UPPER GI BLEEDING

Aetiology
Condition
Ulcers
Oesophageal
Gastric
Duodenal
Erosions
Oesophageal
Gastric
Duodenal
MalloryWeiss tear
Oesophageal varices
Tumour
Vascular lesions, e.g. Dieulafoys disease
Others

Incidence (%)
60
6
21
33
26
13
9
4
4
4
0.5
0.5
5

Principles of management
i. Resuscitation
IV access: peripheral, central and obtain
blood sample
Bladder catheterisation

ii. Investigation/ diagnosis

OGD

iii. Treatment
NOTE: Should be carried out in quick
succession

Bleeding peptic ulcers

Duodenal:
Falling incidence
Gastric antisecretory agents
Eradication therapy for patients with
dyspepsia

Peak incidence in older age group

M>F but less marked difference
Changes related to H.pylori
Other aetiological factor: NSAIDs

Bleeding peptic ulcers

Gastric:
Aetiological factors:
H.pylori, NSAIDs, smoking

Less common cf. duodenal ulcers

Peak incidence in older age group
Incidence in M=F
Prevalence higher in low
socioeconomic groups
Developing world > West

Bleeding peptic ulcers

Diagnosis:
Endoscopic (skill-dependant)
Medical mgt
PPI
Tranexamic acid:
reduces rebleeding rate

Endoscopic
Laser, diathermy, injection of sclerosant

Bleeding peptic ulcers

Surgery
Indications:
Continuous bleeding
Significant rebleeding
Ulcer base: visible vessel, spurting
vessel, clot
Elderly and unfit patients
Higher risk of death

Significant bleeding
Requiring up to 6 units of blood (adults)

Bleeding peptic ulcers

Surgery
Endoscopy helps locate the site
Duodenum: superior and posterior
Kocherization: accessibilty and control of
gastroduodenal a.
Duodenum and pylorus opened longtitudinally
Under-run vessel in ulcer base then close
mucosa
Close pylorus in transverse fashion

Stomach: open at appropriate site then

under-run vessel in ulcer base

Bleeding peptic ulcers

Surgery
Other options:
Gastrectomy
Acid lowering surgery (vagotomy,
antrectomy)
NOTE:
Older, unfit patients: minimal surgery
that stops bleeding
Pharmacological acid inhibition

Stress ulceration
Risk factors
Major injury, illness, surgery
Mostly in ICU patients
Epidemiology:
Reduced incidence with prophylaxis:
Pharmacologic acid inhibition
NG or oral sucralfate administration

Management:
Endoscopic
Surgery (significant bleed, failed
endoscopic mgt)

Gastric erosion
Synonym: Erosive gastritis
Aetiology:
Agents that disturb the mucosal barrier
NSAIDs (inhibition of COX-1)
Alcohol

Management:
Most such bleeding resolves
spontaneously
Endoscopy (preferred)
Surgery

Mallory-Weiss syndrome
Path:
vigorous/ forceful vomiting causing a
vertical split/tear in the gastric mucosa

Location:
immediately below the SCJ at the cardia
(90%)
In the esophagus (10%)

Presentation: haematemesis
DDX:
Intramural rupture
Intramural hematoma
Boerhaave syndrome

Mallory-Weiss syndrome
Diagnosis:
Endoscopy (skill dependent)
Management:
Usually bleeding is not severe
Endoscopic injection therapy
Surgery:
Continued bleeding and endoscopy
unavailable (high index of suspicion)
Upper longtitudinal gastrostomy, palpate
lesion
Under-running sutures

Dieulafoys disease
Path:
Gastric arterial venous malformation
Lesion is covered by normal mucosa
and invisible when not bleeding
Management:
Endoscopic injection therapy
(sclerosant)
If identified at surgery:
Local excision

Tumours
Presentation:
Acute or chronic upper GI bleeding
Path
Commonly gastric stromal tumours
Carcinoma, lymphoma
Management:
As appropriate
Gastrectomy: total vs subtotal
Definitive vs palliative

Portal HTN and portal

gastropathy

Path
Increased portal pressure

distension of esophageal & gastric varices

exuding of blood from the gastric mucosa

Management:
Varices:
sclerotherapy, banding, ballon tamponade
(Sengastaken- Blakemore tube)
Gastric varices: more challenging

Pharm:
Octreotide, glypressin

Aortic enteric fistula

Diagnosis of exclusion
Any patient with hematemesis and maleana
that cannot be otherwise explained
Occasionally seen in patients with untreated
aortic aneurysm

Diagnosis: CT scan
Management:
Expert vascular surgeon
Although bleeding is not always massive,
the morbidity and mortality rates are high

Prognosis
In-patient mortality rate of 5%
Developed world

The End
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