UGIB

SEPSIS
UGIB Rits.Latu
Rits.Latu (MBBS5)
Case 2
Blood Supply
Terminology
Hematemesis: vomiting out fresh blood or “coffee ground like material”

Melena: passing black tarry foul smelling stool as a result of oxidation of
haem
Hematochezia: passing fresh blood in stool or BRBPR
Occult bleeding : gastrointestinal bleeding that is not visible to the patient or
physician
Intro to Upper Gastrointestinal Bleed
UGIB refers to GI blood loss having an origin proximal to the ligament of Treitz
More common than lower gastrointestinal bleeding (approximately 70% of GIB) with
hospitalization rate for UGIB estimated to be sixfold higher than for lower GI bleeding
The incidence of UGIB is higher in men than in women (128 versus 65 per 100,000 in one
study) and increases with age.
More recent studies suggest that while still prominent, ulcer disease is now a less common
cause (approximately 20 to 25 percent of cases) other disorders such as esophagitis are
becoming comparatively more common
Causes
UGIB can be classified into several broad categories based on anatomic and
pathophysiologic factors
From a pathophysiologic perspective, ulcerative and erosive lesions (gastric or duodenal

ulcers, esophagitis, and gastritis) are far more common than vascular lesions (varices,
angiodysplasia), mass lesions (adenocarcinoma, polyps), or traumatic lesions (Mallory-
Weiss tear).
The source of bleeding cannot be identified in 10 to 15 percent of patients with UGIB

Peptic Ulcer Disease
Defects in the gastric or duodenal mucosa that extend
through the muscularis mucosae. Gastric ulcers more
common than duodenal ulcer
The four major risk factors for bleeding peptic ulcers are
as follows
● Helicobacter pylori infection
● Nonsteroidal anti-inflammatory drugs (NSAIDs)
● Physiologic stress
● Excess gastric acid
Portal Hypertension
Several causes of UGIB are the result of portal hypertension,

including esophageal varices, PHG, gastric varices, and
ectopic varices. Most commonly caused by hepatic cirrhosis
Due to blocked caval drainage , blood is shunted into

alternative routes (portocaval anastomosis)
Varices may be identified in the esophagus and/or the

stomach. They may also be seen at sites other than the
esophagus or stomach, such as the small bowel (ectopic
varices)
Vascular Lesions
Vascular lesions in the GI tract that may cause bleeding include
angiodysplasias, Dieulafoy's lesions, and GAVE.
Angiodysplasias are the most common vascular anomalies

encountered in the GI tract
Dieulafoy's lesion : A Dieulafoy's lesion is a dilated aberrant

submucosal vessel that erodes the overlying epithelium in the
absence of a primary ulcer
Gastric antral vascular ectasia (GAVE), or watermelon stomach,

results from ectatic mucosal and submucosal capillaries.
Evaluation
The initial evaluation of a patient with a suspected clinically significant acute upper GI bleed
includes a history, physical examination, and laboratory tests
The goal of the evaluation is to assess the severity of the bleed, identify potential sources of the
bleed, and determine if there are conditions present that may affect subsequent management.
Past Medical History : prev UGIB , comorbidity ( chronic liver dxs/malignancy/AAA) , drug
history of NSAID, anticoagulants & SSRI. Smoker & ETOH consumer
Symptom Assessment
Investigation
Labs :
● Full Blood count
● Blood Grouping
● Serum biochemistries
● Liver function tests (AST, ALT)
● Coagulation studies. (prothrombin time with INR)
● BUN
In addition, serial electrocardiograms and cardiac enzymes
Imaging : Endoscopy (gold standard diagnostic modality)

Acute Management
ABCDE approach is systematically used to assess acutely unwell patient
● Ensure the airway is protected & administer high-flow oxygen if hypoxia is present.
● Establish intravenous access with two large-bore cannulas (> 16 gauge); plus bloods
sent
● Fluid resuscitation : Crystalloid or colloid should be given intravenously while you
are awaiting cross-matched blood. (eg, 500 mL of normal saline or lactated Ringer's
solution over 30 minutes)
○ Vasopressor may be required temporarily
● Blood transfusion : initiate blood transfusion if the hemoglobin is <7 g/dL (<70-g/L)
● Keep NPO
Clotting should be corrected with platelets, fresh frozen plasma and, in patients taking
warfarin, prothrombin complex concentrate (e.g., Octaplex, Beriplex) and vitamin K.
Long Term management
Pharmacological : Acid suppression (eg, PPI) , prokinetics, vasoactive medication , abx for cirrhosis
Complications
Reference(s)
ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding

UGIB

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SEPSIS

Hematemesis: vomiting out fresh blood or “coffee ground like material”

From a pathophysiologic perspective, ulcerative and erosive lesions (gastric or duodenal

The source of bleeding cannot be identified in 10 to 15 percent of patients with UGIB

Several causes of UGIB are the result of portal hypertension,

Due to blocked caval drainage , blood is shunted into

Varices may be identified in the esophagus and/or the

Angiodysplasias are the most common vascular anomalies

Dieulafoy's lesion : A Dieulafoy's lesion is a dilated aberrant

Gastric antral vascular ectasia (GAVE), or watermelon stomach,

In addition, serial electrocardiograms and cardiac enzymes

Imaging : Endoscopy (gold standard diagnostic modality)

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