UPPER GI

BLEEDING
By
Nimmy P S
Assistant Professor
GCON
Definition

Upper GI bleeding refers to

bleeding in the upper GI tract
commonly defined as bleeding
arising from the esophagus. .
A massive upper GI
hemorrhage is generally
defined as a loss of more than
1500 ml of blood or a loss of
25% of intravascular blood
Etiology

Drug induced: due to prolonged use of

corticosteroids (prednisone), NSAIDs (Ibuprofen) &
salicylates (Aspirin)
Esophageal origin:
Chronic esophagitis caused by GERD, ingestion of
drugs irritating the mucosa, alcohol & cigarette
smoking.
Esophageal varices which occurs secondary to
cirrhosis of liver
Mallory Weiss tear related. (Mallory Weiss tear is a
tear in the gastro esophageal junction which is
often related to severe retching(to make effort to
vomit) & vomiting
Etiology contd…
Stomach & duodenal origin:
Gastric cancer causes steady blood loss as it
grows and ulcerates through the mucosa and
blood vessels located in its path.
Hemorrhagic gastritis
Peptic ulcer disease (Bleeding ulcers account for
50% of the cases of upper GI bleeding)
Polyps
Stress related mucosal disease also called
physiologic stress ulcers, occurs in patients who
have sustained severe burns or trauma or had
major surgery
Etiology contd…

Systemic diseases:
Blood dyscrasias (leukemia, aplastic
anemia)
Renal failure
Less common causes of upper GI
bleeding include tumors and
vascular lesions
Types of UGIB

1. Obvious Bleeding
Hematemesis
Bloody vomitus appearing as fresh,
bright red blood or “coffee ground”
appearance (dark, grainy digested blood)
Melena
Black, tarry stools (often foul smelling)
caused by digestion of blood in the GI
tract. The black appearance is from the
presence of iron
Hemateme
sis
melena
Types of UGIB contd…
2. Occult Bleeding
Small amounts of blood in
gastric secretions, vomitus, or
stools not apparent by
appearance; detectable by
guaiac test
Clinical manifestations

Blood in stool
Hematemesis or coffee ground
vomitus
Melena
Abdominal cramps or diarrhea
Fatigue, pallor, anemia
Clinical manifestations
contd…
Significant blood loss is indicated
by:
Pallor
Tachycardia
Tachypnea
Orthostatic hypotension
Restlessness
Confusion
Diagnostic evaluation

Endoscopy is the primary tool for diagnosing the source

of upper GI bleeding.
Angiography is used in diagnosing upper GI
bleeding only when endoscopy cannot be done. it
often allows precise localization of bleeding; and it
enables the use of therapeutic options, which include
embolization or vasopressin infusion. In this procedure a
catheter is placed into the left gastric or superior
mesenteric artery and advanced until the site of
bleeding is discovered.
Diagnostic evaluation
contd…
Barium contrast after the acute bleeding
phase, barium studies can document an
actual lesion but cannot verify that it is the
bleeding source.
CBC, BUN, CRP
Serum electrolytes, platelets, PT, PTT, liver
enzymes, ABGs, examination of vomitus &
stool
Urinalysis including specific gravity
provides information on the patient's
hydration status.
Emergency assessment & management
Approximately 80% to 85% of patients who have
massive hemorrhage spontaneously stop bleeding,
but the cause must be identified and treatment
initiated immediately.
The immediate physical examination includes a
systemic evaluation of the patient's condition with
emphasis on blood pressure (BP), rate and character
of pulse, peripheral perfusion with capillary refill, and
observation for the presence or absence of neck vein
distention.
Vital signs are monitored every 15 to 30 minutes.
Evaluate for the signs and symptoms of shock and
start treatment as soon as possible
Carefully assess the patient's respiratory status.
Thorough abdominal examination & assess for the
presence or absence of bowel sounds. A tense, rigid,
boardlike abdomen may indicate a perforation and
peritonitis.
Once the immediate interventions have begun, ask for
the history of previous bleeding episodes, weight loss,
blood transfusions in the past, and transfusion
reactions, history of any other illnesses (e.g., liver
disease, cirrhosis) or medications that may contribute
to bleeding or interfere with treatment.
Monitor complete blood count (CBC), blood urea
nitrogen (BUN), serum electrolytes, blood glucose,
prothrombin time, liver enzymes, arterial blood gases
(ABGs), and a type and crossmatch for possible blood
transfusions.
All vomitus and stools are tested
for gross and occult blood.
A urinalysis including specific
gravity provides information on the
patient's hydration status.
Fluid and blood replacement:
Administer isotonic crystalloid
solution (e.g., lactated Ringer's
solution). Whole blood, packed red
blood cells (RBCs), and fresh frozen
 Drug Therapy

