ACUTE

NONVARICEAL
BLEEDING
Suryadarma
 G.I. Bleeding

 Acute Vs Chronic

 Acute Upper G.I.Bleeding:

 Acute Lower G.I.Bleeding:

 Types of Bleeding
 Upper GI Bleed

 Lower GI Bleed
below the ligament of treitz
 Acute Upper G.I. Bleeding

 Haematemesis

 Melaena

 Site & Time

 Acute U.G.I. Bleeding
  Aetiology:
– 1. Drugs (Aspirin & NSAIDs)
– 2. Alcohol
– 3.Chronic peptic ulceration (50% of GI
hemorrhage)
– 4.Others: reflux esophagitis, varices, gastric
carcinoma, acute gastric ulcers & erosions.
 Gastrointestinal
bleeding

Local :
Systemic :
Variceal
Haemostatic dis.
Nonvariceal
Acute non variceal bleeding
 Caused Upper UGI Bleeding
nonvariceal

 Gastric antral vascular ectasia

 Peptic ulcer disease
 Haemorrhagic gastritis
 Oesophagitis
 Mallory weiss tear
 Cameron ulcer
 Dieulafoy lesion
 Corrosive ingestion
 Haemobilia
 Predisposing Factors

 Age
 Alcohol Use
 Aspirin Ingestion/Other Drugs
 Hormones
 Hyperacidity
 Infectious
 Inheritance
 Stress
 Clinical manifestation
 ACUTE BLEEDING
Hemet emesis
Coffee ground emesis
Melena
Hematocesia
Occult bleeding
Obscure bleeding
Hypovolemic Shock
 CHRONIC BLEEDING
Anemia
 Acute U.G.I. Bleeding
  Clinical approach:
– 1. recent (24 hrs), then hospitalized.
– 2. if small amount, no immediate Tx, because
CVS can compensate
– 3. 85% stop bleeding during 48 hrs
– 4. history helps in diagnosing the cause of the
hemorrhage, eg: long history of indigestion,
or previous hem. from ulcers.
 Acute U.G.I. Bleeding
 Clinical approach:

– 5. factors include:
 age (60 +)
 amount of bld lost
 continuing visible bld loss.
 signs of chronic liver disease
 classical clinical features of shock
 Acute U.G.I. Bleeding
 Clinical approach:

6. liver disease  severe, recurrent bleeding

(if from varices)

7. splenomegaly  portal hypertension

 PHYSICAL
 Orthostatic changes in pulse & BP
 Cardiopulmonary
 Skin
 Examine oral cavity & nasopharynx
 Lymph nodes
 Abdomen
 Digital rectal
 Acute U.G.I. Bleeding
  Immediate management:
** Emergency management:
 History + exam.
 Monitor: pulse & BP /30 min
 Bld sample: haemoglobin, urea,
electrolytes, grouping & cross-matching
 I.v. access
Acute U.G.I. Bleeding

** Emergency management
(cntd):
 Bld transfusion in case of
– 1) shock 2) haemoglobin <10 g/dl
 Urgent endoscopy
 Surgery when recommended
 Acute U.G.I. Bleeding
**Shock management:

  ABC

  Airway: endotracheal tube, oropharyngeal

airway.
*Give oxygen
 Acute U.G.I. Bleeding
**Shock management (cntd):
  Breathing: support respiratory function
* Monitor: resp. rate, bld gases, chest
radiograph
  Circulation: expand circulating volume:
blood, colloids, crystalloids support CVS
function: vasodilators
* Monitor: skin color, peripheral temp., urine
flow, BP, ECG
 First priority
Resuscitation
A_B_C procedure
Gastric lavage +cooling
Initial evaluation

Major bleeding Minor Bleeding

 Resuscitation
Volume replacement
crystaloid, coloid, blood tranfusion
Comorbidity evaluation
Cardiac failure Monitored :

