Upper Gi BL

Diagnosis and management of upper gastrointestinal bleeding
you will have
The thesis represents a retrospective, unicentric clinical-statistic study, performed on 463 cases of
UGIB of diverse etiology, admitted, investigated and treated in the Clinical county hospital of Con-
stanta, Gastroenterology clinic, within a 2-year period (2019-2021).
316 males, 147 women

This predominance of male gender is maintained in both primary etiopathogenic forms of UGIB, with
the difference that it is more pronounced for non-variceal UGIB (257 men / 108 women) versus
variceal UGIB (59 men / 39 women).
Age -UGIB have been encountered at all ages; with extreme limits ranging from 19 to 88 years and an
average of 59 years.
AIM OF THE STUDY

1. To find out the prevalence of nature of lesion on Upper Gastro Endoscopy
in patients admitted for UGI bleed.
2. To find out the prevalence of nature of lesion in patients with minor,

moderate, major bleed.
Historical Features That Help Assess the Etiology of Gastrointestinal Bleeding1
• Age
• Prior gastrointestinal bleeding
• Previous gastrointestinal disease
• Previous gastrointestinal surgery
• Underlying medical disorder (especially liver disease)
• Use of nonsteroidal anti – inflammatory drugs, including aspirin
• Use of anticoagulation and / or anti – platelet therapy
• Abdominal pain
• Change in bowel habits
• Weight loss
• Anorexia
• History of orophyrangeal disease.
CAUSES OF ACUTE UPPER GASTROINTESTINAL BLEEDING1

Common
• Gastric ulcer
• Duodenal ulcer
• Esophageal varices
• Mallory – Weiss tear
Less Common
• Gastric erosions / gastropathy
• Esophagitis
• Cameron lesions / Dieulafoy lesion
• Telangiectasias
• Portal hypertensive gastropathy / gastric varices
• Gastric antral vascular ectasia (watermelon stomach)
• Neoplasm
Rare
• Esophageal ulcer
• Erosive duodenitis
• Hemobilia
• Pancreatic disease / crohn’s disease
• Aortoenteric fistula
TREATMENT OF PEPTIC ULCER BLEEDING:
Goals of therapy:
1. Treat the peptic ulcer & thus bleeding
2. To stop active bleeding
3. To prevent rebleeding
Pharmacologic Therapy:
Agents to treat active ulcer bleeding are
Octreotide
Stomastatin
Vasopressin
Secretin
Histamine H2 receptor antagonists
Proton pump inhibitors
Anti fibrinolytics
Prostaglandins
The greatest risk of rebleeding from an ulcer is within the first 72 hours after the
Initial bleeding episode.
The acidic pH retards blood clotting and enhances clot dissolution by proteolytic
Enzymes like pepsin.
Elevating intragastric pH may facilitate platelet aggregation, further supporting a

role for acid lowering therapy.
Although H2 receptor antagonists are widely available, non toxic and inexpensive
the available data donot support their use in patients with ulcer bleeding.
Proton pump inhibitors have significantly better acid reducing characteristics,

Particularly at high doses, and effective in preventing ulcer bleeding in high risk
Patients.
The use of nitrovasodilator(Glyceryl trinitrate, isosorbide dinitrate, isosorbide

Mononitrate or transdermally administered nitroglycerin) was associated with a
significantly decreased risk of upper gastrointestinal tract bleeding.
Assessment and resuscitation measures to protect the airway and maintain

adequate tissue perfusion take priority over all endoscopic procedures. Ideally the
patients should be haemodynamically stable with a heart rate of less than 100
beats/ min and systolic blood pressure greater than 100mm Hg. Initially evaluation
should focus on determining whether the bleed is from the upper or the lower
gastrointestinal source. A clear nasogastric aspirate may be seen in 14% of
bleeding duodenal ulcers (DU). 39 Blood transfusions should be instituted in
patients with postural symptoms and haemoglobin less than 10g / dl or patients
with haemoglobin of less than 7 – 8 g / dl even without postural symptoms.
Rockall score here

Endoscopy provides important risk assessment for rebleed. Rockall Risk Score
stratifies the risk of death and re – bleed, with a risk of rebleeding of 5% if the
score is 0 and 40% if score is more than or equal 8. Mortality rate is below 1% and
as high as 41% if the score is 0 -2 and 8 or more, respectively.
Forrest
Predictors of Mortality
Patients characteristic that have been reported to be associated with increase in

mortality are42,44:
1. Age
2. onset of bleeding
3. co – morbidity
4. hypotension and shock at presentation
5. Fresh bleed in Ryle’s tube aspirate
6. Haemoglobin level.at presentation and on serial follow – up
7. Number of packed cells transfusions
8. Corticosteroids
9. Combined use of aspirin and oral anticoagulants.
Patients who start bleeding during hospitalization (secondary bleeding) have a
significantly higher mortality as compared to those who bleed prior to
hospitalization (primary bleeding). This is primarily because of presence of co –
morbidity factors in hospitalized patients. Mortality is significantly higher in
patients with comorbid illness which include CNS diseases, hepatic insufficiency,
pulmonary diseases, cardiac diseases, renal failure, physiological stress and
cancer. The mortality increases with increase of co – morbid conditions.
Predictors of Rebleeding50
As many as 10% patients rebleed after endoscopic therapy.
1. Failure of therapy and recurrent upper GI bleeding is associated with an
increase in mortality. Apart from the
2. Endoscopic stigmata of recent ulcer bleed, many independent factors
predict the rebleeding risk. These include
3. Age more than 65 yrs.
4. Tachycardia and shock at admission,
5. Obesity, haematemesis,
6. Specific ulcer location
7. Diameter more than 2 cm.
Helicobacter pylori and recurrence of ulcer bleed
H. pylori eradication in patients with bleeding ulcers is known to reduce the

