Upper GI Bleed

current endoscopic
management

Dr. B K Jalan, MD

Aditya Diagnostics and

Hospitals,
 Evolution of
multidisciplinary approach
From a purely surgical amenable
disease entity
to
medically treatable condition with
significant role of surgery in large no.
of cases
to
purely therapeutic endoscopically
manageable entity with
Major causes

Other causes include:

Mallory Weiss tear

Cancer
Dieulafoy’s lesions
Polyp etc.
Asian Institute of Gasteroenterology, Hyderabad,India
The most common
causes of
upper GI bleeding
duodenal ulcers(35%) and 
Gastric ulcers (20%).
esophageal varices 5-11%
(incidence varies depending on
geographic location).
Other causes for upper GI bleeding
are
● acute gastric
erosions/hemorrhagic gastritis
Variceal Bleed

Esophageal
Gastric
usual cause is portal hypertension
due to
Cirrhosis of liver
portal thrombosis
others
 Variceal bleed - general
outlook
In about 80% of patients, variceal
bleeding stops spontaneously.
mortality is high, often > 50%.
Mortality depends primarily on severity
of the associated liver disease rather
than on the bleeding itself.
Surviving patients are at high risk of
further variceal bleeding typically 50
to 75% have recurrence within 1 to 2
yr.
Endoscopic sclerotherapy
v successful in controlling acute esophageal
variceal bleeding in up to 90% of patients.
v Hemorrhagic control should be obtained with 1-
2 sessions.
Patients continuing to bleed after 2
sessions should be considered for
alternative methods to control their
bleeding.
v sclerosants:
– sodium tetradecyl sulfate
– sodium morrhuate
Endoscopic sclerotherapy
v Serious complications to sclerotherapy have
been reported in 15-20% of patients, with an
associated mortality rate of 2%.
v Complications of sclerotherapy may include
– mucosal ulceration,
– bleeding,
– oesophageal perforation,
– mediastinitis, and
– pulmonary complications.
– Long-term complications, such as esophageal
stricture formation, may also occur.
 Bleeding esophageal varix
and sclerosant/ glue
lick to edit Master text styles
econd level injection
● Third level
● Fourth level

● Fifth level

Esophageal variceal bleed controlled

after sclerosant and glue injection
respectively
Endoscopic variceal ligation
The esophageal mucosa and the
(banding)
q

submucosa containing varices are

ensnared, causing subsequent
strangulation, sloughing, and
eventual fibrosis, resulting in
obliteration of the varices.

q Very effective in securing hemostasis

from a platelet plug over a recently
bled varix
Bleeding esophageal varix ligated
with immediate control of bleed

Varix being sucked in

the cup and ligated

Esophageal varix with platelet plug

ligated
Endoscopic variceal ligation
q
(banding)
endoscopic field of view may be a problem
because of the device itself and because of
pooling of blood in the cup

q Comparison with sclerotherapy:

q Initial rate of hemostasis same
q Rebleeding rates are less with ligation: 26% vs
45%
q Local complications are less, e.g. strictures
q Systemic complications like pulmonary
infections and bacterial peritonitis : trend
towards less incidence with ligation
Gastric
varices

Glue injection
Banding
Glue injection of bleeding
gastric varix
Mr. Sarma 74 yrs
Presented with
repeated
hematemesis,
precipitated by blood
05 12 transfusions
18 12
2009 2009

22 12 06 01
2009 2010
 Prognosis of variceal
bleeding
The natural course of the disease
causing portal hypertension

The severity of portal hypertension

The location and number of the bleeding

varices

The functional status of the liver and the

 Bleeding erosions

In most cases bleeds due to erosions are minor and

amenable to acid suppression therapy

In cases of significant and generalized ooze, APC

(Argon plasma Coagulation) is the usual method
employed to cause superficial burns in the mucosa
with adequate control of bleeding
Ulcer Bleed –
general outlook

80% of ulcers stop bleeding

spontaneously

Overall mortality is 10%

73.2 % mortality in patients over 60 yrs

of age
Management of
Upper GI Bleed
Resuscitation - ABCs

Assessment – hemodynamic signs

Symptomatic therapy with drugs

Definitive treatment (endoscopy / Surgery

Prevention of
Is early endoscopy necessary ?
● Out of the hours procedure

Who need early endoscopy – high risk

patients ?

