Common causes for Upper GI hemorrhage are esophageal variceal bleeding or peptic ulcer bleeding. It can be managed endoscopically or surgically.

1. Dr.B.SELVARAJ MS;Mch;FICS;
Upper GI Hemorrhage
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‘Surgical Perspective’

2. Upper GI Hemorrhage
Dr.B.Selvaraj MS;MCh;FICS;
Neonatal &Pediatric Surgeon
Melaka Manipal Medical College
Melaka- 75150
Malaysia
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3. Upper GI Hemorrhage
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Definition :
Bleeding originates from GI tract proximal to Ligament of
Treitz.
Presentation :
1. Hemetemesis :
Vomiting of blood Bright red (fresh)
Coffee ground (Old) Melenemesis
2. Melena: Black tarry foul smelling stools.
3. Hematochezia: Bright red stool per rectum
4. Bleeding through Ryle’s tube (in hospitalized patients)

4. Upper GI Hemorrhage-Causes
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Non variceal bleeding (80%) :
1.Peptic ulcer disease (30 to 50%)
2.Mallory Weiss tear (15 -20%)
3.Gastritis or duodenitis (10 – 15%).
4.Esophagitis (5 – 10%).
5.A–V malformation (5%).
6.Tumours (2%)
7.Others (5%)
Variceal Bleed ing(20%) :
1.Gastroesophageal varices > 90%.
2.Portal hypertensive gastropathy < 5%.
3.Isolated gastric varices (rare)
Uncommon Causes:
1.Hemobilia
2.Dieulafoy leison
3.Gastric antral vascular ectasia
(GAVE)
4.Aortoenteric fistula
5.Hemosuccus Pancreaticus

5. Upper GI Hemorrhage-Causes
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6. Upper GI Hemorrhage- Initial
Goals
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1. Detailed patient assessment with
hemodynamic resuscitation
Identification of co-morbid conditions.
2. Diagnosing the cause of bleeding.
3. Specific measures to achieve hemostasis and to
prevent rebleeding.

7. Upper GI Hemorrhage- Initial
Management
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Patient assessment Airway, Breathing, Circulation
Patient resuscitation IV access, blood transfusion, labs
Risk assessment Severe , moderate or mild bleeding
Upper Endoscopy
Low risk lesion High risk lesion
Medical Rx Endoscopic Rx Rebleed Surgery

8. Upper GI Hemorrhage- Initial
Assessment
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1st Step : Assess the severity of
bleeding
A: Check vital sign
B: Assess airway and breathing.
C: Assess circulatory status.
Guide resuscitation.
Prognostic information.
Triage of patient.
Vitals sign % Blood loss Severity of
bleed
Normal < 10% Minor
Postural
hypotension
10 - 20 % Moderate
Shock > 20 – 25 % Massive

9. Upper GI Hemorrhage-
Resuscitation
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Proportional to severity of bleed.
Inspect and clean airway.
Check ventilation.
Supplement oxygen.
Endotracheal intubation and mechanical ventilation if
indicated.
Fluid therapy.
Central venous catheter if indicated.

10. Upper GI Hemorrhage-
Resuscitation
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Elderly > 30%
Young healthy patient > 20 – 25%
Portal hypertension > 27 to 28%
Use of blood and blood product.
A. Whole blood / preferably packed RBC
Target of Hematocrit value :
B. FFP / Platelet transfusion
Vasopressors role
Regular vitals and urine output monitoring.

11. Upper GI Hemorrhage-
HISTORY AND PHYSICAL EXAMINATION
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1. Assess the severity of bleed.
2. Preliminary assessment of site and cause.
3. Identification of risk factors.
History :
Age of patients :
Elderly patient : Carcinoma.
Young patient : Ulcer disease ,esophagitis ,varices

12. Upper GI Hemorrhage-
HISTORY AND PHYSICAL EXAMINATION
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Volume of vomited blood, colour of vomitus, colour of
stool
History of prior GI bleed / Bleed in general.
History previous disease / intervention.
Any history of medical illness.
Ingestion of Asprin / other NSAID.
History of liver disease .
History of retching .
History of nasopharyngeal disease
History of chronic occult blood loss.