During the acute phase, drugs are used to

decrease bleeding, decrease HCl acid
secretion, and neutralize the HCl acid that is
present.
Injection therapy with epinephrine
(1:10,000 dilutions) during endoscopy is
effective for acute hemostasis. Epinephrine
produces tissue edema and, ultimately,
pressure on the source of bleeding. To
prevent rebleeding, injection therapy is often
combined with other therapies (e.g.,
thermocoagulation or laser treatment).
For variceal bleeding, vasopressin (Pitressin) is
used to produce vasoconstriction.
It is used to treat upper GI bleeding in those patients who do

not respond to other therapies and are poor surgical risks.

It is administered systemically through a vein or intraarterially

at the local site of actual bleeding.

Side effects of IV vasopressin include decreased myocardial

contractility and decreased coronary blood flow.

The patient undergoing vasopressin therapy is closely
monitored for its myocardial, visceral, and peripheral ischemic
side effects. Vasopressin is used cautiously in the patient with
a known history of vascular disease.
Histamine2-receptor (H2R) blockers

(e.g., cimetidine [Tagamet]) or

proton pump inhibitors (PPIs) (e.g.,
pantoprazole [Protonix]) are
administered intravenously to decrease acid
secretion, because the acidic environment can
alter platelet function, as well as interfere with
clot stabilization
Antacids (magnesium hydroxide, magnesium
trisilicate, aluminum hydroxide, calcium
carbonate, and sodium bicarbonate) to neutralize
HCl acid Because antacids neutralize HCl acid and increase
the pH of gastric contents to above 5, there is inhibition of
the conversion of pepsinogen to its active form pepsin. (The
most frequently used antacid preparations are Aluminum
hydroxide and magnesium trisilicate are the most useful
because they are nonabsorbable. Calcium carbonate and
sodium bicarbonate are absorbable, and prolonged use can
lead to systemic alkalosis).
Sedatives to control agitation and restlessness should be
administered cautiously.
Anticholinergic drugs are contraindicated in acute
upper GI bleeding episodes, but may be used after the
bleeding has stopped to reduce GI motility.
 Endoscopic therapy
Goal of endoscopic hemostasis: is to
coagulate or thrombose the bleeding vessel.
Endoscopic therapy can be useful to stop
bleeding in patients with severe gastritis,
Mallory-Weiss tear, esophageal and gastric
varices, bleeding peptic ulcers, and polyps.
Techniques of endoscopic
therapy
Several techniques are used, including
Thermal (heat) probe: coagulates tissue by
directly applying a heating element to the
Argon plasma coagulation (APC): is a
noncontact coagulation that delivers
monopolar current to tissue.
For variceal bleeding, other strategies
include variceal ligation, injection
sclerotherapy, and balloon tamponade
 Nursing management
Approach the patient in a calm and assured
manner to help decrease the level of anxiety.
A thorough and accurate nursing assessment is
an essential first step. The assessment includes
the patient's level of consciousness, vital signs,
appearance of neck veins, skin color, and
capillary refill.
Check the abdomen for distention, guarding,
and peristalsis.
Monitored the vital signs every 15 to 30
minutes. Orthostatic vital signs should be
obtained.
Immediate determination of vital signs
indicates whether the patient is in shock
from blood loss and also provides a
baseline BP and pulse by which to
monitor the progress of treatment.
(Signs and symptoms of shock include
low BP; rapid, weak pulse; increased
thirst; cold, clammy skin; and
restlessness).
Administer the prescribed medications.
Instruct to avoid gastric irritants such
