UGIB is bleeding derived from a source proximal to the Ligament of Treitz.
Photo by AJC1
Acute Upper G.I. Bleeding
- The vomiting of blood.
- It indicates that the bleeding is from a cause proximal to the (LOT).
- The colour of the vomited blood is dependent on the concentration of HCL and its admixture with the blood .If the vomiting occurs soon after the UGIB , then haematemesis will be bright red in colour. IF there is a time lag then haematemesis will be dark red brown or black.
- The passage of black and tarry stools.
- Usually due to UGIH.
- It results from more then 60-100 ml of blood with moderate transit time.
- Can be a result of LGIH if the GI transit time was sufficiently prolonged to about 8hrs.
- The passage of fresh blood per rectum due to bleeding from the lower GIT.
- Rarely due to UGIB. Requires more than 1000ml.
- Occult bleeding
- Vomiting of blood
- Bright red or dark
- Proximal to the ligament of Treitz
- Differentiate from hemoptysis, bleeding from mouth & pharynx
- 80-95% cases – Mucosal abnormalities, Varices, Spontaneous resolution
Causes of UGIH
- Esophageal Varices
- Duodenal ulcer
- Gastric ulcer
- Other rare causes are:
- Mallory-Weiss tear.
- Boerhaave syndrome.
- Vascular Ectasia
- Aortoenteric fistula.
- Portal hypertensive gastropathy.
- Clinical manifestations of GI bleeding depends upon extent & rate
- Postural hypotension suggests acute hemorrhage & intravascular volume depletion
- Fatigue & exertional dyspnea typical symptoms with slow, chronic blood loss
Symptoms and Signs
- Hematemesis – 40-50%
- Melena – 70-80%
- Hematochezia – 15-20%
- Syncope – 14.4%
- Presyncope – 43.2%
- Dyspepsia – 18%
- Epigastric pain – 41%
- Heartburn – 21%
- Diffuse abdominal pain – 10%
- Dysphagia – 5%
- Weight loss – 12%
- Jaundice – 5.2%
Differentiate hematemesis from hemoptysis
Amount of blood loss (drops, tablespoonful, clots)
Recently ingested foods (food colors, beets, drugs)
Source of bleed (upper GIT, nose, mouth pharynx)
Prolonged, forceful vomiting (Mallory-Weiss)
Abdominal pain & vomiting (esophagitis, gastritis)
Cracked nipples, Jaundice & Liver disease
Umbilical vein catheterization (portal vein thrombosis)
Familial bleeding diathesis
- Orthostatic changes in pulse & BP
- Examine oral cavity & nasopharynx
- Lymph nodes
- Digital rectal
- Petechiae, Ecchymosis
- Icterus, Palmar erythema, Spider angioma
- Hepatosplenomegaly, Ascites
- Active nasopharyngeal bleed
- Occult blood in stools
Approach to the patient
GOAL — Determine the cause & treat
Phase – 1 Differentiate (blood, food color, Beets etc)
Phase – 2 Assess severity (Hematocrit, Capillary refilling, Vital signs)
Phase – 3 Determine the site ( Epistaxis simulates Upper G I bleed)
- Confirm bleeding
- Assess Severity
- Medical Intervention
- Liaison with surgical/ ITC Team
- Diagnosis of site
- Surgical hand over
Hints for Screening
Make sure – vomited material: is it really blood ?
NG aspirate –ve for blood doesn’t rule out ‘UGIB’
Competent pylorus may mask a duodenal bleed
Bright red blood – active bleed
Dark ‘Coffee grounds’ – denatured by gastric acid
Rapid bleed – a medical emergency
Slower bleed – anemia, occult blood in stools, melena
Hypotension – may not be seen even in a large bleed
Initial Hb – values may be unreliable
Acute U.G.I. Bleeding
–1. if small amount, no immediate Tx, because CVS can compensate –
–2. 85% stop bleeding during 48 hrs –
–3. Criteria for low risk
- Age less then 60 years
- Coffee ground without malena
- Alcohol induced
- Hemodynamically normal
4. Criteria for Hospitalization
- –recent (24 hrs),
- –age (60 +)
- –Continuing visible blood loss.
- –Hemetemsis with malena
- –Cardio-respiratory disease
- –Signs of chronic liver disease
- Poor peripheral circulation
- JVP<1cm (from sternal angle when Patient is flat)
** Emergency management:
(Dyspeptic symptoms, Vomiting preceding blood, Alcohol, Drugs, Previous episode of bleeding, History of jaundice, peptic ulcer, surgery )
- Monitor: pulse & BP /30 min
- Blood sample: haemoglobin, urea electrolytes, grouping & cross-matching
- I.v. access
- Airway: endotracheal tube, oropharyngeal airway.
- *Give oxygen
- Breathing: support respiratory function
- * Monitor: resp. rate, blood gases, chest radiograph
- – Circulation: expand circulating volume: blood, colloids, crystalloids support CVS function: vasodilators
- * Monitor: skin color, peripheral temp., urine flow, BP, ECG
Blood transfusion in case of:
2) haemoglobin <10 g/dl
- Urgent endoscopy
- Surgery when recommended
Rationale for Endoscopy
To identify the source of bleeding
To determine the risk of re-bleeding
To render endoscopic therapy
- Band ligation
- Injection sclerotherapy
- Heater probe
1. Hb, PCV
2. CBC (WBC … etc)
3. Bld glucose
4. Platelets, coagulation
5. Urea, creatinine, electrolytes
6. Liver biochem.
7. Acid-base state
8. Imaging: chest & abd. radiography, US, CT
1. Bleeding scans – Inconclusive Endoscopy
Technitium sulfur colloid (detects rapid bleed)
Tagged RBCs (for small bleeds)
1. H2 – receptor antagonists
2. proton pump inhibitors
Factors in reassessment
1. age: 60 + indicates greater mortality
2. recurrent hemorrhage: +++ mortality
3. re-bleeding: mostly within the 1st 48 hrs
–Rise in pulse
–Decreased urinary output
–General condition deterioration
–Continued bleeding after 6-8 units of blood
–Spurting vessel at endoscopy
Treatment of Uncontrolled Bleeding
- Sengastaken– Blakemore tube
- Surgical shunts
Overall mortality =8-12%
can be reduced to 6-9%