~ By Chan Ei Leen

Definition
y Bleeding from a source proximal to the Ligament of

Treitz (anatomical landmark of duodeno-jejunal junction)

Presentation of UGIB:
y Haematemesis

vomiting of fresh red blood - acute bleeding

y Malaena

Passage of black, tarry stool (oxidation of haemoglobin in the small intestine) vomiting of altered black blood (conversion of haemoglobin to methaemoglobin by acid in the stomach) - recent bleeding

y Coffee ground vomiting

Clinical Situations
y Acute

1. Haematemesis with/without malaena 2. Malaena with/without haematemesis 3. Rarely haematochezia (indicates massive lifethreatening bleed)
y Chronic

1. IDA with/without evidence of visible blood loss 2. Blood loss detected by positive occult blood test.

Prevalence and Mortality

y Medical EMERGENCY y About 72 / 100,000 in Malaysia y Peaked around 4th - 6th decade y Mortality is higher in patient with recurrent bleed or

with significant co-morbid illness

y Mortality ~10%

Malaysian Gastro-Intestinal Registry 1ST Report in 2009

Distribution of site of lesion for UGIB:

Distribution of aetiology of gastric bleed:

Ot ers: a - arci - A i ys lasia

Distribution of aetiology of eosophageal bleed:

Others: - Mallory-Weiss tear - Neoplasm

Distri

ti

f a ti logy of

odenal leed:

Others: - Carcinoma - Vascular malformation

Aetiology
Peptic ulcer disease 2. Erosions 3. Mallory-Weiss Tear 4. Malignancy
1.

1. Peptic Ulcers
y From duodenal ulcers / gastric ulcers y As a result of erosion of blood vessels y Severity depends on the size of the vessel affected y Risk factors: alcoholic, NSAIDS

y Highly associated with H. Pylori infection y Disrupt mucosal barrier y Direct inflammatory effect on mucosal y Eradication of H. Pylori reduce recurrent ulcer and

subsequently reduce bleeding ulcer

2. Erosions
y As a result of diffuse loss of mucosal epithelium

(gastritis, oesophagitis, duodenitis) y Associated with use of NSAIDS, steroids, intake of alcohol and stress y Usually self-limiting

3. Mallory-Weiss Tear
y Acute linear mucosal laceration at the gastro-oesophageal junction y Accounts for 15% of UGIB y Caused by severe vomiting or retching y Mostly involved the gastric mucosa y Presentation: vomiting of bright red blood with vomitus and usually settle spontaneously

4. Malignancy
y Commonly bleed at an advanced ulcerated stage y Prognosis depends on the stage of disease

General Management
(New England Journal- 2008)

y Assess of haemodynamic status y Resuscitation y Blood investigation y Early OGDS y Initiating IV PPI 80mg stat and infusion of 8mg/hour

(while waiting for early OGDS) y Risk stratification

Assessment
y Close monitoring of BP, PR, gross evidence of ongoing

bleeding
y Agitation, pallor, hypotension, tachycardia indicate

shock require immediate volume replacement

y Goal of resuscitation ensure a stable haemodynamic

status prior to OGDS

Classification of Haemorrhagic Shock

Class I Blood loss % Volume Pulse rate BP Pulse pressure Respiratory rate Mental status Fluid replacement <750 < 15% < 100 Normal Normal or increased 14 20 Class II 750 1500 15 30% >100 Normal Decreased 20 30 20 30 Mildly anxious Crystalloid Class III 1500 2000 30 40% >120 Decreased Decreased 30 40 5 15 Anxious, confused Crystalloid and blood Class IV >2000 > 40% >140 Decreased Decreased >35 Negligible Confused, lethargy Crystalloid and blood

Urinary output >30 Slightly anxious Crystalloid

Resuscitation
y Clear airway: y Drowsy or comatose patient has high risk of aspiration y Kept flat on his side y ETT inserted to protect the airway y Two large bore IV brannula y Oxygen supplement y CVP monitoring y Fluid resuscitation with crystalloid and blood

y Pass nasogastric tube: y Red or coffee ground active bleeding y Clear gastric fluid probable bleeding from duodenum y Bile without blood unlikely UGIB

Investigations
y FBC y y y y

Hb (may be normal during acute stage), PLT BUSE/Cr - Urea severe bleeding GXM LFT PT/APTT/INR

Blood Transfusion
y Aim:

- restore blood volume and pressure - correct anemia (maintain Hb>10)

y Transfusion of:

- Packed cells are preferred - FFP if PT >1.5 times higher than normal - PLT if PLT < 50,000

y Indications:

- systolic BP < 110mmHg - postural hypotension - pulse > 110 bpm - Hb < 8.0 - angina or cardiovascular disease with Hb <10

