Upper Gastrointestinal Bleeding

Upper Gastrointestinal Bleeding (UGIB) 

Definition

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

Anatomical Classification

Etiology

1. Non-Variceal UGIB (≈ 80–85%)

Peptic Ulcer Disease (most common)

• Duodenal ulcer > Gastric ulcer
• Causes:H. pylori,NSAIDs,Stress ulcers 

Other causes

• Erosive gastritis / duodenitis
• Esophagitis (reflux, pill-induced)
• Mallory–Weiss tear
• Dieulafoy lesion
• Upper GI malignancy
• Iatrogenic (post-ERCP, biopsy)
• Aortoenteric fistula(present with melena as a sentinel bleed before the development of brisk, hemodynamically significant bleeding. Patients typically have a history of endovascular intervention of the aorta, where graft material erodes through the gastrointestinal lumen.)
• Hemosuccus pancreaticus 
• Hemobilia

2. Variceal UGIB (≈ 15–20%)

• Esophageal > gastric varices

History

Physical Examination

Clinical Presentation

Symptoms

• Hematemesis
• Fresh blood → active bleed
• Coffee-ground → old bleed
• Melena
• Hematochezia (if massive UGIB with rapid transit of blood through the GI tract)
• Syncope, dizziness

Initial Investigations

Laboratory

• CBC (Hb may be normal initially)
• blood urea nitrogen to creatinine ratio >30 suggests an upper GI source of bleeding.
• Blood group & cross-match
• PT/INR, aPTT
• LFTs
• TEG if cirrhosis or complex coagulopathy (e.g., DIC).
• RFTs(Hepatorenal syndrome)
• Serum lactate
• ABG (shock)

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

Risk Stratification Scores

Initial Resuscitation

Fluids

• Balanced crystalloids
• Avoid over-resuscitation in cirrhotics
• Variceal hemorrhage originates from the portal venous circulation; therefore, excessive fluid administration can increase central venous and portal pressures, potentially worsening bleeding. Patients with portal hypertension and cirrhosis often have a lower baseline blood pressure (typically systolic 80–90 mmHg) and may tolerate mild hypotension. Consequently, a restrictive resuscitation strategy is preferred, as aggressive volume replacement may exacerbate ongoing hemorrhage and increase the risk of rebleeding.

Blood Transfusion

• Restrictive strategy preferred
• Target Hb >7g/dL
• Exceptions:—-CAD,Ongoing massive bleeding(target hemoglobin >8 g/dL).

Correction of Coagulopathy

 if Patient is actively bleeding and 

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

if Patient is Not bleeding actively and prepping For Endoscopy

Pharmacological Therapy 

1. Non-variceal Bleed

• IV Pantoprazole:Reduces high-risk stigmata
• Intermittent IV PPI(40 mg IV B.D or Q.I.D) ≈ continuous infusion (recent meta-analysis)
• Still infusion preferred in high-risk ulcers

• High-risk for rebleeding Peptic  lesion → 72 hr IV infusion
• peptic ulcers with low-risk features, then an oral daily dose can be continued for ulcer treatment.

Preferred Vasopressor: Norepinephrine

Norepinephrine

Why?

• Recommended first-line vasopressor in hemorrhagic shock.
• Potent vasoconstriction with less tachycardia than dopamine.
• Maintains MAP while definitive bleeding control is achieved.

Target—MAP ≥65 mmHg

Dose—0.05–1 mcg/kg/min (titrate to MAP)

If refractory shock—Add:Vasopressin (0.03 units/min)

2. Variceal Bleeding Suspected

Terlipressin or Octreotide(These are not being used primarily as vasopressors but as Splanchnic Vasoconstrictors)

 A. TERLIPRESSIN 

selective V1 receptor action-Potent splanchnic vasoconstriction

• 2 mg IV every 4-6 hours until bleeding is controlled ,upto 48 hours 
• After bleeding control 1 mg IV every 4–6 hr upto 48-72 hr

Contraindication

• Myocardial ischemia,heart failure, prolonged Qtc
• Peripheral ischemia
• Hyponatremia
• Only drug shown to reduce mortality in variceal bleed??

 B. OCTREOTIDE(First Choice)

• Analogue of Somatostatin
• Dose-50 mcg IV bolus → 50 mcg/hr infusion
• Duration-2–5 days

Side Effects

• Bradycardia
• Hyperglycemia / hypoglycemia
• GI upset

If Variceal Bleeding Patient Remains in Shock

Use both:

1. Portal pressure reducing agent—Octreotide or Terlipressin
2. Systemic vasopressor—Norepinephrine (preferred)

C. SOMATOSTATIN

intravenous bolus of 250 µg, followed by a continuous infusion of 250 to 500 µg/hour. 