13. Upper GI Hemorrhage-
HISTORY AND PHYSICAL EXAMINATION
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Vitals, pallor, icterus , lymphadenopathy , Pedal edema.
Cutaneous sign e.g. Spider Angiomata , Duputyren’s contracture
Liver disease: Ascites, Caput medusa
Malignancy : Acanthosis nigricans, Lymphadenopathy
Pigmented lip lesion: Peutz - Jegher
Abdominal tenderness - Peptic ulcer, pancreatitis
Abdominal mass : Lymphadenopathy, hepatosplenomegaly
ENT examination.

14. Upper GI Hemorrhage-
LABORATORY EXAMINATION
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CBC
Electrolytes
Glucose
BUN / S.Creatinine
Coagulation study
LFT
Blood group and cross match

15. Upper GI Hemorrhage-
RISK FACTORS
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1. Age > 60 years.
2. Comorbid disease -Renal -Liver
-Respiratory -Cardiac
3. Magnitude of hemorrhage :
Systolic BP < 100 on presentation
Transfusion requirement
4. Persistent / Recurrent hemorrhage
5. Need for surgery.

16. Upper GI Hemorrhage-
SCORING SYSTEM
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1. Predict risk for rebleeding and mortality.
2. Evaluate the need for ICU admission.
3. To determine need for urgent endoscopy
Bleeding classification :
1. On going bleeding.
2. Systolic BP < 100.
3. PT greater 1.2 times of control.
4. Altered mental status.
5. Unstable comorbid disease.

17. Upper GI Hemorrhage-
RISK ASSESSMENT
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1. Mild to moderate :
< 60 year (no chronic medical illness).
No signs of hemodynamic instability.
Hematocrit > 30%.
2. Severe :
> 60 year.
Sign and hemodynamic instability.
Acute bleeding.
Drop in hematocrit > 6%.
Severe comorbid disease.

18. Upper GI Hemorrhage-
Diagnosing the cause for bleeding
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1. History and physical
examination.
2. NG tube
3. Esophagogastrodud-
enoscopy (EGD)
4. Tagged RBC scan
5. Angiography

19. Upper GI Hemorrhage-
NG Tube
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Definite or suspected acute UGI bleeding have a NG tube
Not contraindicated even in esophageal or gastric varices
false +ve low – caused by nasogastric trauma.
Useful to assess the rate of ongoing bleed (not accurate).
Not provide information about the etiology of bleed.
Nature of aspirate can serve as a prognostic indicator.
It also helps in endoscopy by performing gastric lavage.
Aspirate is (-)ve for blood in upto 25% of patient with UGI
bleed.

20. Upper GI Hemorrhage-
Upper GI Endoscopy
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Early EGD is performed within 24
hours to maximize efficacy.
Defines source of bleeding.
Stratify the risk of rebleed.
Decrease blood transfusion
requirements, decrease need of
surgery, decrease hospital stay.
Facilitating operative planning.
Provide endoscopic therapy.

21. Upper GI Hemorrhage-
Upper GI Endoscopy
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Accuracy limited by :
1. Active massive bleeding.
2. Abnormal anatomy as a result of previous surgery.
Complication (emergency EGD) :
1. Aspiration.
2. Respiration depression.
3. GI perforation
Timing :
Patient with sign of ongoing bleeding URGENT.
Others – within 24 hours.

22. Upper GI Hemorrhage-
Upper GI Endoscopy
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Done when adequate resuscitation achieved
Best done in endoscopy unit.
In severely bleeding patient endoscopy should be done with
ET tube in place.
Insertion of NG tube and stomach lavage is recommended.
Some endoscopist recommends iv erythromycin prior to
endoscopy

23. Upper GI Hemorrhage-
Upper GI Endoscopy
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24. Upper GI Hemorrhage-
Upper GI Endoscopy
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25. Upper GI Hemorrhage-
Upper GI Endoscopy
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26. Upper GI Hemorrhage-
Tagged Red Blood cell Scintigraphy
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Patients with massive hemorrhage in whom a bleeding source
is not identified.
Technetium sulphur colloid or (99Tc) pertechnetate-labeled
red blood cells can be used.
Detect a bleeding as low as 0.1 mL/min
Highly variable accuracy rates for localizing bleeding, ranging
from 24 to 91% (grade B evidence)
Must have active bleeding
Radionuclide screening appears to increase the diagnostic
yield of arteriography by a factor of 2.4

27. Upper GI Hemorrhage-
Tagged Red Blood cell Scintigraphy
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Advantages:
1. Safe
2. Noninvasive
3. Low in cost
Disadvantages:
1. lack of therapeutic capability and doubt
about its accuracy.
2. Surgical therapy not recommended on
the basis of result of tagged RBC
scintigraphy alone.

