Approach to Upper Gastrointestinal Hemorrhage 
Mehret Dessalegn and Richard Davis 
OPEN ACCESS MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
Background:  
 
Upper gastrointestinal (GI) hemorrhage is 
one of the commonest causes of acute presentation 
to the emergency department. It is a bleed from any 
part of the GI tract proximal to the ligament of 
Treitz. Commonest sites are the distal esophagus, 
stomach and the 1 st and 2nd part of the duodenum. 
Potential causes of upper GI bleeding 
include esophageal or gastric varices, gastric or 
duodenal ulcers, Mallory-Weiss tear, vascular 
malformations (including Dieulafoy’s lesion,) and 
neoplasms.  
 
It is usually easy to distinguish between 
upper and lower GI bleeding; a history of 
hematemesis or epigastric pain usually indicate an 
origin proximal to the ligament of Treitz. However, 
hematochezia can originate from upper GI bleeding 
up to 15% of the time; if the bleeding is brisk enough 
it will still be bright red in color when it emerges 
from the anus. In such cases a nasogastric tube may 
be placed and the aspirate examined: if it is bilious 
without blood, an upper GI source is unlikely. If 
there is no output or the output is clear only, an upper 
GI hemorrhage has not been ruled out. This test is the 
only role of nasogastric tube placement in GI 
hemorrhage. Maneuvers such as cold water lavage, 
once thought to induce vasoconstriction, will only 
worsen hypothermia and coagulopathy.  
 
Upper GI hemorrhage is a life-threatening 
condition that requires immediate attention. Careful 
attention should be paid to airway, breathing and 
circulation, with immediate placement of two large-
bore IV cannulas. Interventions such as intubation, 
blood 
transfusion, 
urgent 
endsoscopy 
with 
intervention and large-bore central line placement 
are made as appropriate. Patients who are not treated 
immediately should be watched carefully in a 
monitored setting in case of rapid deterioration.  
 
 
Anatomy:  
 
Gastroesophageal Varices 
Varices are veins that are enlarged due to 
increased flow. In the case of hypertension at any 
part of the portal venous system, collaterals between 
the portal and systemic venous systems become 
enlarged and dilated due to increased flow. When 
these collateral veins are near to a mucosal surface, 
they bulge into the lumen of the organ. As pressure 
and flow increase they can bleed intermittently. 
Dilated vessels can be seen on upper endoscopy as 
esophageal or gastric varices, or on proctoscopy as 
enlargement of the hemorrhoidal venous plexi.  
 
Esophageal varices are raised columns of dilated veins that 
protrude into the lumen of the esophagus. Sites of recent 
bleeding appear as red dots at the center of the varices. These 
are also known as Red Wale spots. Source: 
https://en.wikipedia.org/wiki/Esophageal_varices 
 
Esophageal varices are caused by elevated 
pressure throughout the entire portal venous system: 
the collaterals in the esophageal submucosa enlarge 
as blood flows from the gastric (portal) venous 
system to the thoracic (systemic) venous system. 
Acute treatment is directed at locating and arresting 
the bleeding by applying a band directly to the site. 
Longer term treatment focuses on eliminating the 
varices altogether through repeated banding.  
Conversely, gastric varices are caused by 
obstruction and hypertension in one specific part of 
the portal system, usually the splenic vein. 
Collaterals in the fundus of the stomach enlarge as 
blood flows from the short gastric veins (portal 
system,) through the esophageal submucosal veins, 
into the thoracic (systemic) venous system. 
Esophageal varices are usually present as well due 
to increased flow. When the bleeding is from the 
gastric varices, one must not band the esophageal 
varices, as this can increase the pressure 
“downstream” in the gastric varices and lead to an 
increase in bleeding.  
 
Bleeding Gastric Ulcers 
Approach to Upper Gastrointestinal Hemorrhage 
Mehret Dessalegn and Richard Davis 
OPEN ACCESS MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
Gastric ulcers can be benign or malignant 
and thus should be biopsied at endoscopy if it is 
safe to do so. However, if the patient is presenting 
with acute upper gastrointestinal hemorrhage, 
biopsy should be deferred and endoscopic 
interventions to slow or stop the bleeding should be 
done if possible. Previous biopsy results, if 
available, are crucial to decision-making.  
 
