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 (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 Investigations

Laboratory

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

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 = 0-1 → outpatient management and Early endoscopy 

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 7–8 g/dL
• Exceptions:—-CAD,Ongoing massive bleeding

Correction of Coagulopathy only if Patient is actively bleeding and 

• 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

• High-risk lesion → 72 hr IV infusion
• Then oral PPI:
• BD × 14 days → OD × 4–8 weeks
• Intermittent IV PPI ≈ continuous infusion (recent meta-analysis)
• Still infusion preferred in high-risk ulcers

2. Variceal Bleeding Suspected

Vasoactive Drugs-Terlipressin or Octreotide

 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??

According to current guideline-based management of acute variceal hemorrhage, vasopressors such as noradrenaline (norepinephrine) can be used concurrently with terlipressin when the patient has septic shock, hemorrhagic shock, or persistent hypotension despite resuscitation. They act through different mechanisms and are not mutually exclusive.

 B. OCTREOTIDE

analogue of Somatostatin

Dose-50 mcg IV bolus → 50 mcg/hr infusion

 Duration-3–5 days

Side Effects

• Bradycardia
• Hyperglycemia / hypoglycemia
• GI upset

 C. SOMATOSTATIN 

Dose-250 mcg bolus → 250 mcg/hr infusion

 Mechanism (ALL ABOVE)

• ↓ portal venous pressure
• ↓ splanchnic blood flow

Antibiotic Prophylaxis

TRANEXAMIC ACID (TXA)

 Evidence

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

 PROKINETICS (PRE-ENDOSCOPY)

 Role-Improve endoscopic visualization

 Erythromycin

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

Side Effects

• QT prolongation
• Arrhythmia

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

• Balloon tamponade (temporary)
• Early TIPS (within 72 hrs) in high-risk patients

Secondary Prevention

Non-Variceal

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

Variceal

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

Drugs & Dose

 Titration-Adjust to HR 55–60 bpm

 Side Effects

• Hypotension
• Bradycardia
• Bronchospasm

Balloon Tamponade in Acute Variceal Bleeding (Temporary Measure)

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