UPPER GASTROINTESTINAL HAEMORRHAGE

S5 UNIT2006 MBBS BATCH

TRIVANDRUM MEDICAL COLLEGE

ANATOMY

Bineesh Prakash

DEFINITION

• Upper GI bleeding is defined as bleeding from a source proximal to the Ligament of Treitz

ARTERIAL SUPPLY - STOMACH

VENOUS DRAINAGE - STOMACH

NERVE SUPPLY - STOMACH

BLOOD SUPPLY OF DUODENUM

ARTERIES : Upper half - superior pancreaticoduodenal A Lower half - inferior pancreaticoduodenal A

VEINS : Superior pancreaticoduodenal V portal V Inferior pancreaticoduodenal V superior mesenteric V

PORTAL SYSTEMIC VENOUS ANASTOMOSIS

REGION PORTAL CICULATION SYSTEMIC CIRCULATION

ESOPHAGUS LEFT GASTRIC VEIN AZYGOUS VEIN

RECTAL SUPERIOR RECTAL VEIN MIDDLE AND INFERIOR RECTAL VEIN

PARAUMBILICAL PARAUMBILICAL VEIN SUPERFICIAL EPIGASTIC VEIN

RETRO PERITONEAL RIGHT, MIDDLE & LEFT COLIC VEIN

RENAL, SUPRA RENAL, PARAVERTEBRAL & GONADAL VEIN

BARE AREA OF LIVER HEPATIC VENULES PHRENIC AND INTERCOSTAL VEIN

PORTO-SYSTEMIC ANASTOMOSIS

PORTAL VENOUS SYSTEM

ETIOPATHOGENESIS OF NON VARICEAL BLEEDING

Atul JG

Peptic Ulcer Disease

• Most frequent cause of upper GI Bleed (40% of all cases)

Duodenal Ulcer-gastroduodenal A.

PUD Gastric ulcer-left gastric A.

Ulcer

Decreased mucosalprotectionNSAID’sSteroidsHypersecretion of acidH.pylori (75% of gastric

ulcers caused by this)Smoking and Alcohol

correlationGastrin (Zollinger-Ellison)

Modified Johnson classification for gastric ulcer

Mallory-Weiss Tears• Mallory-Weiss syndrome refers to bleeding from tears (a Mallory-Weiss

tear) in the mucosa at the junction of the stomach and esophagus, usually caused by severe retching, coughing, or vomiting.

• Mallory-Weiss tears account for 5% to 10% of cases of upper GI bleeding.

Mechanism Forceful contraction of the abdominal wall against an

unrelaxed cardia, resulting in mucosal laceration of the proximal cardia as a result of the increase in intragastric pressure.

Causes

ALCOHOLISM

HIATUS HERNIA

Sress gastritis

• Appearance of multiple superficial erosions of the entire stomach, most commonly in the body

Stress Gastritis

decrease splanchnic

mucosal blood flow

altered gastric luminal acidity

Seen in…

NSAID users

Sepsis

Respiratory failure

Hemodynamic instability

Head injuries with I.C.T (Cushing ulcer)

Burn injuries (Curling ulcer)

Multiple trauma

Oesophagitis

Osophagitis (or esophagitis) is inflammation of the esophagus.

Causes

GERD Inflammation c/c Blood lossInfectious agents in immunocompromised

hosts.

Other causes

CROHN’S DISEASE

Dieulafoy’s Lesion

• Vascular malformations along the lesser curve of the stomach within 6 cm of the GEJ

• represent rupture of unusually large vessels (1-3 mm) in the gastric submucosa.

• Erosion of the gastric mucosa overlying these vessels leads to hemorrhage.

Gastric Antral Vascular Ectasia

• “watermelon stomach”

• collection of dilated venules appearing as linear red streaks converging on the antrum in longitudinal fashion, giving it the appearance of a watermelon.

Malignancy

• usually associated with chronic anemia or hemoccult-positive stool

• Occasionally, malignancies present as ulcerative lesions that bleed persistently.

• most characteristic of the GIST

• Also occur with leiomyomas and lymphomas.

Aortoenteric fistula

abdominal aortic aneurysm repair

pseudoaneurysm at the proximal anastomotic suture line

Infection

fistulization into the overlying duodenum

“sentinel bleed”

Haemobilia

• typically associated with trauma, recent instrumentation of the biliary tree, or hepatic neoplasms.

• suspected in anyone who presents with hemorrhage, right upper quadrant pain, and jaundice

Haemosuccus pancreaticus• bleeding from the

pancreatic duct. • typically caused by

erosion of a pancreatic pseudocyst into the splenic artery.