recurrence of bleeding. In various small studies with a follow up period ranging
from 4 to 48 months, the rate of duodenal ulcer relapse and rebleeding was
significantly reduced in patients with successful eradication of H. pylori .
In patients with bleeding peptic ulcer associated with H. pylori, eradication should
be confirmed by urea breath test or the biopsy urease test at endoscopy.
ENDOSCOPIC THERAPY—-injections, thermal methods, hemoclips, argon plasma coagulation, band liga-
tion, endoloops (details)
variceal bleeding—-Primary Prophylaxis to prevent first episode of variceal bleed

Algorithm for the Management of acute variceal bleeding
Graphics
- sex distribution
- Demographic distribution ( more on rural enviorment)
- Etiological forms (Non-variceal UGIB- 364, Variceal UGIB (98 cases)
- Beginning-admission interval of UGIB ( <6 hours; 6-24 hours; 1-2 days; 2-3 days; 3-4 days)- they are
more in 6-24 hours, then 1-2 days.
- Patient distribution according to the form of the exteriorisation ( 1. Hemathemesis and melena followed
by melena and the hemathemesis)
- Distribution of patients with UGIB according to severity of bleeding. (Number of patients for every ane-
mia grade….grade I (10-12 g/dl), grade 2 (8-10g/dl), grade 3 (5-8 g/dl), grade 4 (<5g/dl)
- Admission-Endoscopy interval of UGIB ( % )
- Rockall score for every age category… severe in older patients
Endoscopic hemostasis was performed in 134 cases representing …..% of endoscopically investi-
gated cases and. ……% of total UGIB. The following endoscopic hemostasis methods were used: elec-
trothermocoagulation in 28 patients , elastic bands ligatures in 23 patients adrenaline injection in visible ves-
sel of ulcers in 29 patients , and Mallory Weiss lesions 11 patients , and 43 endoclips in bleeding ulcers .
Surgical treatment, once the main mean of hemostasis, was performed in 46 cases, a percentage which fits in
the limits of literature data; of these 2 were variceal UGIB and 44 non-variceal ulcerative disease.
-Surgical treatment of UGIB (graphic with number of patients —-look up)

- evolution graphics- favorable for 80 % of patient
Conclusions:
1. UGIB is a major medical-surgical emergency, striking a still high mortality and significant social costs.
2. The UGIB incidence was …..%, most common among male patients (…….%), belonging to age groups of
over 50 years (…….%) coming from rural areas (…….%).
3. Non-variceal hemorrhages were the major etiopathogenic form of UGIB (…….%).
4. Gastro-duodenal ulcer (……. cases) and acute gastritis (40 cases) were the main cause of bleeding in non-
variceal UGIB.
5. The UGIB diagnosis is a complex one, developed by an algorithm that includes positive diagnosis, gravity
diagnosis, evolutionary and etiological diagnosis.
6. Severe hemorrhages (Grade III and IV) accounted for over half of the cases (51%)
7. EDS is the elective method of etiological diagnosis and hemostasis - it was performed in 87% of cases.
8. The management of UGIB is a complex, conservative and surgical medical, the weight of the two thera-
peutic attitudes depending on the etiopathogenic type of hemorrhage, the causal lesion, the severity and the
evolution of the bleeding and the therapeutic response.
9. Endoscopic therapy performed in ………. patients used according to causal lesion the following therapeu-
tic procedures: electrothermocoagulation in ……. patients (…..%), elastic ligatures in ……. patients (….%),
injection of adrenaline in vascular ulcers visible at …… patients (…..%) and Mallory Weiss injuries in …….
patients (…….%) and ……… endoclips in bleeding ulcers (……..%).
10. UGIB are still struggling with a high rate of postoperative morbidity (……..%) and a general (………%)
and postoperative (…………..%) mortality

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Diagnosis and management of upper gastrointestinal bleeding

you will have

316 males, 147 women

AIM OF THE STUDY

2. To find out the prevalence of nature of lesion in patients with minor,

Historical Features That Help Assess the Etiology of Gastrointestinal Bleeding1

CAUSES OF ACUTE UPPER GASTROINTESTINAL BLEEDING1

TREATMENT OF PEPTIC ULCER BLEEDING:

Elevating intragastric pH may facilitate platelet aggregation, further supporting a

Proton pump inhibitors have significantly better acid reducing characteristics,

The use of nitrovasodilator(Glyceryl trinitrate, isosorbide dinitrate, isosorbide

Assessment and resuscitation measures to protect the airway and maintain

Rockall score here

Patients characteristic that have been reported to be associated with increase in

Helicobacter pylori and recurrence of ulcer bleed

H. pylori eradication in patients with bleeding ulcers is known to reduce the

variceal bleeding—-Primary Prophylaxis to prevent first episode of variceal bleed

-Surgical treatment of UGIB (graphic with number of patients —-look up)

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