Risk Stratification

Risk Factors for Death after Hospital Admission for UGIB

y Advanced age y Shock on admission y PR>100 bpm, systolic BP <100 mmHg y Comorbidity y particularly hepatic or renal failure and disseminated malignancy y Diagnosis y worst prognosis for advanced upper GI malignancy

Endoscopy for Risk Assessment

y Early OGDS (within 12-24h) help in management y Roles:

1. Diagnosis (source of bleeding) 2. Treatment 3. Risk stratification

Forrest Classification For Bleeding Peptic Ulcer y Ia : Spurting bleeding y Ib : Non spurting active bleeding y IIa : Visible vessel (no active bleeding) y IIb : Non bleeding ulcer with overlying clot y IIc : Ulcer with haematin covered base y III : Clean base ulcer

Risk of Rebleeding and Mortality

Endoscopic Finding

Risk of Rebleeding (%)

55 43 22 10 5

Mortality (%)
11 11 7 3 2

Active bleeding (Ia, Ib) Visible vessel (IIa) Adherent clot (IIb) Flat spot (IIc) Clean base (III)

Use of Risk Stratification Scoring Systems

y There are a number of scoring system for outcome y Rockall risk assessment score: y 2 : mortality of 0.1%, rebleeding of 4.3% y >8 : mortality of 41%, rebleeding of 42.1%

y Glassgow-Blatchford Score: y 0 : Low risk and suitable for outpatient management and deferred an OGDS treatment y 6 : 50% risk of needing an intervention

Parameter Blood Urea

Level 65 <80 80 <100 100 <250 25

Score 2 3 4 6 1 3 6 1 6 1 2 3 1 1 2 2 2

Hemoglobin (g/L) for men

12.0 <13.0 10.0 <12.0 <10.0

Hemoglobin (g/L) for women Systolic blood pressure (mm Hg)

10.0 <12.0 <10.0 100 109 90 99 <90

Pulse 100 (per min) Presentation with melaena Presentation with syncope Hepatic disease Cardiac failure

Treatment

Endoscopic Therapy
y Thermal y Electrocautery, argon plasma coagulation y Injection y Adrenaline (1:10000), sclerosants y Mechanical y Clips, band ligation y Combination therapy y Injection + thermal therapy y Injection + mechanical therapy

Pharmacological Therapy
y

Platelet aggregation, coagulation and fibrinolysis are highly dependent on gastric pH In low pH:
y y y

Peptic may digest thrombus (pH 1-3.5) Pepsin still functioning (up to pH 5) Platelet aggregation is impaired

1. H2 y y y

Receptor Antagonist

Eg: Ranitidine, Cimetidine Competitive antagonist of histamine at parietal cells H2 receptor reduce production of gastric acid A meta-analysis (27 randomised trial) showed there is no significance benefit in treatment of UGIB by using H2-receptor antagonist compared with placebo

Protocol: The use of H2-antagonist in UGIB is not recommended

2. Proton Pump Inhibitor

y Eg: Omeprazole, Pantoprazole y Irriversibly blocking H+/K+ ATPase (proton pump) of

gastric parietal cells (which is the terminal stage in gastric acid secretion) y More effective than H2 antagonist y Can reduce gastric acid secretion up to 99%

y In a meta-analysis comparing PPI with H2-antagonist y Persistent or recurrent bleeding was less frequent with PPI (6.7%) than with H2-antagonist (13.4%) y The need for surgery and mortality rates are reduced with PPI

Protocol: After endoscopic therapy, to give IV Omeprazole 80mg stat and infusion of 8mg/hour for 72h

y According to Lau NEJM 2000, 30 days rebleed rate: y With the use of PPI: 6.7% y With placebo: 22.5% PPI reduce rebleeding rate y According to Sung Ann Intern Med 2003, 30 days

rebleed rate:
y With PPI only: 11.6% y With PPI and endoscopic therapy: 1.1%

Combination of endoscopic therapy and PPI is better

Management of other Causes of UGIB

1. y

Mallor-Weiss Tears Endoscopic therapy with adrenaline, thermal methods, mechanical clips

2. Vascular Malformations y Argon plasma coagulation, heater probe therapy

Surgery
Indications y Massive bleeding
y Uncontrolled by endoscopic procedure y Failure of endoscopic visualization due to profuse

haemorrhage

y Ulcer inaccessible by endoscopy y Duodenum deformed and narrowed

Type of surgery y Local

y Over-sewing of ulcer y Excision of ulcer

y Radical surgery y Gastric resection y Vagotomy

Interventional Radiology y Embolization therapy y In patients whom endoscopic therapy was failed y Bleeding stopped in 83% cases y Rate of complications: 14% y Use: sodium diatrizoate, metal coils, tissue adhesives, Gelfoam particles

Follow Up
y Discharged with PPI y Those with gastric ulcer should be re-endoscoped in

6/52 to assess healing and rule out malignancy y Eradication of H. Pylori if positive y Change NSAIDS to COX-2 inhibitor

Thank You