Upper Gastrointestinal Bleeding (UGIB) 

Definition

Upper GI bleeding refers to hemorrhage originating proximal to the ligament of Treitz (esophagus, stomach, duodenum).

Epidemiology

  • Common in:
    • Elderly
    • NSAID / antiplatelet / anticoagulant use
    • Cirrhosis and portal hypertension
    • ICU stress-related mucosal disease

Anatomical Classification

Site

Examples

Esophagus

Varices, Mallory–Weiss tear, esophagitis

Stomach

Peptic ulcer, erosive gastritis, malignancy

Duodenum

Peptic ulcer, Dieulafoy lesion

Etiology

1. Non-Variceal UGIB (≈ 80–85%)

Peptic Ulcer Disease (most common)

  • Duodenal ulcer > Gastric ulcer
  • Causes:
    • H. pylori
    • NSAIDs
    • Stress ulcers (ICU)

Other causes

  • Erosive gastritis / duodenitis
  • Esophagitis (reflux, pill-induced)
  • Mallory–Weiss tear
  • Dieulafoy lesion
  • Upper GI malignancy
  • Iatrogenic (post-ERCP, biopsy)

2. Variceal UGIB (≈ 15–20%)

  • Portal hypertension
  • Esophageal > gastric varices
  • High mortality, rapid exsanguination risk

Clinical Presentation

Symptoms

  • Hematemesis
    • Fresh blood → active bleed
    • Coffee-ground → old bleed
  • Melena
  • Hematochezia (if massive UGIB)
  • Syncope, dizziness

Signs of Severity

  • Tachycardia
  • Hypotension
  • Postural drop
  • Altered sensorium
  • Shock

Initial Assessment – ICU Perspective

A – B – C – D – E Approach

Airway

  • Intubate if:
    • Ongoing hematemesis
    • Encephalopathy
    • Shock
    • High aspiration risk

Breathing

  • Oxygen
  • ABG if shock / encephalopathy

Circulation

  • Two large-bore IV cannulas
  • Arterial line (ICU)
  • Foley catheter (urine output)

Initial Investigations

Laboratory

  • CBC (Hb may be normal initially)
  • Blood group & cross-match
  • PT/INR, aPTT
  • LFTs
  • RFTs
  • Serum lactate
  • ABG (shock)

Important Concept

Urea rises disproportionately in UGIB due to digestion and absorption of blood proteins.

Risk Stratification Scores

Glasgow-Blatchford Score (GBS) – Pre-endoscopy

  • Identifies low-risk patients
  • GBS = 0 → outpatient management

Rockall Score

  • Clinical + endoscopic
  • Predicts mortality and rebleeding

Initial Resuscitation

Fluids

  • Balanced crystalloids
  • Avoid over-resuscitation in cirrhotics

Blood Transfusion

  • Restrictive strategy preferred
    • Target Hb 7–9 g/dL
    • Variceal bleed: 7 g/dL
  • Exceptions:
    • CAD
    • Ongoing massive bleeding

Correction of Coagulopathy

  • INR > 1.5 → FFP / PCC
  • Platelets < 50,000 → transfuse
  • DOACs → specific reversal if life-threatening

Pharmacological Therapy (Start BEFORE Endoscopy)

1. Proton Pump Inhibitors (Non-variceal)

  • IV Pantoprazole:Reduces high-risk stigmata

2. Variceal Bleeding Suspected

Start immediately:

Vasoactive Drugs-Terlipressin or Octreotide

Antibiotic Prophylaxis

  • Ceftriaxone -Reduces mortality & rebleeding

Timing of Endoscopy

  • Within 24 hours (all UGIB)
  • Within 12 hours (suspected variceal bleed)
  • After hemodynamic stabilization

Endoscopic Management

Non-Variceal Bleed

  • Injection therapy (adrenaline)
  • Thermal coagulation
  • Hemoclips
  • Combination therapy preferred

Variceal Bleed

  • Endoscopic variceal ligation (EVL)
  • Cyanoacrylate injection (gastric varices)

Failure of Endoscopic Control

Non-Variceal

  • Repeat endoscopy
  • Angioembolization
  • Surgery (last resort)

Variceal

Secondary Prevention

Non-Variceal

  • H. pylori eradication
  • Stop NSAIDs
  • Long-term PPI if needed

Variceal

  • Non-selective beta blockers (propranolol / carvedilol)
  • Repeat EVL sessions

Balloon Tamponade in Acute Variceal Bleeding (Temporary Measure)

Definition

Balloon tamponade is a temporary mechanical method to control life-threatening variceal hemorrhage by direct compression of bleeding varices using an inflatable balloon placed in the esophagus and/or stomach.