• presents with abdominal pain and hematochezia

• past history of pancreatitis

Iatrogenic Bleeding

• may follow therapeutic or diagnostic procedures

• common causes of iatrogenic bleeding – endoscopic sphincterotomypercutaneous transhepatic procedures

• 2% of cases• It is often mild and self-limited

ETIOPATHOGENESIS OF VARICEAL BLEEDING

CHANDHU A S

IMPORTANCE Inc. risk of

Rebleeding

transfusion

hospital stay

mortality Freq. massive 6 wk mortality rate 20 %

VARICEAL BLEEDING

Isolated gastric varices

Gastroesophageal varices (90%)

Hypertensive portal

gastropathy (5%)

SARIN CLASSIFICATION

GASTRO OESOPHAGEAL VARICESPHTN

Dil. S/M veins in oeso. & stomach

Mucosa tenuous & excoriated

Bleeding

HYPERTENSIVE PORTAL GASTROPATHY

PHTN

c/c gastric congestion

Multiple punctuate erythema

Bleeding

Isolated gastric Varices

MechanismSinistral PHTN – Splenic

vein thrombosis

Causes Pancreatic pseudocyst Pancreatic Trs Pancreatitis

CLINICAL FEATURES

ASWIN R.M.

HAEMATEMESIS

Red – Fresh blood Coffee ground – altered blood (acid haematin) Differentiate from Haemoptysis Bleeding from Pharynx , nasal passage

MELAENA Black tarry offensive stools 1) Gastric acid

2) Digestive enzymes

3) Luminal bacteria Feature of UGI bleed Can be seen in LGI bleed also Atleast 14 hrs in GIT Non GI bleed – swallowing Oral Fe Bi mimics melaena

HAEMATOCHEZIA 10 % of upper GI bleed Acute massive bleeding transit time

Crampy abd. pain Rt. Upp. quad. pain - haemobilia Hemosucuss pancreaticus Peptic ulcer Malignancies

PAIN

OCCULT BLOOD Presents with features of c/c blood loss

Suspected in pt with Fe def anaemia

Test for occult blood

COLONOSCOPY

ENDOSCOPY

Enteroscopy , Capsule endoscopy

(--)

(--)

(+)

ASSO. FEATURES Rapid severe blood loss syncope pre syncope angina dyspnoea Peptic ulcer , GERD Pain Dyspepsia Heartburn

ASSO. FEATURES Mallory Weiss tears Antecedent vomiting & retching binge drinking ? Slow Blood loss Fatigue Anaemia Malignancy Wt loss Dysphagia Early satiety Features of obstruction

PAST HISTORY Previous episodes of GI bleed sentinel bleed H/O instrumentation H/O head injury Co-morbid Conditions Liver Disease

Renal Disease

Cardiovascular Disease

Chronic respiratory conditions

PERSONAL HISTORY

Alcoholism Wt loss Anorexia

DRUG HISTORY

Salicylates/ NSAIDs Anticoagulants Corticosteroids Anti TB Drugs Oral Fe, Bi ( mimic melaena )

PHYSICAL EXAMINATION

Pallor , signs of dehydration , Shock Icterus Clubbing Oedema Lymphadenopathy Virchows node Vital Signs tachycardia hypotension tachapnoea

}Liver d/s

PHYSICAL EXAMINATION• Caput medussae• Ascites• Fetor hepaticus• Spider naevi• Palmar erythema• Dupuytrens contr.• Leuconychia• Gynecomastia, testicular atrophy• Bleeding manifestations• Scars of previous Sx• Acanthosis nigricans• Sister Joseph nodules• Trosseau sign

ABDOMEN EXAMINATIONINSPECTION Distention , Dil. Veins Swelling Visible peristalsisPALPATION Tenderness HSM, secondary mets Mass PERCUSSION Shifting dullness HSMAUSCULTATION Absent BS Cruveilhier-Baumgarten venous hum

PR EXAMINATION

Haemarroids Melaena , blood Blumer shelf

INVESTIGATIONS IN UPPER GI BLEED

ASHIRVAD M.

INVESTIGATIONS

• Laboratory investigations

• Imaging

• Endoscopy

LAB ASSESSMENT

• Full Blood Count- Hb, Platelet• PCV*• Coagulation Profile• Liver Function tests• Serum urea and electrolytes• Blood urea nitrogen• Cross matching of blood.• Serial ECG

• PCV* : decreased only by 24 to 72hrs, after bleed

• Renal Function Tests

• Gastrin level

• Nasogastric aspiration

1. Red blood-current bleeding 2. Coffee ground-recent 3. Continuous aspiration-severe active bleed Lavage not +ve- i) bleeding has stopped ii) beyond pylorus

IMAGING TECHNIQUES

CXR–1) Aspiration pneumonia

–2) Pleural effusion

1) Aspiration pneumonia

2) Pleural effusion

II) Abdominal X-Ray - Perforations

• USS and CT SCAN

– Liver disease, hemorrhagic

pancreatitis & cholecystitis, aorto-

enteric fistula etc.