D.Role of Noradrenaline in Variceal Bleeding

Noradrenaline (norepinephrine) does NOT treat variceal bleeding itself. It is used to treat hemorrhagic shock and maintain organ perfusion while definitive hemostatic therapy is provided.If Variceal Bleeding Patient Remains in Shock

Use both:

1. Portal pressure reducing agent—Octreotide or Terlipressin
2. Systemic vasopressor—Norepinephrine (preferred)

E. Role of Vasopressin in Upper GI Bleeding

1. Not a Routine First-Line Vasopressor

In UGIB with hemorrhagic shock, the preferred vasopressor is:

• Norepinephrine

Vasopressin is not routinely used as first-line therapy because:

• May cause excessive vasoconstriction
• Risk of myocardial ischemia
• Risk of mesenteric ischemia
• Risk of digital ischemia

2. Role in Refractory Hemorrhagic Shock

When hypotension persists despite:

• Adequate blood product resuscitation
• Control of bleeding
• Moderate/high-dose norepinephrine

Add:Vasopressin 0.03 units/min

Antibiotic Prophylaxis(Controversial)

• No role(one thought)
• (Second thought)Antibiotic prophylaxis for 2 to 5 days is advised in patients with cirrhosis presenting with acute GI bleeding due to the risks of bacterial translocation, aspiration pneumonia, and spontaneous bacterial peritonitis. Antibiotics can be discontinued once bleeding is controlled and no active infection is evident. 
• Empiric antibiotics, if initiated, should be reassessed within 48–72 hours and discontinued if microbiological studies remain negative and there is no clinical evidence of infection.

TRANEXAMIC ACID (TXA)

 Evidence

• HALT-IT trial → NO mortality benefit
• ↑ thromboembolic events

PROKINETICS 

 Role-Improve endoscopic visualization

 Erythromycin

• 250 mg IV over 30 min
• Given 30–90 min before endoscopy

Side Effects

• QT prolongation(contraindication)
• Arrhythmia

Review Medication

• Discontinue anticoagulants (e.g., DVT prophylaxis).
• Discontinue antihypertensives.
• Aspirin for Primary Prevention (No Prior Cardiovascular Event) Stop aspirin during acute UGIB and do not routinely restart it.
• Aspirin for Secondary Prevention (Prior MI, Stroke, PCI, CABG)—Temporarily hold aspirin if bleeding is ongoing or endoscopic hemostasis has not yet been achieved.After Hemostasis Restart aspirin early, usually within 1–3 days, and certainly within 3–5 days after successful endoscopic control.

Endoscopy

• Within 24 hours (all UGIB)
• Within 12 hours (suspected variceal bleed).
• In patients who achieve hemostasis after initial endoscopy, high-risk patients should undergo evaluation for preemptive or “early” TIPS. 

Failure of Endoscopic Control

If endoscopy doesn’t show any source of bleeding, consider CT angiography to evaluate for a lower GI bleed.

Non-Variceal

• Angioembolization(interventional radiology)
• Surgery (last resort)

Variceal

• Balloon tamponade (temporary)
• Salvage TIPS(interventional radiology)

Intubation

• Indication-Poor GCS,unable tolerate procedure, severe hemetmesis
• High risk of aspiration-Consider NG suction to reduce the risk of aspiration (varices aren’t a contraindication to NG tube placement)
• High risk of Collapse—Resuscitate and start vasopressor before intubation.

Secondary Prevention

Non-Variceal

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

Variceal

• Non-selective beta blockers (propranolol / carvedilol)—During Acute GI Bleeding Hold initially.Restart before discharge or within several days after successful hemostasis.
• Repeat EVL sessions

Drugs & Dose

 Titration-Adjust to HR 55–60 bpm

 Side Effects

• Hypotension
• Bradycardia
• Bronchospasm

Management of Rebleeding

• This will depend on the lesion seen initially. However, the usual sequence of events is as follows:
• 1st line: Repeat endoscopy.
• 2nd line: Interventional radiology.
• 3rd line: Surgery.

Balloon Tamponade 

Indications

• 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

Insertion Technique 

  Mandatory endotracheal intubation Prevents aspiration

• Insert orally (preferred) or nasally
• Advance to 50–55 cm
• Inflate with 250–300 mL air
• Confirm position:
• Auscultation over epigastrium
• Chest X-ray (best)

 Apply Traction

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

 Assess Bleeding

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

 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 

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