28. Upper GI Hemorrhage-
Angiography
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Rate of atleast 0.5- 1ml/min.
Specificity 100%, sensitivity 30-
47%
Advantages :
No bowel preparation
Accurate localization of
rapidly bleeding lesions
Immediate hemostasis .
Limited to patient with
continued bleeding
Serious complication
Arterial thrombosis
Contrast reactions
Acute renal failure

29. Upper GI Hemorrhage-
Angiography
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A. Intraarterial vasopressin – Stops bleeding in 20-80% of patients.
Complication :
1. Bowel ischemia.
2. Heart, brain, renal or other and organ ischemia.
3. High chances of rebleeding.
Contraindication :
1. Coronary artery disease.
2. Ischemic bowel disease.
B. Embolic agent : Gelfoam, tissue adhesive beads, clips.
Complication :
1. Rebleeding
2. Ischemia
3. Infarction
4. Abscess formation

30. Management of Bleeding Varices
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31. Grading of Esophageal Varices
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32. Management of Bleeding Varices
Pharmacotherapy
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Should be started as soon as possible
Specific agent chosen depends upon availability and physician
preference.
Should be continued upto 5 days to prevent rebleed.
Best is to use them with endoscopic therapy.
A. Drug that decrease portal blood flow :
1. Non selective β blocker.
2. Vasopressin
3. Somatostatin with its analogue -- Octrotide
B. Drugs that decrease intrahepatic resistant (experimental) :
1. Nitrates
2. α1 adrenergic blocker.
3. Angiotensin receptor blocker.

33. Management of Bleeding Varices
Endoscopic Therapy
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Only treatment modality that is widely accepted for
prevention, control and rebleeding of varices.
– Sclerotherapy
– Band ligation
Sclerotherapy largely supplant by endoscopic band
ligation except when poor visualization precludes
effective band ligation of bleeding varices

34. Management of Bleeding Varices
Sclerotherapy
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1. Intravariceal injection : Injected directly into varices.
Solution : Ethanolamine oleate (5%)
Sodium morrhuate 5%.
Optimal volume : 1 to 2 ml of sclerosants per injection.
Total volume 10 to 15 ml.
2. Paravariceal injection :
Injected submucosally adjacent to varices
Solution 0.5 or 1% polidocanol.
0.5 to 1 ml is injected into each site between varices

35. Management of Bleeding Varices
Sclerotherapy
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36. Management of Bleeding Varices
Banding (EVBL)
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Band strangulates the
varices, causes thrombosis
Multiband devices can be
used
Advantage
Easy to perform.
Fewer complication.
Fewer session.
Disadvantage
Gastric fundal varices.
Banding induced ulcers.
Use of overtubes causes
mucosal tear and esophageal
perforation.

37. Complications of Endoscopic Variceal
Therapy
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A. During procedure :
1. Retrosternal chest pain.
2. Aspiration pneumonia
B. Following procedure :
1. Local ulcer
2. Bleeding
3. Stricture
4. Dysmotility
5. Perforation
6. Mediastinitis
C. Systemic : (Usually with Sclerotherapy)
1. Sepsis
2. Pulmonary embolism

38. Management of Bleeding Varices
Banding (EVBL)
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Temporary measure in patients with active, life
threatening hemorrhage refractory to endoscopic and
pharmacological therapy.
It controls bleeding in 90% cases.
Serious complications :
1. Esophageal perforation.
2. Aspiration pneumonia.
3. Rarely asphyxiation.
On deflation of balloon rebleeding is seen in high
proportion of cases
Management of Bleeding Varices
Baloon Tamponade