• Nuclear Scan - Areas of active hemorrhage

• Arteriography - Site of bleeding if endoscopy

fails

ENDOSCOPY• Most important component of investigation• 90% accuracy In diagnosis if done with in 24

hours

Forrest Classification• Classification based on actual appearance of

peptic ulcer at endoscopy• The first 4 are called the Stigmata of recent

bleed

FI Active bleeding

FII a Ulcer with visible vessel or pigmented protuberance (40 – 80%)

FII b Ulcer with an adherent clot (20%)

FII c Ulcer with a pigmented spot (10%)

FIII Ulcer with clean base (rarely bleeds)

Peptic ulcer- Forrest classification

FI- active bleeding

FIIa-visible vessel.(40-80%)

FIIb-adherent clot(20%)

FIIc- pigmented Spot.(10%)

FIII-clean ulcer base (rarely bleeds)

ENDOSCOPIC IMAGES

A typical esophageal cancer

AORTO ENTERIC FISTULA

Endoscopy CA Stomach

MALLORY WEISS –ENDOSCOPIC PICTURE

ENDOSCOPIC IMAGES

Pre pyloric ulcers due to use of NSAIDs

• Portal Hypertension Bleeding oesophageal or gastric varices can

be seen Oesophageal varices Gastric Varices

Hypertensive Portal gastropathy

Snake skin appearance

WATERMELON STOMACH (gastroantral vascular ectasia)

Video capsule endoscopy

•Examination of whole bowel possible•Indicated in GI bleeding of obscure source

THERAPEUTIC ENDOSCOPY

Bipin Thomas Panicker

VARICEAL BLEED

NON VARICEAL BLEEDING

Mechanical methods

Injection Therapy Thermal therapy

Variceal BleedsHemostasis

Eradicate varices

Medical Management of Upper G.I. Haemorrhage

Ashis samuel

Airway:

–Secure to prevent aspiration

– Endotracheal tube

*Give oxygen

Resuscitation

Resuscitation...

• Breathing –support respiratory function

• Circulation- expand circulatory volume 2 i/v lines large bore cannula

Class I & II Shock ( upto 30% blood loss )

– Crystalloids ( 3 – 1 Rule )

– Ringer lactate or 0.9% Normal saline

Fluid replacement…

Class III & IV Shock ( >30% blood loss )

– IV bolus followed by maintenance therapy

– Crystalloids and

– Blood transfusion, packed red cells

Fluid replacement…

Correct any coagulopathy with

– 10 - 15 ml/kg of FFP (if PT INR > 1.5) and/or

– platelet transfusions (if platelet count <

50,000/cu.mm) Monitor:

skin color, peripheral temperature

Pulse Rate, BP

Respiratory Rate, O2 saturation of blood

Urine output (Foley’s Catheter)

NON VARICEAL BLEEDING

• NSAIDS.SSRIs.Smoking.

• PPIs

15-30mgOD 20-40mg OD

Peptic ulcer...

• H.pylori Treatment-TRIPLE THERAPY

• 1000mgBD 40mgBD 500mgBD

• Supportive therapy. bcoz....90% episodes are self limiting mucosa heals within 72hrs• Ongoing bleeding-local endoscopic therapy

Mallory weiss tears

• Significant bleed rarely encountered ventilator support>48hrsgroup highrisk group

coagulopathy

• Resuscitation

Stress gastritis

stress gastritis-prophylactic therapy

antacids..

PPIs.. H2 antagonists..

• Oesophagitis acid suppressive therapy endoscopic therapy• Dieulafoy’s lesion endoscopic control• Gastric antral vascular ectasia endoscopic therapy antrectomy• Malignancy surgical resection

• Aortoenteric fistula ligation of aorta removal of infected prosthesis• Hemobilia angiographic embolisation• Hemosuccus pancreaticus distal pancreatectomy• Iatrogenic bleeding percutaneous endoscopic gastrotomy

Pharmacotherapy for portal hypertension vasopressin + nitroglycerine Somatostatin

Mech of axn splanchnic blood flow portal & variceal

pressure

Variceal bleeding

50 mcg stat followed by 25mcg/h for two days or till bleeding stops

SURGICAL MANAGEMENT

Deepak James

The Key

Early identification and surgery for patients in who other lines of management are likely

to fail.

