# Upper GI Bleeding: Surgical Perspective
## Overview
Upper gastrointestinal bleeding (UGIB) originates proximal to the ligament of Treitz and remains a significant cause of morbidity and mortality, with an overall mortality of 2 to 10%. While endoscopy is the primary diagnostic and therapeutic modality, the general surgeon must understand the indications for operative intervention, the relevant surgical anatomy, and the definitive surgical procedures required when endoscopic and interventional approaches fail.
## Etiology
### Common Causes
**Peptic ulcer disease** is the most common cause, responsible for 35 to 50% of cases, with duodenal ulcers more common than gastric ulcers. **Esophagogastric varices** account for 10 to 20% and are associated with portal hypertension and cirrhosis. **Mallory-Weiss tears** (5 to 10%) are longitudinal mucosal tears at the gastroesophageal junction caused by retching. **Erosive gastritis and esophagitis** (10 to 15%) result from NSAIDs, stress, alcohol, or bile reflux. **Dieulafoy lesions** (1 to 5%) are abnormally large submucosal arterioles, usually located in the gastric fundus or body.
### Less Common Causes
Less frequent etiologies include angiodysplasia (arteriovenous malformations), gastric cancer, aortoenteric fistula (secondary post-aortic graft is far more common than primary), hemobilia (from trauma, iatrogenic injury, or tumor), hemosuccus pancreaticus (a pancreatic pseudoaneurysm eroding into the pancreatic duct), Cameron lesions (erosions at the diaphragmatic hiatus in large hiatal hernias), and Boerhaave syndrome (transmural esophageal perforation with bleeding).
## Initial Assessment and Resuscitation
### Hemodynamic Assessment
The severity of bleeding is determined by the nature of the blood loss -- hematemesis, melena, coffee-ground emesis, or hematochezia (which indicates massive UGIB when originating from an upper source). Signs of shock include tachycardia above 100 bpm, hypotension with systolic blood pressure below 90 mmHg, and orthostatic changes. Two large-bore IV access lines (16 to 18 gauge peripheral) should be placed immediately. Initial laboratory studies include type and crossmatch, CBC, BMP, coagulation studies, liver function tests, and lactate.
### Resuscitation
Crystalloid resuscitation is initiated first. A **restrictive transfusion strategy**, transfusing for hemoglobin below 7 g/dL (with a threshold of 8 to 9 g/dL for patients with active coronary disease), improves outcomes in UGIB. A massive transfusion protocol is activated for patients who remain hemodynamically unstable despite initial resuscitation. Coagulopathy should be corrected with FFP, platelets, vitamin K, or prothrombin complex concentrate as needed, and anticoagulants should be reversed when possible.
### Risk Stratification
The **Glasgow-Blatchford Score (GBS)** is a pre-endoscopy tool that identifies low-risk patients who may not require intervention; a score of 0 to 1 may support outpatient management. The **Rockall Score** is calculated post-endoscopy and predicts mortality and rebleeding. The **AIMS65 score** (Albumin below 3, INR above 1.5, Mental status alteration, SBP below 90, age above 65) predicts inpatient mortality.
## Medical Management
### Proton Pump Inhibitors
For high-risk ulcer stigmata identified at endoscopy, IV PPI bolus (pantoprazole 80 mg) followed by continuous infusion (8 mg/hour for 72 hours) is standard. This regimen reduces rebleeding, need for surgery, and mortality. Intermittent IV or oral PPI is acceptable for low-risk lesions.
### Variceal Bleeding -- Specific Measures
**Octreotide** (50 mcg IV bolus then 50 mcg/hour infusion) reduces splanchnic blood flow. **Prophylactic antibiotics** (ceftriaxone 1 g IV daily for 7 days) reduce rebleeding and mortality in cirrhotic patients. Over-resuscitation must be avoided, with a target hemoglobin of 7 to 8 g/dL, as over-transfusion worsens portal hypertension. **Balloon tamponade** with a Sengstaken-Blakemore or Minnesota tube serves as a temporary bridge to definitive therapy for uncontrolled variceal hemorrhage, with a maximum duration of 24 hours.
### H. pylori Testing and Treatment
All patients with peptic ulcer bleeding should be tested for *H. pylori*. Eradication reduces ulcer recurrence from approximately 60% to less than 5%. Standard triple therapy consists of a PPI plus clarithromycin plus amoxicillin (or metronidazole) for 14 days.
## Endoscopy
### Timing
**Urgent endoscopy** (within 12 hours) is indicated for hemodynamic instability, suspected variceal bleeding, or transfusion requirement. **Early endoscopy** (within 24 hours) is appropriate for all other UGIB. Very early endoscopy (within 6 hours) in stable patients has not been shown to improve outcomes.
