 362 UGIB
45,5%
29,4%
22,7%
20%
9,1%
5,9%
3,8% 0%
Klebl, Int J Colorectal Dis 2005

7. MORTALITY in UGIB Mortality of patients during hospitalization
40%
p < 0,05
11%
Bleeding
only before
admission
Bleeding
before + after
admission
Adapted from
Palmer, PMJ 2004

8. MORTALITY FOR UGIB: Time Trend
1996
19,5%
p=0,05
1996
2000
p=0,03
11,7%
11,1%
2000
7,2%
Fiore, Eur J Gastr Hep 2005

9. UGIB: Diagnostic Endoscopy
Identifies the bleeding lesions >95% of sensitivity and specificity
Doesn’t alter patient outcome:
Morbidity
Mortality
Transfusions
Length of stay
Surgery
Peterson, NEJM 1981
Cappell, Med Clin N Am 2002

10. UGIB: Therapeutic Endoscopy
Only patients with persisten or recurrent bleeding
80% patients don’t have further bleeding
Optimal utilization
IDENTIFY HIGH RISK PATIENTS

11. to assess risk of mortality and rebleeding
UGIB: ROCKALL SCORE
Developed in 1996
to assess risk of mortality and rebleeding
in UGIB patients
Rockall, BMJ 1996
Rockall risk score
Variable Score Score Score Score 3
AGE
SHOCK
CO-MORBID
DIAGNOS
MAJOR SRH
< 60
None
Mallory-Weiss
No lesions
None or
dark spots
60-79
Pulse > 100 bpm -
All other
diagnoses
> 80
Fc>100,PAOs <100
Cardiac failure
Malignancy upper GI
Blood in upper
GI tract, blood clot
Renal,liver
failure

12. UGIB: ROCKALL SCORE Retrospective study, 222 patients
Distribution of Rockall Score 7 5 4 6 8
% of patients 9 3 10 2
Bessa, DLD 2006

13. UGIB: ROCKALL SCORE Retrospective study, 222 patients Rebleeding Risk
Mortality Risk
p < 0,001
p = ns
Rockall < 5
Rockall > 6
Rockall < 5
Rockall > 6
Bessa, DLD 2006

14. UGIB WHICH PATIENTS ARE MORE LIKELY TO REBLEED?

15. UGIB: Clinical Risk Large volume bleeding Shock Age > 60 years
Bleeding onset after admission
Comorbidity
Variceal Bleeding

16. Scoring Systems for UGIB
Baylor bleeding score (1993)
Cedars-Sinai predictive index (1996)
Rockall Score (1996)
Blatchford Score (2000)
Das, Gastrointest Endosc 2004

17. UGIB: Blatchford Score
Derived from clinical information at presentation such as:
Urea Hb
Blood pressure
Comorbidity (syncope, melena, heart and/or liver disease)
Blatchford, Lancet 2000

18. “CLINICAL INTERVENTION”
BLATCHFORD vs ROCKALL
BETTER ROC FOR
“CLINICAL INTERVENTION”
Blatchford, Lancet 2000

19. PEPTIC ULCERS CLASSIFICATION
FORREST CLASSIFICATION
ACUTE HEMORRHAGE
Forrest I a Arterial, spurting hemorrhage
Forrest I b Oozing hemorrhage
SIGNS OF RECENT HEMORRHAGE
Forrest II a Visible vessel
Forrest II b Adherent clot
Forrest II c Hematin covered lesion
LESIONS WITHOUT RECENT BLEEDING
Forrest III No signs of recent hemorrhage

20. Forrest IIb
Forrest IIa

21. FORREST CLASSIFICATION
Forrest 1a
Spurting bleeding
Forrest 1b
Non-spurting active bleeding
Forrest 2a
Non-bleeding visible vessel
Forrest 2b
Non-bleeding with adherent clot
Forrest 2c Forrest 3
Ulcer with haematin-covered base Ulcer with clean base

22. PEPTIC ULCERS: RISK FACTORS?
Male, Advanced age
History of ulcer disease
Helicobacter Pylori
Corticosteroids
NSAIDs
Blood-thinning drugs

23. Endoscopy and endoscopic therapy
MANAGEMENT OF UGIB
Resuscitation
Endoscopy and endoscopic therapy
Drug Therapy

24. Endoscopy and endoscopic therapy
MANAGEMENT OF UGIB
Resuscitation
Endoscopy and endoscopic therapy
Drug Therapy

25. RESUSCITATION Airway, Breathing, Circulation Shocked Actively bleeding
Central Venous Pressure (elderly and cardiopathic)
Crystalloids (carefully in liver disease!)
Colloids in major hypotension
Blood transfusion
Shocked
Actively
bleeding
Hb < 10 g/dL
Palmer, PMJ 2004