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Management of Bleeding Varices
Baloon Tamponade
1. Linton -Nachlas tube
2. Sengstaken Blackemore
tube
3. Minnesota 4 lumen tube

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Management of Bleeding Varices
TIPS
Reduces elevated portal
pressure.
Use to treat many
complication of portal
hypertension.
Prerequisite (not strict)
1.Platelet count >60000/ µl
2.PT < 1.4
3.Broad spectrum antibiotic
coverage

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Management of Bleeding Varices
TIPS
Complication :
1. Procedure related
2. Early post procedure (1 to 30 day)
Major
Minor
3. Late (> 30 days)
Hemorrhage controlled in > 90% of patient but mortality very
high > 60% in 60 days .
Because of increased mortality and risk of hepatic
encephalopathy TIPS can not be recommended as first choice
of treatment .

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Management of Bleeding Varices
Surgical Treatment
A. Shunt Surgery
Reduce variceal
bleeding and prevent
recurrent bleeding.
Indications:
Failed emergency
medical treatment.
Sites not accessible to
sclerotherapy.
Bleeding following
sclerotherapy.
Isolated portal vein
thrombosis.
Where long term care
not be assured.

44. Surgical Treatment
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Management of Bleeding Varices
Advantages :
High control rate of bleeding and low rebleeding rates.
One time procedure .
Improvement in postoperative growth parameters.
Disadvantages :
Postoperative encephalopathy.
High failure rate of shunts in children (< 10 years).
Thrombosis.
Accelerated liver failure .
Development of effective spontaneous portosystemic shunt
with time (48%).
Failure of liver transplantation.

45. Surgical Treatment
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Management of Bleeding Varices
B. Non decompressive surgery :
Splenectomy :In patients who bleed from gastric varices
secondary to isolated splenic vein thrombosis
Esophageal transaction and devascularization
procedure:(Suguira Procedure)
Indication:
Vessels not available for shunting .
Extrahepatic portal vein obstruction.
Preexisting encephalopathy.
Severely impaired liver function .
Candidates for liver transplantation.
Limited effect and rebleeding rate is high.

46. Surgical Treatment
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Management of Bleeding Varices
Suguira Procedures : include
esophageal transaction and
reanastmosis, truncal vagotomy
with either thoracoabdominal or
transabdominal portoazygous
devascularization of upper half of
stomach and lower l/3 of
esophagus. Highly effective in
controlling active hemorrhage

47. Gastric Varices
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Management of Bleeding Varices
Sarin classification :
GOV1 GOV2
IGV1 IGV2
Endoscopy : preffered
N butyl– 2 cynoacyrlate
Advantage : Ulcer occur less
Risk of rebleed is less
Complication :
Bacteremia
Variceal ulceration
Cerebral& Pulmonary
thrombosis
Damage endoscope

48. Algorithm
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Management of Bleeding Varices

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Management of Bleeding Peptic Ulcer
Most common specifically
identified cause of UGIB.
Incidence:duodenal ulcer
twice that of gastric ulcer.
Ulcer located high on the
lesser curvature of
stomach, posteroinferior
wall of duodenal bulb are
most likely to bleed and
rebleed .

50. Predisposing Factors
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Bleeding Peptic Ulcer
Gastric acids .
H.pylori infection.
Use of NSAID – Most important predisposing factor.
CVS and cerebrovascular disease.
Chronic pulmonary disease, cirrhosis.
Drugs – Glucocorticoids, bisphosphonate alendronate.
Ethanol.
Anticoagulants.
Hospitalization (poor outcome).

51. Forrest Classification
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Bleeding Peptic Ulcer

52. Rockall Scoring for rebleeding risk
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Bleeding Peptic Ulcer
A simplified scoring
system based on
endoscopic and clinical
variables has been
developed

53. Pharmacological Therapy
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Management of Bleeding Peptic Ulcer
A.Proton pump inhibitor :
considered additive to that of therapeutic endoscopy.
Mechanism :
1. Acid pH retard blood cloting and enhances clot dissolution. (it
raises gastric pH )
2. Elevating gastric pH facilitates platelet aggregation.
3. Improve ulcer healing in less acidic environment.
Advantages : Decrease bleeding , rebleeding , surgery, death.
Side effect : loose stool, abdominal pain, muscle and joint
pain, leucopenia, Hepatic dysfunction.On long term -Atrophic
gastritis.