It is a bridge therapy until definitive treatment (endoscopic therapy or TIPS) can be performed.

Indications

Used ONLY when:

  • Massive variceal bleed
  • Failure or unavailability of endoscopic control
  • Hemodynamic instability despite resuscitation
  • As a bridge to early TIPS or repeat endoscopy

⚠️ Not definitive therapy

Contraindications (Relative/Absolute)

  • Unprotected airway (must intubate first)
  • Esophageal rupture or stricture
  • Recent esophageal surgery
  • Uncontrolled coagulopathy (relative)

Types of Balloon Tamponade Devices

1. Sengstaken–Blakemore (SB) Tube

  • 3 lumens
    • Gastric balloon
    • Esophageal balloon
    • Gastric aspiration

Used for esophageal varices

2. Minnesota Tube

  • 4 lumens
    • Gastric balloon
    • Esophageal balloon
    • Gastric aspiration
    • Esophageal aspiration

Allows better suction above esophageal balloon

3. Linton–Nachlas Tube

  • Large gastric balloon
  • Used mainly for gastric varices
  • Less commonly used now

Mechanism of Action

  • Gastric balloon compresses:
    • Gastroesophageal junction
    • Gastric varices
  • Esophageal balloon directly compresses:
    • Esophageal varices

Pre-Procedure Preparation (VERY HIGH-YIELD)

1. Airway Protection

Mandatory endotracheal intubation

  • Prevents aspiration
  • Facilitates safe insertion

2. Hemodynamic Stabilization

  • Large-bore IV access
  • Blood products ready
  • Vasoactive drugs ongoing (terlipressin/octreotide)

3. Equipment Checklist

  • Balloon tamponade tube
  • 50–60 mL syringes
  • Manometer (if available)
  • Lubricant
  • Suction
  • X-ray confirmation

Step-by-Step Insertion Technique (Exam Favorite)

Step 1: Test Balloons

  • Inflate balloons with air
  • Check for leaks
  • Deflate completely

Step 2: Tube Insertion

  • Insert orally (preferred) or nasally
  • Advance to 50–55 cm

Step 3: Gastric Balloon Inflation

  • Inflate with 250–300 mL air
  • Confirm position:
    • Auscultation over epigastrium
    • Chest X-ray (best)

Step 4: Apply Traction

  • Pull tube gently until resistance felt
  • Fix with:
    • Helmet
    • 500 mL IV fluid bottle as counterweight

Step 5: Assess Bleeding

  • Aspirate gastric contents
  • If bleeding stops → do NOT inflate esophageal balloon

Step 6: Esophageal Balloon (If Needed)

  • Inflate to 30–45 mmHg
  • Use manometer
  • Clamp lumen

Duration of Use

⏱ Maximum: 12–24 hours

  • Esophageal balloon:
    • Deflate every 6 hours (5–10 min) to prevent ischemia
  • Remove as soon as definitive therapy available

Efficacy

  • Controls bleeding in 80–90% initially
  • High rebleeding rate once deflated
  • Does NOT improve mortality

Complications (VERY IMPORTANT FOR EXAMS)

Common & Dangerous

  • Aspiration pneumonia
  • Esophageal ulceration
  • Esophageal necrosis
  • Esophageal perforation
  • Airway obstruction
  • Pressure necrosis
  • Rebleeding after deflation

Risk increases with

  • Prolonged use (>24 h)
  • High balloon pressure
  • Improper positioning

Monitoring in ICU

  • Continuous vitals
  • Hourly suction output
  • Balloon pressure checks
  • Chest X-ray
  • Watch for:
    • Chest pain
    • Subcutaneous emphysema
    • Sudden deterioration

Role in Current Guidelines

  • Baveno VII / AASLD / ESGE
    • Balloon tamponade = salvage bridge therapy
    • Prefer early TIPS over prolonged tamponade
  • Self-expanding esophageal metal stents (SEMS)
    • Emerging alternative
    • Fewer complications
    • Can remain for up to 7 days