26. WHEN SHOULD WE TRANSFUSE PATIENTS?
Age > 60 years
Hb < 8.2 g/dL
Blood Transfusion
Cardiologic Evaluation
cTropI Curve
Gastro PD, BLISC

27. Endoscopy and endoscopic therapy
MANAGEMENT OF UGIB
Resuscitation
Endoscopy and endoscopic therapy
Drug Therapy

28. UGIB: TO SCOPE
Early endoscopy identifies and treats patients with high risk of rebleed improving patient outcomes
PPI therapy alone is not as effective as endoscopic therapy for high risk lesions

29. UGIB: NOT TO SCOPE
No benefit from early endoscopy if the findings do not change patient care

30. Time with intragastric pH>4 / 24h
DRUG THERAPY
IV PPI vs IV RANITIDINE
Time with intragastric pH>4 / 24h
96%
93%
67%
p<0,001
43%
Merki,
Gastroenterology 1996

31. MANAGEMENT OF NON VARICEAL BLEEDING
Non-variceal, upper GI bleeding
IV PPI bolus + infusion
Upper Endoscopy
High-risk stigmata
Low-risk stigmata
Endo therapy +
IV PPI
Oral PPI therapy
Triadafilopoulos,
Alim Pharm Ther 2005

32. BLEEDING PREVALENCE: 30-40% MORTALITY I BLEEDING: 20-45%
OESOPHAGEAL VARICES
80-90% CIRRHOSIS
BLEEDING PREVALENCE: 30-40%
MORTALITY I BLEEDING: 20-45%
PRIMARY PREVENTION
SECONDARY PREVENTION
TREATMENT ACUTE BLEEDING

33. CIRRHOSIS SMALL VARICES LARGE VARICES REBLEEDING PRIMARY PREVENTION
INCIDENCE/YEAR
5-30%
INCIDENCE/YEAR
5-50%
MORTALITY 30-50%
INCIDENCE/YEAR 5-10%
CIRRHOSIS
SMALL VARICES
ACUTE BLEEDING
LARGE VARICES
REBLEEDING
60% 1 YEAR
PRIMARY PREVENTION
 50% BLEEDING
25-45% MORTALITY’

34. RISK FACTORS HIGHER BLEEDING RISK CHILD B-C
EXTENSION (63% Ls vs 45% Li)
DIMENSION (F1,15%;F2,32%;F3,68%)
RED WALL MARK
(red spots e wall marking 76% vs 17% without)
COLOR (blue 80% vs white 45%)
PORTAL VEIN PRESSURE (> 12 mmHg)
HIGHER BLEEDING RISK

35. VARICEAL BLEEDING VASOACTIVE ANTIBIOTIC DRUGS EGDS IN 12 HRS
RESUSCITATION
PLASMA EXPANDERS
UEC
VARICEAL BLEEDING
VASOACTIVE
DRUGS
ANTIBIOTIC
De Franchis, J Hepatol 2000

36. MEDICAL TREATMENT ANTIBIOTICS
INFECTIONS 
35-66% BLEEDING CIRRHOTICS
UTI 12-29% E.Coli + Klebsiella
SBP 7-23% Gram -/+
PULMONARY INFECTIONS 6-10%
SEPSI 4-11%
Dell’Era, APT 2004

37. INFECTIONS  BLEEDING CONTROL FAILURE  MORTALITY RELATED BLEEDING
PREDICTIVE FACTOR OF REBLEEDING

38. MEDICAL TERATMENT VASOACTIVE DRUGS
TERLIPRESSIN
2 mg e.v. qd 4-6 hrs per 24 hrs
then
1 mg e.v. qd 6 hrs per 4 days

39. TAKE HOME MESSAGES EGDS VASOACTIVE DRUGS, BLOOD TRASFUSION
RESUSCITATION, COLLOIDS, ANTIBIOTICS
EGDS
VARICEAL BAND LIGATION
SCLEROTHERAPY
MEDICAL TREATMENT
Failure
Vasoactive drugs (5 days long)
II EGDS
Failure
BLAKEMORE
Surgery (child A) TIPS (child B,C)
Lata J et al Dig Dis 2003