### Forrest Classification
The Forrest classification guides management of peptic ulcers:
| Forrest Class | Description | Rebleed Risk (untreated) | Endoscopic Therapy |
|---------------|-------------|-------------------------|-------------------|
| Ia | Active spurting | ~90% | Yes |
| Ib | Active oozing | ~50% | Yes |
| IIa | Non-bleeding visible vessel | ~50% | Yes |
| IIb | Adherent clot | ~30% | Remove clot, treat underlying lesion |
| IIc | Flat pigmented spot | 5–10% | No |
| III | Clean-base ulcer | <5% | No |
**Forrest Ia** (active spurting) carries a 90% rebleed risk without treatment. **Forrest Ib** (active oozing) and **IIa** (non-bleeding visible vessel) each carry approximately 50% rebleed risk. **Forrest IIb** (adherent clot) has a 30% risk, **IIc** (flat pigmented spot) 5 to 10%, and **III** (clean-base ulcer) less than 5%.
### Endoscopic Therapy
Endoscopic therapy is indicated for high-risk stigmata (Forrest Ia, Ib, and IIa). **Combination therapy is superior to monotherapy**: injection (epinephrine) combined with thermal (bipolar cautery, heater probe) or mechanical (hemoclips) methods. A critical principle is that epinephrine injection alone is insufficient and must be combined with another modality. The over-the-scope clip (OTSC) is increasingly used for refractory or large ulcers. For Forrest IIb (adherent clot), targeted irrigation should be used to remove the clot, and the underlying stigmata treated. Forrest IIc and III lesions require no endoscopic therapy, only PPI therapy.
### Variceal Band Ligation
Endoscopic band ligation (EBL) is the first-line endoscopic therapy for esophageal varices, superior to sclerotherapy with fewer complications and lower rebleeding rates. Sessions are repeated every 2 to 4 weeks until variceal obliteration is achieved. Cyanoacrylate glue injection is used for gastric (fundal) varices.
## Interventional Radiology
### Angioembolization
Angioembolization is indicated when endoscopic therapy fails, when recurrent bleeding occurs after endoscopic therapy, or when massive hemorrhage precludes endoscopy. Detection requires an active bleeding rate of at least 0.5 mL/min. Superselective catheterization and embolization are performed using coils, gelfoam, or glue, with a success rate of 70 to 90%. The risk of ischemia or infarction is 5 to 10%, though duodenal ulcers carry lower risk due to their dual blood supply. For bleeding duodenal ulcers, the gastroduodenal artery (GDA) is embolized.
### TIPS
Transjugular intrahepatic portosystemic shunt (TIPS) is used for refractory variceal bleeding that fails endoscopic and medical therapy. It creates a portosystemic shunt to reduce portal pressure. Complications include hepatic encephalopathy (30 to 40%) and shunt stenosis or thrombosis. TIPS can serve as a bridge to liver transplantation in appropriate candidates.
## Surgical Management
### Indications for Surgery
Surgical intervention is indicated after two failed endoscopic attempts, for hemodynamic instability despite resuscitation requiring more than 6 units of pRBCs in 24 hours, for rebleeding after initial endoscopic hemostasis (especially with high-risk stigmata), for perforation or giant ulcers not amenable to endoscopic therapy, for aortoenteric fistula, and when a concurrent surgical indication such as malignancy exists.
### Surgical Procedures for Bleeding Peptic Ulcers
#### Bleeding Duodenal Ulcer
The standard approach is **duodenotomy with direct suture ligation**: a pyloroduodenotomy is performed, and the bleeding vessel (typically the GDA) is oversewn with a U-stitch using three-point ligation (proximal, distal, and transverse pancreatic branch). **Truncal vagotomy and pyloroplasty** can be added for definitive acid reduction, though this is less common in the PPI era. **Truncal vagotomy and antrectomy** has the lowest recurrence rate (1%) but the highest operative morbidity, with reconstruction via Billroth I (gastroduodenostomy) or Billroth II (gastrojejunostomy). In current practice, suture ligation alone with *H. pylori* eradication and PPI therapy is most commonly performed.
#### Bleeding Gastric Ulcer
Biopsy to exclude malignancy is mandatory in all cases. Options include ulcer excision or wedge resection with primary closure, or distal gastrectomy including the ulcer for large or suspicious lesions. The approach varies by ulcer location: Type I (lesser curve) ulcers are managed with antrectomy; Type II (body plus duodenal) and Type III (prepyloric) ulcers require antrectomy with vagotomy; and Type IV (proximal, high lesser curve) ulcers require subtotal gastrectomy or the Csendes procedure.
