UPPER

GASTROINTESTINAL
BLEEDING

by
Siti Nurdjanah
Gastroenterology-Hepatology Division, Internal Medicine,
Faculty of Medicine, University of Gadjah Mada,
Dr. Sardjito Hospital, Yogyakarta
DEFINITIONS
* HEMATEMESIS : is vomiting fresh red blood
A site of bleeding proximal to the duodenal-
jejunal junction ( Upper Treitz Ligament )
The Colour of vomitus depends on how long
the blood has been in the stomach
* Coffee ground vomiting is vomiting of altered
black blood
* Melaena is the passage of black tarry stools
 Causes of Haematemesis
and Melaena
Oesophagus
Oesophageal Varices
Mallory-Weiss tear
Oesophageal carcinoma
Reflux oesophagitis
Foreign body
 Causes of Haematemesis
and Melaena
Stomach
Peptic ulcer
Erosions/ Gastritis
Gastric varices
Portal hypertensive gastropathy
Gastric carcinoma
Lymphoma
Leiomyoma
Angiodysplasia (including Oslers disease)
Dieulatorys erosion
 Causes of Haematemesis
and Melaena
Duodenum/jejunum
Peptic ulcer
Erosions/ Gastritis
Vascular malformations
Haemobilia
Polyps (including Peutz-Jeghers
syndrome and other polyposis syndromes)
Aorto-enteric fistula
Causes of massaive upper
gastrointestinal bleeding

Oesophageal or gastric varices

Gastric ulcer
Duodenal ulcer
Stress ulceration
Dieulatorys erosion
Aorto-enteric fistula
 Aetiology of Non-Variceal Upper
Gastrointestinal Bleeding
Mallory-Weiss tear, Reflux Oesophagitis, Oesophageal Ulcer,
Oesophagus Barrets ulcer, Cameron ulcer within hiatus hernia*, Oesophageal
neoplasm

Mallory
* Important causes of obscure UGIB
 Aetiology of Non-Variceal Upper
Gastrointestinal Bleeding
Gastric ulcer, Gastric erosions, Haemorrhagic gastritis, Gastric
carcinoma, Gastric lymphoma, Leiomyoma, Gastric polyp, Hereditary
Stomach haemorrhagic telangiectasia, Dieulafoy lesion*, Gastric Antral
Vascular Ectasia (GAVE)*, Angiodysplasia*

A gastric ulcer caused by H. pylori

* Important causes of obscure UGIB

 Aetiology of Non-Variceal Upper
Gastrointestinal Bleeding
Duodenal Ulcer, Duodenal erosions, Vascular malformation, Aorta-
duodenal fistula, Polyp (including Peutz-Jeghers syndrome and
Duodenum other polyposis syndromes), Carcinoma of ampulla, Carcinoma
of pancrease, Haemobilia*

A duodenal ulcer caused by H pylori Two angiodysplasias (arrows)

in the duodenum
 Aetiology of Non-Variceal Upper
Gastrointestinal Bleeding
Small Stomal ulcer, Diverticulum (including Meckels diverticulum),
Vascular malformation, Tumor
bowl

Treatment of a bleeding diverticulum

Endoscopic stigmata associated with
high risk of further gastrointestinal bleeding.
Top left : an active, spurting haemorrhage from
a peptic ulcer is associated with an 80% risk of
Continuing bleeding or rebleeding in shocked
patients. Top right : a non-bleeding, visible vessel
Represents either a pseudoaneurysm of an eroded
artery or a closely adherent clot, and 50% of such
patients rebleed in hospital. Left: large varives
with red spots are also strongly associated with bleeding
Klasifikasi V.E.
I. Kl. Degradi
II. Kl. Palmer & Brick
III. Kl. Omed
IV. Kl. Perhimpunan Endoskopi GI
Jepang
 Kl. Perhimpunan Endoskopi GI
Jepang

1. Warna (colour)
2. Tanda Warna merah (red colour sign)
3. Bentuk (form)
4. Lokalisasi
 Warna

Colour White (CW)

Colour Blue (CB)
 Tanda warna merah
(red colour sign/RCS)

Red Wale Marking (RMW) gambar 1

Cherry Red Spot (CRS) gambar 2
Hemato Cystic Spot (HCS) gambar 3
Diffuse Redness (DR)
 (RWM)
Red Wale Marking)

