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Master
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Continous Medical
Education (CME)
Md Azhari
HOSPITAL KAJANG

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Clinical Case Master
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 68 / C/ Gentleman is admitted to the hospital with
CC: emesis of bright red blood.
 Patient reports that he was shopping when he
began throwing up blood at the store. He denies any
associated pain, melena, hematochezia, liver
disease, or prior episodes.
 Patient reports some lightheadedness with
standing, denies CP, SOB, visual disturbances.
 He is taking indomethicin for gout. Patient denies
abdominal pain, chest pain, cough and diarrhea.

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 PMHx:
Gout, HTN
He had a gout flare up while in the hospital 3 months
ago and was discharged home with a steroid taper. He
was prescribed Indomethacin 50 mg po q 8 hr prn pain
but he was taking it daily for the last month.
 PSHX: Nil
 Allergic Hx : NKA
 FAMILY Hx : Gout

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 Physical examination:
Alert and Concious, Lethargic, no stigmata of chronic
liver disease
Vital sign : BP – 104/70 PR-104 RR-26 T-37
Eyes: conjunctiva pale, no icterus
Chest: Clear
CVS: DRNM
Abdomen: Soff NT, No Organomegaly, +BS
Rectal: no stool

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Diagnosis??

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UPPER
GASTROINTESTINAL
BLEEDING

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Upper Gastrointestinal Master
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Bleeding
 UGIB – Bleeding from esophagus, stomach or
duodenum (Proximal to the Ligament of Treitz)
 Presentation
 Sx Anemia
 Haematemesis
 Coffee ground emesis
 Melena
 Hematochezia
 Hypovolumia & shock
 Nonspecific complaint ( dypsnea, abdominal cramps, chest
pain & fatigue)

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CAUSES % edit
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PEPTIC ULCER 50
MUCOSAL LESION (GASTRITIS, 30
DUODENITIS)
MALORY WEISS TEAR 5-10
VARICES 5-10
REFLUX ESOPHAGITIS 5

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Differential Diagnoses title style
Esophagus Gastric Duodenum Systemic
Varices Ulcer Ulcer Leukamia
Esophagitis Gastritis Aotoenteric Fistula Hemophilia
Tumour Gastric Varices Erosion of the Thrombocytopenia
Pancreatic tumor
Tumor(malignant & Coagulopathy
benign)
Dieulafoy’s Lesion Hereditary
Hemorrhagic
Telangiectasia
Mallory Weiss Tear

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Peptic Ulcer Disease title style
• Duodenal ulcer – epigastric pain, relieved by eating
• Gastric ulcer – epigastric pain, may precipitated by
food
• Exacerbation factors – stress, smoking, alcohol,
NSAIDS, steroids, hyperparathyroidism, Zollinger-
Ellison syndrome
• Diet history
*A perforated Ulcer Rarely Bleed And A bleeding Ulcer Rarely Perforates

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Esophageal Varices title style
 Portal hypertension
 Chronic liver disease
 Social history – alcohol
 Hemorrhoids, ascites, bleeding tendency
 Stigmata of chronic liver disease

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Resuscitation Master
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• Airway
- secure the airway
- Intubate if necessary
- Prevent risk of aspiration pneumonia
• Breathing
- give supplemental oxygen
- Monitor SpO2 > 96%

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• Circulation
-Insert 2 large bore branula (16G) on each arm.
-Consider CVP line in elderly with profound shock and
significant comorbid.
-Do blood i(x) for : FBC, LFT, clotting profile, GXM,
BUSE and creatinine, Glucose level.
-Give crystalloid (Normal Saline, Hartman).
-Give colloid infusion (Gelofusil) if in shock.
-Monitor vital signs. Do baseline ECG in elderly.

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Investigations title style
• FBC- Hb, platelet
• Coagulation profile
• RP
• LFT
• GXM
• Endoscopy
• ECG
• Chest X-ray

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Blood transfusion should be given if:
- systolic BP < 110 mmHg.
- Significant postural hypotension.
- Persistent tachycardia >110/min
- Initial Hb < 8g/dL
- Hb < 10 g/dL + CVs Disease
 Give FFP if INR >1.5 or PT is prolonged.
 Transfuse platelet if <50,000/mm3

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Endoscopy Master
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 Done after patient stable hemodynamically.
 For diagnostic, therapeutic and risk stratification.

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Forrest Classification For
Bleeding Peptic Ulcer
 Ia: Spurting bleeding
 Ib: Non spurting active bleeding
 IIa: Visible vessel (no active bleeding)
 IIb: Non bleeding ulcer with underlying clot (no
visible vessel)
 Ilc: Ulcer with hematin covered base
 III: Clean ulcer ground (no clot, no vessel)

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Malaysian Society Of Gastroenterology & Hepatology

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Risk of Rebleeding And Mortality In title style
Patients With Peptic Ulcer Bleeding
Endoscopic Risk of Mortality (%)
Finding Rebleeding (%)
Active Bleeding 55 11
Visible vessel 43 11
Adherent clot 22 7
Flat spot 10 3
Clean base 5 2

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Esophageal Varices Master
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The Japanese classification is the preferred grading scale
for the staging of oesophageal varices

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Gastric Varices Master
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Gastro-Esophageal Varices (GOV)
GOV 1 GOV 2
Isolated Gastric Varices (IGV)
IGV 1 IGV 2

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Classification of gastric varices is based on location, size
and endoscopic features of the varices
Gasroesophageal Varices (GOV) extend beyond the
gastro-oesophageal junction (OGJ) and are always
associated with oesophageal varices
 GOV Type I : The varices are a continuation of
oesophageal varices and extend for 2-5 cm below the
OGJ along the lesser curvature of the stomach.
 GOV Type II : The varices extend below the OGJ
towards the fundus of the stomach.