#### Giant Ulcers
Giant gastric or duodenal ulcers (greater than 2 cm) carry higher risks of bleeding, perforation, and malignancy, are more likely to require surgery, and have a higher mortality rate.
### Surgical Management of Variceal Bleeding
Surgical management of variceal bleeding is rarely performed in the era of TIPS and endoscopic therapy. The **portocaval shunt** (non-selective) is highly effective but carries a high encephalopathy rate. The **distal splenorenal shunt (Warren)** is selective and preserves hepatopetal portal flow. **Devascularization procedures** (Sugiura) involving esophageal transection and devascularization are reserved for situations where shunts and TIPS are not feasible. Liver transplantation is the definitive treatment for portal hypertension.
## Special Scenarios
### Aortoenteric Fistula
Secondary aortoenteric fistula (post-aortic graft) is far more common than primary. The classic presentation is a "herald bleed" -- a self-limited GI bleed that precedes massive exsanguination by hours to days. The third portion of the duodenum is most commonly involved. Diagnosis is made by CT with IV contrast showing perigraft air and loss of the tissue plane between graft and bowel, along with endoscopy. Treatment requires emergent surgery: graft excision, bowel repair, and extra-anatomic bypass (axillofemoral) or in-situ graft replacement.
### Dieulafoy Lesion
A Dieulafoy lesion is an aberrant submucosal arteriole (1 to 3 mm) that fails to undergo normal branching and tapering, usually located in the gastric fundus or body within 6 cm of the GEJ. Endoscopic therapy (hemoclips, band ligation, or thermal coagulation) is first-line. Surgery (wedge resection) is reserved for cases where endoscopic treatment fails.
Anatomical illustration of the arterial blood supply to the stomach and duodenum showing the celiac trunk branches (left gastric, splenic, common hepatic arteries), gastroduodenal artery giving rise to the superior pancreaticoduodenal artery, and the SMA giving rise to the inferior pancreaticoduodenal artery. Highlight the gastroduodenal artery as the most common source of bleeding in posterior duodenal ulcers, and the left gastric artery in lesser curve gastric ulcers. Show the dual blood supply to the duodenum.
Endoscopic images illustrating the Forrest classification of peptic ulcer bleeding: Ia (active spurting), Ib (active oozing), IIa (non-bleeding visible vessel), IIb (adherent clot), IIc (flat pigmented spot), and III (clean-base ulcer). Include the corresponding rebleeding risk percentage for each category and indication for endoscopic therapy.
Surgical illustration showing the technique of duodenotomy and three-point suture ligation of a bleeding posterior duodenal ulcer. Show the pyloroduodenotomy incision, exposure of the ulcer crater in the posterior duodenal wall, and placement of three sutures: proximal GDA, distal GDA, and transverse pancreatic branch. Include a cross-sectional detail showing the relationship of the ulcer to the gastroduodenal artery and pancreas.
## Clinical Pearls
A restrictive transfusion strategy targeting hemoglobin above 7 g/dL improves outcomes in UGIB; over-transfusion in variceal bleeding worsens portal pressure and increases rebleeding. Epinephrine injection alone is not adequate endoscopic therapy and must be combined with thermal or mechanical hemostasis. All patients with peptic ulcer bleeding should be tested for *H. pylori* and treated if positive, as eradication dramatically reduces recurrence. The posterior duodenal ulcer erodes into the gastroduodenal artery and is the most common cause of massive UGIB requiring surgery. After two failed endoscopic attempts, the surgeon should proceed to surgery or interventional radiology rather than continuing with repeated endoscopy. In suspected aortoenteric fistula, a "herald bleed" may precede massive hemorrhage by hours to days -- any GI bleed in a patient with a prior aortic graft is an aortoenteric fistula until proven otherwise. Prophylactic antibiotics with ceftriaxone in cirrhotic patients with variceal bleeding reduce infections, rebleeding, and mortality. A Glasgow-Blatchford Score of 0 to 1 identifies very low-risk patients who may be safely discharged with outpatient follow-up.
## References
- Laine L, Barkun AN, Saltzman JR, et al. ACG clinical guideline: Upper gastrointestinal and ulcer bleeding. *Am J Gastroenterol*. 2021;116(5):899-917.
- Barkun AN, Almadi M, Kuipers EJ, et al. Management of nonvariceal upper gastrointestinal bleeding: guideline recommendations from the International Consensus Group. *Ann Intern Med*. 2019;171(11):805-822.
- Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management. *Hepatology*. 2017;65(1):310-335.
- Villanueva C, Colomo A, Bosch A, et al. Transfusion strategies for acute upper gastrointestinal bleeding. *N Engl J Med*. 2013;368(1):11-21.