Gambar 1
 (CRS)
Cherry Red Spot

Gambar 2
 (HCS)
Hemato Cystic Spot

Gambar 3
 (DR)
Diffuse Redness

Gambar 4
 Bentuk

Tingkat I : VE lurus (straight line

varises/F1) gambar 5
Tingkat 2 : VE bentuk untaian tasbeh
menempati 1/3 lumen (F2) gambar 6
Tingkat 3 : VE yang besar, berkelok-
kelok >1/3 lumen (F3) gambar 7
Tingkat 1, varises yg lurus
(Straight line varicess/F1)
Tingkat 2, varices berbentuk
untaian manik-manik (rosary like varicess)
yg menempati 1/3 lumen(F2)
Tingkat 3, varices yg besar dan berkelo-kelok
Menempati lebih dari 1/3 lumen (F3)
 Lokalisasi
VE sp diatas bifurkasi trakhea (LS)
VE yg menempati daerah dibawah
bifurkasi trakhea (Lm)
VE yg menempati daerah dibawah 1/3
distal (Li)
VE yang menempati cardia lambung (lg)
 Ls
superior

Lm
middle

Li
inferrior

Lg
gastric
 PENATALASANAAN AWAL
Anannesis & pemeriksaan fisis
Tanda vital, Jalan infus yg sangat besar
Selang nasogastrik Hb, Ht, trombosit,
hemostaisis
Hemodinamik stabil
Tidak ada perdarahan aktif Hemodinamik tidak stabil
Perdarahan aktif
Pengobatan empirik RESUSITASI
Cairan krostaloid, cairan koloid,
Transfusi darah, koreksi
faktor koagulasi

Hemodinamik stabil
Perdarahan berhenti Hemodinamik stabil
Perdarahan tetap berlangsung Obat Vasoaktif
Perdarahan berhenti Octreotide, Somat ostatin,
Vasopressin
Elektif Emergensi atau Dini
Endoskopi SCBA Endoskopi SCBA

Varises esophagus Sumber perdarahan

lambung Tukak Tak tervisualisasi
Skleroterapi Injeksi, Radiologi, Intervensional
Atau ligasi hemostatik Diagnostik & terapeutik
Pengobatan
Bedah Jika Atau SB tube Atau bedah segera Atau bedah segera
definitif
gagal
Resuscitation
a. Mild or Moderate Bleed
* Pulse and blood pressure : N
* Hb > 10 mg/ml
* Without comorbidity
* Less than 60 years of age
b. Severe Bleed
Pulse > 100 beats/min
Sistolic blood pressure < 100
mmHg
Hb < 10 mg/ml
Aged > 60 years
 Table 1. Hypovolaemic shock: symptoms, sign, and fluid replacement
Blood loss (ml) <750 750-1500 1500-2000 >2000
Blood loss (%bv) <15% 15-30% 30-40% <40%
Pulse rate <100 >100 >120 >140
Blood pressure Norma Norma Decreased Decreased
Pulse pressure Normal or increased Decreased Decreased Decreased
Respiratory rate 14-20 20-30 30-40 >35
Urine output >30 20-30 30-40 >35
Mental status Slightly anxious Mildly anxious Anxious & confused Confused & letargic
Fluid replacement Crystalloid Crystalloid Crystalloid & blood Crystalloid blood

Adapted from Grenvick A, Ayres SM, Holbrook PR,

et al. Textbook of critical care. 4th edition. Philadelphia WB Saunders Company; 40-5
Minnesota tube
Endoscopic treatment of varices. Intravariceal injection of sclerosant
(left) and band ligation of oesophageal varices (right)
 Endoscopic Treatment For Non-variceal
Upper Gastrointestinal Bleeding
Thermal
Heater probe
multipolar electrocoagulation (BICAP, Gold Probe)
Argon plasma coagulation
Laser

heter probe

Laser application Heater probe application

for bleeding ulcer for bleeding erosion

Argon_plasma_coagulation
 Endoscopic Treatment For Non-variceal
Upper Gastrointestinal Bleeding
Injection
Adrenaline (1:10000)
Procoagulants (fibrin glue, human thrombin)
Sclerosants (ethanolamine, 1% polidoconal)
Alcohol (98%)

Sclerotherapy of bleeding spot AdrenalineUlcer-active_bleeding

 Endoscopic Treatment For Non-variceal
Upper Gastrointestinal Bleeding
Mechanical
Clips
Band Ligation
Endoloops
Staples
Sutures
Methods rarely used are depicted in italics.

Hemoclip application of bleeding erosion

Banding of bleeding spot

 Conclusion
Early upper gastrointestinal Endoscopy ( within
24 hours). Is the cornerstone of management of
AUGB
Early Endoscopy has 3 major roles
- Diagnosis
- Treatment
- Risk Stratification