Bleeding Duodenal Ulcers  
Duodenal ulcers in the anterior bulb, or the 
second or third portions of the duodenum, may 
bleed in the same manner as gastric ulcers. 
However, duodenal ulcers in the posterior bulb are 
prone to erode into the gastroduodenal artery and 
have the most dramatic and life-threatening 
presentations.  
 
Illustration showing the stomach and first portion of the 
duodenum reflected upwards. The Gastroduodenal artery (Red 
Arrow) passes posterior to the first portion of the duodenum, 
variably giving side branches to the pancreas. An ulcer of the 
posterior first portion of the duodenum which erodes into this 
artery and its branches will result in brisk, life-threatening 
hemorrhage.  
 
 
Posterior duodenal ulcer with ongoing bleeding. These may be 
difficult to visualize endoscopically, as they are often just 
inside the pylorus and obscured by it. Source: World J 
Gastroenterol 2015; 21(5): 1666-1669 
URL: https://www.wjgnet.com/1007-9327/full/v21/i5/1666.htm 
 
 
Patients may give a history of epigastric 
pain, previous treatment for ulcers, or a previous 
positive helicobacter pylori test. Abdominal 
examination is usually unrevealing although there 
may be epigastric tenderness.  
 
Dieulafoy and other vascular malformations 
Arterial and arterio-venous malformations 
are usually easy to visualize on endoscopy. One 
exception to this rule is a Dieulafoy lesion, an 
abnormally dilated mucosal arteriole which can be 
very difficult to visualize unless it is actively 
bleeding at the time of endoscopy. Occasionally 
there will be a small circular ulcer at the site. This 
lesion can be treated with endoscopic band ligation. 
Dieulafoy lesion should be suspected if endoscopy 
is completely unrevealing, but the hemorrhage is 
clearly from the upper GI tract.  
Approach to Upper Gastrointestinal Hemorrhage 
Mehret Dessalegn and Richard Davis 
OPEN ACCESS MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
Typical appearance of an actively bleeding Dieulafoy lesion. 
A small ulcer may be visible, or the blood may appear to be 
coming directly from normal mucosa. Source: World J 
Gastroenterol 2010; 16(5): 631-635 
 https://www.wjgnet.com/1007-9327/full/v16/i5/631.htm 
 
 
A non-bleeding Dieulafoy lesion may be seen as a small ulcer 
on the otherwise normal mucosa. Source: World J 
Gastroenterol 2020; 26(30): 4557-4563 
URL: https://www.wjgnet.com/1007-
9327/full/v26/i30/4557.htm 
 
Mallory-Weiss Tears 
These are superficial linear tears at the 
gastroesophageal junction caused by excessive 
vomiting. A careful history will sometimes elicit 
that vomiting was initially non-bloody and then 
turned bloody. Heavy alcohol users will often fail to 
mention drinking and subsequent vomiting 
episodes. The classic teaching is that bleeding from 
a Mallory-Weiss tear is self-limited, however in 
settings where endoscopic interventions are not 
available, the surgeon is occasionally forced to 
perform laparotomy and gastrotomy to oversew 
these lesions to control bleeding.  
 
Tumors 
Esophageal, gastric or duodenal tumors will 
rarely cause life-threatening hemorrhage that 
requires immediate intervention. However, it can be 
difficult to distinguish them from other life-
threatening conditions on presentation. Patients give 
a history of bloody sputum or hematemesis, and 
they can be severely volume depleted or even in 
shock due to poor fluid intake and blood loss. It is 
prudent to treat such patients urgently until other 
causes of upper GI hemorrhage are ruled out. Often 
these patients will respond to resuscitation and 
become stable after fluid and blood losses are 
replaced.  
 
Epistaxis  
Bleeding from the nose, nasopharynx, or 
other source above the upper esophageal sphincter 
may lead to swallowed blood which is then 
vomited. A clinician may then assume that the 
patient has an upper GI bleed. A careful history and 
physical examination can usually avoid this 
problem. Patients who have hematemesis after blunt 
trauma usually fall into this category, as blunt 
trauma never causes an immediate upper GI bleed.  
 
Principles:  
 
In patient presenting acutely with upper GI bleeding 
the overall clinical condition should be assessed and 
plan to control the bleeding as we continue to 
resuscitate the patient should ensue. 
 