Instruct the patient, the methods of testing
vomitus or stools for the presence of occult blood.
Positive results should be promptly reported to
the health care provider or the nurse.
Instruct the patient on regular administration of
ulcerogenic drugs, such as aspirin,
corticosteroids, or NSAIDs, regarding the
potential adverse effects related to GI bleeding &
to avoid these drugs if possible.
If aspirin must be prescribed, enteric-coated
tablets can be substituted for regular tablets.
Taking the drugs with meals or snacks lessens the
potential irritating effects. The coadministration
of an NSAID with a PPI can reduce bleeding risk.
Administer misoprostol (Cytotec) for
the patient at risk for gastric ulcers
because of NSAID use. This
prostaglandin analog inhibits acid
secretion and reduces upper GI
bleeding episodes associated with
NSAID use.
For patient who has a history of liver
cirrhosis with esophageal varices,
instruct to avoid known irritants, such
as alcohol and smoking.
Monitor for upper respiratory tract infection. Severe
coughing or sneezing can create increased pressure
on the already fragile varices and may result in
massive hemorrhage.
The patient who is known to have blood dyscrasias
(e.g., aplastic anemia) or liver dysfunction or who is
taking cancer chemotherapeutic drugs has a
potential bleeding problem because of altered
hemostasis caused by a decrease in clotting factors
and platelets. When these patients also have a
history of ulcer disease, gastritis, varices, or drug
and alcohol abuse, they should be carefully
instructed regarding their disease process and
drugs, and they should be closely observed for
bleeding.
Assess for the level of consciousness.
Monitor for jugular venous distention, capillary
refill, CVP.
Accurate intake & output record should be
maintained.
Fluid & blood replacement therapy should be
initiated.
Urine output should be measured hourly
If the patient has a central venous pressure line or
pulmonary artery catheter in place, readings
should be recorded every 1 to 2 hours.
Hemodynamic monitoring provides an accurate
and quick assessment of blood flow and pressure
within the cardiovascular system
The patient with a history of
cardiovascular problems is observed
closely for signs of fluid overload.
Electrocardiographic (ECG) monitoring is
also used to evaluate cardiac function.
Auscultate the breath sounds and
closely observe the respiratory effort.
Assess the stools for presence of blood.
Monitor the patient's laboratory studies
to estimate the effectiveness of therapy
Initiate oxygen therapy
Evaluate the hemoglobin and hematocrit every 4 to
6 hours if the patient is actively bleeding.
When oral nourishment is begun, observe the patient
for symptoms of nausea and vomiting and a
recurrence of bleeding. Feedings initially consist of
clear fluids or milk and are given hourly until
tolerance is determined.
The patient in whom hemorrhage was the result of
chronic alcohol abuse requires close observation for
delirium tremens as withdrawal from alcohol takes
place. Symptoms indicating the beginning of delirium
tremens are agitation, uncontrolled shaking,
sweating, and vivid hallucinations
Teach the patient & family how to avoid future
bleeding episodes
 Nursing Diagnoses
Fluid volume deficit related to acute loss of
blood, as well as gastric secretions
Ineffective tissue perfusion related to loss of
circulatory volume
Decreased cardiac output related to loss of blood
Anxiety related to upper GI bleeding,
hospitalization, uncertain outcome, source of
bleeding
Ineffective coping related to situational crisis and
personal vulnerability
Risk for aspiration related to active bleeding and
altered level of consciousness