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Isolated gastric varices (IGV) : Gastric varices in
the absence of oesophageal
varices
 IGV Type I : The varices are located in the fundus
of the stomach and fall short of the cardia by a few
centimetres.
 IGV Type II: Include isolated ectopic varices and
can present anywhere in the stomach.

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Peptic Ulcer
Oesophageal / Gastric Varices.
Other causes.

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Endoscopic
Medical
Surgical

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Endoscopic Treatment edit
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1. Thermal 3. Mechanical title style
 · Heater probe  · Clips
 · Multipolar electrocoagulation  · Band Ligation
(BICAP,Gold Probe)  · Endoloops
 · Argon plasma coagulation  · Staples
 · Laser  · Sutures
2. Injection 4. Combination therapy
 · Adrenaline (1:10000)  · Injection plus thermal therapy
 · Procoagulants(fibrin  · Injection plus mechanical
glue,human thrombin) therapy
 · Sclerosants (ethanolamine, 1%
polidoconal)
 · Alcohol (98%)

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Medical treatment title style
 High dose PPI needs to be given.
 H.pylori eradication regime
 Pantoprazole 40 mg bd
 Amoxycillin 1 gm bd 1/
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 Clarithromycin 500 mg bd

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Surgical Treatment Master
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INDICATION
• Bleeding cannot be control endoscopically
• Failure conservative therapy
• Malignancy cannot be excluded or suspected

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GASTRIC ULCER edit
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 Billroth I gastrectomy ( distal ulcer )
 Billroth II gastrectomy ( proximal ulcer)

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DUODENAL ULCER title style
 Partial gastrectomy (Polya or Billroth II)

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COMPLICATIONS title style
Early complications
 Hemorrhage
 Suture line leakage - peritonitis

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Intermediate complications (for title style
gastrtic resection)
 Vomiting
 Dumping
 Diarrhoea
 General nutritional effects
 Anaemia – megaloblastic anaemia ( def B12 and folate )

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Late complications
 Carcinoma
 Cholelithiasis

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Esophageal Varices
Gastric Varices

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Esophageal Varices title style
1-Resuscitation
2-Pharmacotherapy
IV Terlipressin: 2mg bolus and 1mg every 6 hours for 2-5 days
IV Somatostatin: 250mcg bolus followed by 250mcg/hour infusion
for 5 days
IV Octreotide: 50mcg bolus followed by 50mcg/hour for 5 days
Metoclopramide - constrict lower oesohageal sphincter and empty the stomach

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3-Antibiotic prophylaxis in patients with
cirrhosis
Norfloxacin 400mg bd
/ Ciprofloxacin 500mg bd
/ IV 200mg bd 1/
/ Third generation cephalosporins 52
(e.g. Ceftriaxone 1g daily)
4-Upper GI Endoscopy
- As soon as possible
-If endoscopy is unavailable and there is presence of active
bleeding, consider balloon tamponade and referral to tertiary centre

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5-Control of Bleeding
-Endoscopic variceal ligation (EVL) is recommended
-Endoscopic sclerotherapy can be used if EVL is
technically difficult
6-Persistent Active Bleeding
-Consider repeating endoscopy, TIPS or surgical
intervention
-Balloon tamponade may be considered

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Secondary PROPHYLAXIS
-Non-selective beta-blockers, EVL or both should be
used Rx offirst choice
• Propanonol 20mg bd stat and increase to 40-80 mg tds until resting HR is
reduced by 25%
-TIPS or shunt surgery if non-compliant or refractory to
pharmacological and/or endoscopic therapy

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Gastric Varices title style
GOV Type 1
Treat as for oesophageal varices
GOV Type 2 and IGV
- For acute bleeding: injection with cyanoacrylate
-If persistent active bleeding
• TIPS or surgical intervention
• Balloon tamponade should be considered
-Secondary prophylaxis
• Beta-blockers, injection with cyanoacrylate or TIPS

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ALGORITHM: MANAGEMENT OF ACUTE VARICEAL BLEEDING

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Sengstaken-Blakemore Tube title style
 Indication
-bleeding from oesophagus or gastric varices that
fails medical treatment or endoscopic heamostasis
failed or unavailable.
 Contraindication
 Variceal bleeding stops or slows
 Recent surgery that involved the esophagogastric
junction
 Known esophageal stricture

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Steps edit
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• Positioning- 45⁰ / left lateral decubitus
• Analgesia- spray / jelly
• Check balloons
• Estimate length
• Lubricant
• Insert the tube preferably through mouth but can
also thorough nostril.
• Suction of gastric content
• Inflate gastric balloon (450-500mL water)

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• Secure proximal end using traction device (0.45-
0.91 kg) or use 500mL bag of IV fluid or use
football helmet
• Inflate oesophageal balloon (30-45mmHg air)
• If bleeding persist increase external traction
(max 1.1kg)
• If bleeding controlled  deflate oesophagus
balloon by 5mmHg every 4-6hrs for 5-10 minutes
maintain 12-24 hrs remove

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• If bleeding recurs reinflate gastric ballon ± Master
oesophageal balloon for another 24 hrs title style
• If fail consider :
• Stapled oesophago-gastric junction
• Portosystemic shunting/ tranjugular
intrahepatic portosystemic stent
shunting (TIPSS)
• Liver transplant

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Treatment for Other edit
Master
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Causes
• Mallory Weiss tear:
- endoscopic adrenaline injection, thermal,clip.
• Dieulafoy’s tear:
- Injection, band ligation, thermal method.
• Vascular malformation/telangiectasias:
- Heater probe, APC

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