● Assess the patient’s airway, respiratory and 
hemodynamic parameters continuously as you 
start resuscitation of the patient 
● Large bore IV opened bilaterally 
● Prepare either O negative blood or typed and 
cross-matched blood depending on the urgency 
● Alert the operating room team 
● When obtaining consult for endoscopy, obtain 
consent also for laparotomy.  
 
Decision Making: 
 
Immediate vs. Delayed Intervention 
Approach to Upper Gastrointestinal Hemorrhage 
Mehret Dessalegn and Richard Davis 
OPEN ACCESS MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
Appropriate resuscitation is mandatory. 
Patients present dramatically, with hemorrhagic 
shock and hematemesis that may be repetitive. Do 
give blood and fluids as the patient needs, but do not 
be tempted to over-resuscitate. The patient must be 
monitored for signs that bleeding has stopped and 
that resuscitation end-points have been met. This is 
especially true with elderly patients, or those with 
pre-existing heart disease. 
The most important decision to be made is 
whether the patient requires immediate intervention, 
or whether they can be integrated with the day’s 
elective endoscopy list. The best way to make this 
decision is to serially evaluate the patient during 
resuscitation. Patients who respond to initial fluid 
resuscitation and remain stable over the next 1-2 
hours may safely be admitted to a monitored setting 
and endoscopy done on an urgent but not emergent 
basis, unless they deteriorate again. Patients who do 
not respond to resuscitation, or who respond but then 
become hypotensive or tachycardic again, clearly 
have 
ongoing 
bleeding 
and 
need 
prompt 
intervention. Waste no time taking these patients to 
the endoscopy suite.  
Unstable patients and “transient responders” 
should be explained and provide informed consent 
for both endoscopy with intervention (see Chapter) 
and laparotomy and oversewing of bleeding gastric 
or duodenal ulcer (see Chapter.) Endoscopy should 
be done under general anesthesia, with as large a 
scope as possible, warm irrigation and well-
functioning suction all available.  
Endoscopic interventions are much less 
likely to succeed in resource-limited settings because 
of lack of equipment and expertise. The standard in 
a resource-rich setting is to operate after two failed 
endoscopic interventions. In our setting, we obtain 
informed consent for laparotomy in every patient 
going for an endoscopic intervention, and we 
perform laparotomy if the patient rebleeds after a 
single attempt at endoscopic intervention.  
 
Gastric Ulcers 
Gastric ulcers present a difficult challenge if 
their etiology is unknown. The surgeon in resource-
limited settings who is forced to operate on a 
bleeding (or perforated) gastric ulcer will decide 
whether to oversew the ulcer, excise it in a wedge, 
or perform a formal oncologic resection. This 
decision will likely be made without intraoperative 
pathology assistance. The surgeon must be guided 
by the gross appearance of the ulcer and 
surrounding tissue, a careful abdominal exploration 
for signs of metastasis, and the condition of the 
patient. It is acceptable to perform a non-oncologic 
resection on a patient in extremis, but suture lines 
through tissue that is infiltrated by tumor will be 
likely to leak. As explained below, the surgeon is 
much more likely to be faced with this difficult 
decision with a perforated, rather than a bleeding 
ulcer. However, if the surgeon is forced to operate 
on a bleeding gastric ulcer, it is crucial to 
understand exactly where it is when making the 
gastric incision. Once the stomach is opened, 
finding a small ulcer within the folds of mucosa can 
be difficult if one is unclear about exactly where it 
is located. 
Patients with a GI tract tumor that is clearly 
malignant, who present with hemorrhage, will 
usually respond to initial resuscitation. It is rare for 
such patients to remain unstable and to require 
emergency intervention. A careful history and 
physical examination will occasionally reveal the 
diagnosis. Symptoms that may distinguish these 
patients include dysphagia, postprandial vomiting 
prior to the onset of hemorrhage, and weight loss. 
Signs 
include 
palpable 
abdominal 
mass, 
supraclavicular or axillary lymph nodes, and 
temporal wasting. Such patients can usually be 
resuscitated, biopsied and staged, and then undergo 
the appropriate treatment without emergency 
intervention.  
 