Probable non-responders

Clinical Findings

Shock at presentation

Low Hb at presentation

Endoscopic Findings

Forrest classification

Forrest I and IIa

Location of ulcer

Posterior duodenal

wall

Gastric ulcer

Size of ulcer

>2cm

Absolute Indications• Hemodynamic instability despite vigorous resuscitation (>6

units transfusion)

• Failure of endoscopic techniques to arrest hemorrhage

• Recurrent hemorrhage after initial stabilization (with up to two attempts at obtaining endoscopic hemostasis)

• Shock associated with recurrent hemorrhage

• Continued slow bleeding with a transfusion requirement exceeding 3 units/day

Relative Indications

• Rare blood type or difficult crossmatch• Refusal to transfusion• Shock at presentation• Advanced age• Severe comorbid diseases• Bleeding chronic gastric ulcer where

malignancy is a possibility

Priorities

•Control Hemorrhage !!• Definitive procedure for the underlying pathology

Duodenal Ulcers

• Exposure of bleeding site– Longitudinal duodenostomy– Pyloroduodenostomy

• Hemostasis• Anterior ulcer

– 4 quadrant suture-ligation

• Posterior ulcer– suture ligature of the vessel proximal and distal to the ulcer

Gastric Ulcer

• Exposure of bleeding site– Gastrostomy

• Control of bleeding– Suture ligation

Definitive Procedures

Definitive procedures

• Gastric ulcer resection (malignancy)• Distal gastrectomy• Proximal or near-total gastrectomy • Distal gastrectomy combined with resection of

a tongue of proximal stomach to include the ulcer

• Wedge resection• Simple oversewing of ulcer

Distal Gastrectomyor

Antrectomyor

Hemi Gastrectomy

BillRoth I Gastroduodenostomy

Sub-total Gastrectomy

Billroth II Gastrojejunostomy

Acid Reducing Procedures

•Truncal Vagotomy

•Selective Vagotomy

•Highly selective Vagotomy or Parietal Cell vagotomy

Truncal Vagotomy

Selective Vagotomy

Highly Selective Vagotomy

Effects of Operations for PUD on Gastric Emptying and Motility

Operation Antral Innervation

Liquid Emptying Solid Emptying

Proximal gastric vagotomy

Preserved Fast Normal

Truncal vagotomy Divided Fast Slow

Truncal vagotomy and drainage

Divided Fast Fast

Truncal vagotomy and antrectomy

Divided Fast Fast

Mallory-Weiss Tears

• Angiographic embolisation• High gastrostomy and suturing of the mucosal

tear

Stress Gastritis

• Rarely indicated• Vagotomy and pyloroplasty, with oversewing

of the hemorrhage, or• Near-total gastrectomy

Dieulafoy's lesion

• Prior endoscopic tattooing • Gastrotomy • Identifying the bleeding source• Oversewn• Partial gastrectomy

Variceal Bleeding

Esophageal Balloon Tamponade

•Sengstaken – Blakemore tube

•Minnesota tube

(Deflate every 4

hours for 15

minutes )

Complications• Esophageal rupture• Tracheal rupture• Duodenal rupture• Respiratory tract obstruction• Aspiration• Hemoptysis• Tracheoesophageal fistula• Jejunal rupture• Thoracic lymph duct obstruction• Esophageal necrosis• Esophageal ulcer

Surgeries for Variceal Bleeding

Transjugular intrahepatic portosystemic stent shunts

(TIPSS)

The role of portal hypertension !!!

Surgery for Portal Hypertension

• Indications– Child Class A, initial bleed managed by

sclerotherapy

–Never Prophylactic

Surgical Options

• Shunt Surgeries

• Non-selective– Porto-caval

• Selective– Spleno-renal

• Esophagogastric Devascularisation

• Orthotopic Liver Transplantation

Side-to-side Porto-caval Anastomosis

End-to-side Porto-caval Anastomosis

Eck Fistula !!!

Interposition Shunts

Spleno-renal Anastomosis

Non-selective Shunts Selective Shunts

Poor hepatopetal flow Poor Ascites Control

Hepatic dysfunction Technically demanding

Hepatic encephalopathy

Better control of Ascites

Interposition ShuntsIntricacies of hilar dissectionFuture Liver transplantation possibleIntentional shunt ligationGraft thrombosis !!!!

