1. UPPER GI Bleed BY
DR DENNIS PRABHU DAYAL

2. GI Bleeding
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

3. Emergency Resuscitation
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)

4. Estimating Degree of Blood Loss
RR, HR, and BP can be used to estimate degree of blood loss/hypovolaemia

5. History and Examination
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)

6. History in patients with GI bleeding
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

7. Upper GI bleed
Upper GI bleeding refers to bleeding from oesophagus, stomach, duodenum (i.e. Proximal to ligmanet of treitz)
Bleeding from jejunum/ileum is not common

8. Presentation 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

10. Risk Stratification: Rockall Score
Identifies patients at risk of adverse outcome following acute upper GI bleed
Score <3 carries good prognosis
Score >8 carries high risk of mortality

11. Management (Non-variceal)
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)

12. Variceal Bleeds
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

13. Management of Variceal bleeds
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)

14. TIPSS
Sengstaken-Blakemore Tube

15. Surgical porto-systemic shunt (spleno-renal shunt)

16. Variceal Bleed: Prognosis
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

17. THANK YOU