54. Pharmacological Therapy
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Management of Bleeding Peptic Ulcer
B. H2 antagonist :
Disappointing , do not provide maximum acids suppression.
Various agent. Cimetidine, Ranitidine, famotidine, Roxatidine.
Adverse effect : GI effect.CNS effect .Bolus IV injection causes
release of histamine .
C. Nitrates : May play protective role in upper GI hemorrhage.
Under experimental phase.
D. Somatostatin / Octerotide: patients who are severely bleeding and waiting for
endoscopy or surgery or other drug therapy is not possible.
E. Antifibrinolytic therapy : Recent metanalysis has shown tranexmic acid
therapy will not reduce ulcer rebleeding but appears to reduce mortality.

55. Endoscopic Therapy
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Management of Bleeding Peptic Ulcer
Any of the three modality can be used Injections, Thermal or
Mechanical
No single modality has been shown to be superior than other .
Operator experience plays a significant role.
Repeat endoscopy
(a) If there is clinical evidence of active rebleeding (Grade C).
(b) If there are concerns regarding optimal initial endoscopic
therapy ( Grade C)

56. Endoscopic Therapy
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Management of Bleeding Peptic Ulcer
A. Injections :
1. Adrenaline
2. Fibrin glue
3. Human thrombin
4. Butyl 2 cyanoacrylate (0.5% to 1%).
5. Sclerosant.
Sodium tetradecyl sulphate (1-3%)
Sodium morrhuate (5%)
Ethanolamine oleate (5%)
Absolute alcohol

57. Endoscopic Therapy
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Management of Bleeding Peptic Ulcer
B. Thermal
1. Heat probe
2. Bicap probe
3. Gold probe
4. Argon plasma
coagulation
5. Laser therapy (Nd-
YAG)

58. Endoscopic Therapy
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Management of Bleeding Peptic Ulcer
1. Hemoclips
2. Banding
3. Endoloop
4. Staples / sutures.
C. Mechanical

59. Endoscopic Therapy
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Management of Bleeding Peptic Ulcer

60. Angiographic Therapy
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Management of Bleeding Peptic Ulcer
Indication : Severe persistent bleeding with endoscopy
unsuccessful or unavailable and surgery too risky.
Superselective angiogaphic approach is used
A. Intraarterial vasopressin– Stop bleeding in 20-80% of patients.
Contraindications :
• Coronary artery disease.
• Ischemic bowel disease.
B. Embolic agent : Gelfoam, tissue adhesive beads, clips.

61. Surgery
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Management of Bleeding Peptic Ulcer
Bleeding is severe and uncontrolled in 5% to 10%.
Mortality rate of approximately 25% as compared to 10% (non
operated).
Indication :
– Hemodynamic instability despite vigorous resuscitation (>6
units transfusion).
– Failure of endoscopic techniques.
– Recurrent hemorrhage after initial stabilization.
– Shock associated with recurrent hemorrhage.
– Continued slow bleeding with a transfusion requirement
exceeding 3 units/day.

62. Surgery
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Management of Bleeding Peptic Ulcer

63. Types of Gastric Ulcer
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Management of Bleeding Peptic Ulcer

64. Bleeding Gastric Ulcer
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Management of Bleeding Peptic Ulcer
In type I ulcers, partial gastrectomy /ulcer excised and closed/
ulcer is biopsied and oversewen .
Type II and type III bleeding ulcers. Excision with primary
closure / a distal gastrectomy /gastric ulcer excision with a
vagotomy and pyloroplasty is used . Postoperatively patients
should have H. pylori infection eradication and avoid use of
NSAIDs.

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Long term Management of Bleeding
Peptic Ulcer
Gastric ulcers repeat endoscopy
approximately six weeks after
discharge . Proton pump
inhibitor continued until that
point (Grade C).
Endoscopic confirmation of
duodenal ulcer healing
following H pylori eradication is
probably not necessary although
the subgroup needing to
continue NSAID while receiving
ulcer healing therapy probably
should be re-endoscopied
(Grade C).