Can some non endoscopy treatment buy

 Patients at High
Risk of Increased
Mortality
Age above 60years
Recurrent bleeding
Severe co-morbidity
Active bleeding e.g.
● witnessed hematemesis,
● red blood per naso-gastric tube,
● RBC transfusion of 6 units or more,
● Supine hypotension <100mm of Hg
 Rockall score
Age score Evidence score Co- score
in Of morbidity
years shock

>60 0 none 0 none 0

CCF, IHD
60 - 79 1 Pulse>10 1 or any 2
0 other
SBP>100 major
disease
Renal /
>80 2 SBP<100 2 liver 3
failure,
HIGH RISK: ≥4 MODERATE RISK: 2-3
 early
endoscopy ?
Endoscopy within 1 to 24 hours

after initial resuscitation and

stabilization
As first case during usual endoscopy
timings

What to do in the intervening

Proper personals, proper equipment
10
9
8
7
6
5
4
3
2
1
0
 Forrest Rebleedin
g
Surgical
Incidence
of
Classification Incidence
Requirement
Death
Type I: Active Bleed
Ia: Spurting
Bleed
55-100% 35% 11%

Ib: Oozing Bleed

Type II: Recent Bleed 

IIa: Non-Bleeding
Visible Vessel 40-50% 34% 11%
(NBVV) 

IIb: adherent clot

20-30% 10% 7%
Type III: Lesion without
Bleeding 10% 6% 3%
Flat Spot
Endoscopic therapeutic
options

Injection
Thermal
● Heater probe
● Bipolar probe
● Nd: YAG laser
● Argon Plasma Coagulation
Mechanical
● Hemoclips
Injection temponade
1:10000 to 1:20000 adrenalin solution
injected round the bleeding site to
produce local compression

Large volumes up to 30 to 40 cc may be

injected

Up to 90 to 95% cases there is

immediate arrest of bleeding
 Bleeding duodenal ulcer

Injection of adrenalin 1:20000

Local blanching with cessation of

bleed
 Thermal coagulation
Co-aptive
coagulation
Usually , a gold probe is used with an
ordinary diathermy equipment

The culprit vessel is compressed to

occlude and burned and sealed off
completely

A combination of injection temponade

Combination of
methods
Combination of methods is better.
In a meta-analysis, Calvet showed that
● The rate of re-bleed reduces from 18.4% to 10.6%

● Rate of emergency surgery reduced from 11.3%

to 7.6%

● Mortality reduced from 5.1% to 2.6%

Adherent clot
Best treated or left alone ??

Cold snare to remove the clot and

then treat the underlying vessel in the
usual way

Left alone :: rebleed rate as high as

clips
Mechanical hemostasis
No tissue destruction
Repeat application safe

One or more clips can be applied to

occlude the bleeding area
Multi-clip devices are available
Clips’ limitations

Posterior wall duodenal ulcers

High lesser curve ulcers
Fibrotic ulcers

Comparison of clips with thermal methods

don’t show superiority of one over other
 Forrest Endoscopic treatment
Classification modalities
Type I: Active Bleed Injection
Ia: Spurting Plus
Bleed thermal method or clip

Ib: Oozing Bleed Injection or thermal method or both

Type II: Recent Bleed  Clips plus injection

IIa: Non-Bleeding Or
Visible Vessel clips plus coagulation
(NBVV)  or
clips only
IIb: adherent clot Removal of clots plus injection plus
thermal methods
Type III: Lesion without
Bleeding
Flat Spot
No endoscopic treatment required
Clean Base
Recurrent
bleed

How likely?

bleeding recurs in 15 to 20%

Acid suppression
therapy
For healing ulcers a pH >4.0 is
adequate

High intragastric pH (>6.0) facilitates

platelet aggregation and stabilzes the
clot
 IV PPI reduce re-bleeding
from ulcers after endoscopic
Cumulative rebleeding rate %

therapy
10

Omeprazole 80mg IV followed by 8mg hourly for 72 hours followed by

Variability in response to PPIs

Asians respond better than non Asians

they are slow metabolizers (20%
population) compared to Europeans and
Americans (2% population)

Even among Asians, response to different

PPIs is different
summary
Endoscopic therapy is now the mainstay of
treatment of bleeding peptic ulcers

IV PPI before and after endotherapy facilitate

therapy, prevent rebleeding, reduce the
emergency surgery rate and hospital stay and
probably reduce mortality.

Patients with significant co- morbid conditions

rebleed

About 2 to 5% patients may still re-

bleed
Role of 2nd look endoscopy ?
● Not required in all patients
● High risk patients may require
● Ulcer size more than 2 cms
● shock

Endotherapy / surgery ??
Follow up treatment

Full four weeks course of PPIs

orally followed by

Anti H pylori treatment in the last

one week
My sincere thanks and gratitude

for the opportunity,

for your rapt attention and

for being kind enough to overlook any

inadvertent shortcomings