Schistosomiasis 
On some occasions, patients with hepatic 
schistosomiasis will benefit from splenectomy and 
distal splenorenal shunt. Schistosomiasis is 
characterized by presinusoidal fibrosis, leading to 
preserved liver function in the presence of portal 
hypertension. Such patients can be expected to 
tolerate general anesthesia and some blood loss 
during surgery. This indication is the only one 
where we would recommend surgical treatment of 
portal hypertension.  
Nevertheless, this operation should not be 
performed acutely in patients presenting with 
variceal upper GI bleed; they should be managed as 
described here and this difficult operation deferred 
until it can be done electively. A shunt operation is 
extremely dangerous in a patient in hemorrhagic 
Approach to Upper Gastrointestinal Hemorrhage 
Mehret Dessalegn and Richard Davis 
OPEN ACCESS MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
shock. Also, at the time of presentation, the etiology 
of the varices, and the degree of underlying hepatic 
dysfunction, will be unclear. Splenectomy and distal 
splenorenal shunt are described elsewhere in this 
Manual. 
 
When There is no Endoscopy 
Flexible upper endoscopy is the mainstay of 
decision making in patients with upper GI bleeding. 
If one is forced to manage patients without 
endoscopy, the decision making is similar to that 
described above: patients who do not respond to 
resuscitation, or who respond only transiently, need 
immediate intervention. A careful history and 
physical examination are key to directing surgery, 
looking for signs and symptoms of ulcer disease, 
hepatic disease, or malignancy. Especially if you are 
forced to operate without an endoscopic diagnosis, it 
is worth taking time and discussing the history with 
the patient and family; the timing, character and 
chronicity of symptoms may provide important clues 
towards the diagnosis. 
Few 
guidelines 
exist 
for 
operative 
management of upper GI bleeding without an 
endoscopic diagnosis. At laparotomy, perform a 
thorough inspection and palpation, including 
opening and looking in the lesser sac, looking for 
dilated branches of the portal venous system and 
palpable induration in the stomach or duodenum. If 
there are no such signs, an anterior gastrotomy in the 
area of the body allows inspection of the stomach. 
Once the stomach is opened, it becomes a confusing 
mass of mucosal folds. Make the incision large 
enough to allow manipulation, 15cm is acceptable. 
Two Deaver or Maleable retractors held opposite 
each other, with headlight illumination, allows the 
surgeon to examine the fundus, gastroesophageal 
junction, body, antrum and pylorus. Be systematic; 
life threatening hemorrhage can come from a very 
small lesion such as a Mallory-Weiss tear or 
Dieulafoy’s lesion. If bleeding seems to be coming 
from the pylorus, a separate incision can be made 
over the distal antrum, extending through the pylorus 
into the duodenum, as described in the chapter, 
Gastrotomy and Duodenotomy for Bleeding Ulcer. 
 
A Deaver and a narrow malleable retractor, held opposite each 
other through a gastrotomy, allow a thorough and systematic 
exploration of the stomach.  
 
Unfortunately, there are no legitimate 
surgical options for bleeding esophageal varices. Do 
not attempt surgical heroics such as a Sugiura 
procedure or a portocaval shunt on a patient in 
extremis.  
(See following page for a description of a 
Resource-Rich setting resource.)  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Approach to Upper Gastrointestinal Hemorrhage 
Mehret Dessalegn and Richard Davis 
OPEN ACCESS MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas  
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License 
 
 
 
Mehret Enaro Dessalegn MBBS 
Fellow, Pediatric Surgery 
AIC Kijabe Hospital 
 
Richard Davis, MD FACS FCS(ECSA) 
Consultant General Surgeon 
AIC Kijabe Hospital 
 
March 2022 
Resource-Rich Settings 
 
Trans-Jugular Intra-Hepatic Stent placement (TIPS) has revolutionized management of portal hypertension in 
resource-rich settings. This is the placement, usually by an interventional radiologist, of a covered stent from 
inside the vena cava, through the liver parenchyma, to one of the branches of the portal vein. Placement of a 
TIPS allows direct decompression of the portal venous system without the need for general anesthesia, a 
laparotomy, and a vascular operation such as porto-caval shunt, on a patient with the severe comorbidities that 
come with portal hypertension. The introduction of TIPS has led to a virtual abandonment of surgical 
operations for portal hypertension, which were almost always high in morbidity and mortality.   
 