66. Algorithm
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Management of Bleeding Peptic Ulcer

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Dieulafoy Lesion
Definition
Location
Bleeding is massive and
recurrent
Endoscopic options
Coagulative therapy APC
Hemoclips
Banding
Surgery:
1. Gastrotomy with sewing of
bleeding source.
2. Partial gastrectomy if
bleeding is not identified

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Mallory Weiss Tear
Mucosal or submucosal
tear that occur near GE
junction
Diagnosis based upon
history & endoscopy .
Important to perform a
retroflexion maneuver.
Most tear occur along
lesser curvature

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Mallory Weiss Tear
Supportive therapy in 90%.
Endoscopy therapy with injection or electrocoagulation
Angiographic embolisation
Surgery – high gastrotomy and suturing of mucosal tear is
indicated.
Recurrent bleeding is uncommon.

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Gastric Erosions
Gastritis affect gastric mucosa
not muscularis mucosa , major
blood vessel are not injured.
Gastropathy often erosive
Superficial gastric erosion
developed in following
condition
1. Stress related
2. NSAID induced.
3. Consumption of ethanol

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Gastric Erosions
Who develops significant bleed can be managed by –
1. Acid suppressive therapy :
Most often successful in controlling bleed
2. Endoscopic therapy
3. Angiography -Octerotide / vasopressin in left gastric artery
Embolization
4. Surgery – Rarely indicated.
Vagotomy and pyloroplasty with over sewing of
hemorrhage.
Near total gastrectomy
Mortality is high 60%

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Esophagitis
Common cause
Causes occult blood loss more
commonly
Causes :
GERD
Infectious
Medication
Crohn’s disease
Radiation.
Treatment :
Therapy directed against cause
Acid suppressive therapy.
Endoscopic control (Electrocoagualtion or heat probe)
Operation is seldom necessary

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Duodenitis
Very rare cause of acute bleed.
Risk factors for severe erosive duodenitis are similar to those
patient with bleeding peptic ulcer.
(NSAID, H.pylori, anticoagulation therapy).
Bleeding is rarely usually self limited and rarely required
intervention.

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Malignancy
More often associated with
occult, self limited
asymptomatic bleeding.
Most common advanced
gastric adenocarcinoma.
Endoscopic therapy often
successful in controlling
hemorrhage but rebleeding
rate is high.
Therefore surgical treatment
is important

75. Gastric Antral Vascular Ectasia
(GAVE)
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Middle age, elderly female
with
1. Achlorhydria
2. Atrophic gastritis
3. Cirrhosis.
Characterised by aggregates
of ecstatic vessels that
appears red spot of gastric
mucosa.
Arranged in linear pattern
in the antrum of stomach.
“Watermelon Appearance”
Endoscopic therapy
If fail antrectomy is done

76. Aortoenteric Fistula
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Primary aortoduodenal fistula are rare ,previous abdominal
aortic repair , inflammatory or infectious aortitis.
Mechanism : Development of pseudoaneurysm. Subsequent
fistulalization into overlying duodenum.
Hemorrhage massive and fatal ,Sentinel bleed.
Bleeding in distal duodenum 3rd or 4th part is diagnostic.
CT Scan with iv contrast : Air around graft , Possible
pseudoaneurysm , Rarely IV contrast in duodenal lumen.
Treatment : Ligation of aorta proximal to the graft, removal of
the infected prosthesis and extra anatomical bypass.

77. Hemobilia
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It is typically associated with trauma, recent instrumentation
of the biliary tree, or hepatic neoplasms.
Presents with hemorrhage, right upper quadrant pain, and
jaundice Quenk’s Triad
Endoscopy can be helpful by demonstrating blood at the
ampulla.
Angiography is diagnostic procedure of choice,
angiographic embolization is preferred treatment

78. Hemosuccus Pancreaticus
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Caused by erosion of pancreatic pseudocyst into the
splenic artery.
Patients with abdominal pain, blood loss and a past
history of pancreatitis.
Angiography is diagnostic and permits embolization,
which is often therapeutic.
In cases that are amenable to a distal pancreatectomy,
often results in cure.

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