Distal Spleno-Renal Shunt

WarrenNote the left gastric and

right gastroepiploic

veins

Contraindications

• Medically intractable ascites• Splenic Vein diameter < 6-7 mm

Sugiura Procedure

Also…

• Left gastric (coronary) vein and the Paraesophageal collateral veins

• Portoazygous collateralization

Orthotopic Liver Transplantation

“ Orthotopic liver transplantation is the most definitive form of therapy for complications of

portal hypertension”• Poor hepatic functional reserve – Advanced

Child class B or Child C• Non surgical methods during the wait !!!

Acute Variceal Bleed

Not Controlled

Endoscopy

TIPS

Tamponade, Surgery

Controlled!!!

Controlled!!!

Controlled !!!

Controlled !!!

Assess Child Class

Transplant candidate

Don’t Touch the PORTA !!!

Mesocaval Interposition or

DSRS

Not future candidate

Intractable Ascites

Side-to-Side Porto-caval

Ascites absent or

manageable

End-to-side Porto-caval

PROGNOSIS

Deepa K P

Rockall Numerical Risk Scoring System

0 1 2 3

age ˂60 60-79 ˃80

shock No tachycardia

hypotension

comorbid

no CF,IHD ……

RF,LF,Malign

Initial score [Out of 7]

Additional criteria[out of11]

0 1 2 3

diagnosis MWT, no lesions seen

All other diag

Mal of upper GI

Stigmata of bleeding

None, dark spots only

Bld in upper GIVisible vessels, spurting,adherant clot

CHILD PUGH’S CRITERIA FOR HEPATIC FUNCTIONAL RESERVE

(C) ADVANCED

(B) MODERATE

(A) MINIMAL

MEASURE

>3 2-3 <2.0 Serum bilirubin (mg/100ml)

<3 3-3.5 >3.5 Serum albumin (g/100ml)

Poorly controlled

Easily controlled

None Ascitis

Advanced coma

Minimal None Encephalopathy

˃6 4-6 ˂4 Prothrombin time[sec prolonged]

REBLEED

Risk of mortality increases by

10 fold!!!

Risk of RECURRENT BLEEDING

Prevent rebleeding

• Pharmacotherapy

• Endoscopic therapy• Combination• Surgery

APPROACH TO THE PATIENT WITH ACUTE GASTROINTESTINAL HEMORRHAGE

Blessy Babu

CLINICAL CASERavi,56 yrs, male

PRESENTING COMPLAINTS Dark stools – 7 days

Vomiting of blood – 1dayAbdominal distension – 1 day

H/O PRESENT ILLNESS• Dark, tarry stools• distension of abdomen• Vomiting of blood

»2 episodes»Basin full»Frank blood

PAST HISTORYDM-past 10 yrs on treatment

PERSONAL HISTORYNon smoker

chronic alcoholic takes abt 250ml everyday for 30yrs

EXAMINATION

• GENERAL EXAMINATION– Drowsy,– Pallor,icterusPR 140/’BP 90/50 mm of HgCold clammy skinSpider naevi ,ascites

Abdomen examination

• Abdomen soft• Distended• Hepatomegaly• Splenomegaly• Shifting dullness

Initial assessment & resuscitation

History and physical examination

Localisation of site of bleeding

Institutionof specific therapy

INITIAL ASSESSMENT & RESUSCITATION

• Assess A, B, CSeverity of hemorrhage:

• Obtundation• Agitation• Hypotension with cold clammy skin• If resting HR >100 - loss of 20-40% blood volume}

loss of >40% blood volume

INITIAL ASSESSMENT….

• Orthostatic vital signs should be checked in patients not in shock.

• An elevation of pulse rate more than 20 or a fall in BP more than 10mmHg indicates atleast a 20% blood volume loss.

RESUSCITATION

• Intubation• Two large bore IV lines-

Ringer lactate• Initial lab assessment-

Hematocrit & HbType & crossmatch

Coagulation profile,

platelet ct Serum electrolytes, LFT

RESUSCITATION

• Urine output• Supplemental Oxygen• Transfusion of packed red cells• Coagulation defects corrected by FFP &

platelets

HISTORY AND PHYSICAL EXAMINATION• Characteristics of bleeding• Time of onset,volume and

frequency• Associated symptoms:

syncope,vomiting,dyspepsia,LOW• Medications: salicylates,NSAIDS,Warfarin, LMW heparin • Past medical history-

peptic ulcer,liver disease,heart disease

PHYSICAL EXAMINATION

• Examination of nose & oropharynx• Abdominal examn-mass,splenomegaly• Stigmata of chronic liver disease

PHYSICAL EXAMINATION

• LOCALISATION OF SITE OF BLEEDING by endoscopy• INSTITUTION OF SPECIFIC THERAPY PharmacologicEndoscopicSurgical modalities