Respiratory Ds CVP

Renal Ds Urine output

Intubation
Blood pressure
Liver cirrhosis Antibiotic
 Initial evaluation
 Rockall score
 Clinical severity of bleeding
 Blood sample :
 FBC,Urea,creatinine,
 Electrolyte,cloting profil,
 Blood group & cross match
 Severity bleeding : clinical criteria
Severity bleeding criteria
Mild < 1g/dl drop Hb
Minimal/ no anemia
Stable hemodynamic
Infrequent melena
Coffee hemet emesis

Moderate 1-2 g/dl drop Hb

Hb : 10 g/dl
Tachycardia
Melena
Hemet emesis

Severe 2 g/dl drop Hb

Hb < 10 g/dl
Orthostatism/shock
Hematochesia > 350 cc
Repeated hemet emesis
 Acute U.G.I. Bleeding
  General Investigations:
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
 Acute U.G.I. Bleeding
**General management:
  Blood volume
1. restore volume to normal
2. transfusion
  Endoscopy
1. shock, suspected liver disease or
continued bleeding
2. control varices or ulcers to reduce
re-bleeding
 Acute U.G.I. Bleeding
**General management:
  Drug therapy
1. H2 – receptor antagonists
2. proton pump inhibitors
  Factors in reassessment
1. age: 60 +  greater mortality
2. recurrent hemorrhage: +++ mortality
3. re-bleeding: mostly within the 1st 48 hrs
4. surgical procedures in case of severe
bleeding.
Management ulcer bleeding
 Management of Ulcer bleeding
 Essential documented location, size and SRH (sign of
recent hemorrhage)
 Modified Forrest classification :
 Class I : (actively bleeding ulcer)
 Ia spurting
 Ib oozing
 Class II: (non-actively bleeding)
 IIa: non-bleeding visible vessel
 IIb: ulcer with surface /adherent clot
 IIC: ulcer with red/dark spots
 Class III: ulcer with clean base
Treatment of acute ulcer
bleeding
 A.Endoscopic therapy
 ULCER
 Injection : adrenaline
 alcohol
 sclerosants
 thrombin
 Thermal : heater probe
 electrocoagulation
 argon beamer
 neodymium YAG laser
 Other : microwave coagulation
 cyanoacrylate glue

 B.Mechanical closure
by endoclips
C. Drug therapy for peptic ulcer bleeding
PPI iv follow infusion 72 h
or
PPI daily iv
or
PPI oral ?

Following with healing dose 8 weeks

H pylori eradication
re-scope 2-3 mo
MALLORY-WEISS TEAR
 Mallory-Weiss
 Tear of mucosa around esophagogastric
junction, after retching vomiting
 Bleeding occurs when involves plexus
venous or arterial
 Usually in middle age
 Prompt endoscopies diagnostic procedure
: longitudinal ulcer
 Differential Diagnosis
 Reflux esophagitis
 Infectious esophagitis
 Usually, focal lesion with normal adjacent
 Contrast with other cause
 Barium x-ray : nondiagnostic
 Complication : very rare
Re-bleeding
Perforation ( Boerhaave syndrome)

Treatment :
 usually stop bleeding spontaneous
 endoscopic treatment
 H2 blocker, PPI accelerate healing
Small intestinal bleeding
 Small intestinal bleeding
causes (obscure bleeding)
 Angiodysplasia
 Small bowel polyp/tumor
 Zollinger-ellison syndrome
 Meckel diverticulum
 Jejunal diverticulosis
 NSAIDs
 Crohn disease
 Ulcerativa jejunitis
 Vasculitis
 Intussusception
 Small bowel infarction
Investigation small intestinal bleeding

 Push enteroscopy
 Intraoperative enteroscopy
 Hemostatic during enteroscopy
 Capsul endoscopy
 Mesenteric angiography
 Radioisotope bleeding scans
 Exploratory laparotomy
INDICATIONS FOR ADMISSION
& REFERRAL
 Admit pts with h/o recent brisk bleeding &
orthostatic changes
 Admit pts with less sever blood loss who have
co-morbid conditions aggravated by anemia
 Profound anemia with no evidence of blood loss
 Refer pts who are candidate for endoscopy or
colonoscopy when source of bleeding is elusive