Upper GI bleed

Chew Yongzhi
Firman Khan
 Upper GI bleeding

● Acute gastrointestinal bleeding is a potentially life-threatening

abdominal emergency and remains a common cause of
hospitalization.
● Upper gastrointestinal bleeding (UGIB) is defined as bleeding
derived from a source proximal to the ligament of Treitz.
● Upper gastrointestinal bleeding (UGIB) is a common problem
with an annual incidence of approximately 80 to 150 per 100,000
population, with estimated mortality rates between 2% to 15
*UGIB is 4 times as common as bleeding from lower GIT, with a
higher incidence in male.
Initial evaluation of patients with acute UGIB involves an assessment of hemodynamic stability and resuscitation

Diagnostic studies ( i.e endoscopy ) follow, with the goal of diagnosis and treatment

Goal of the evaluation with history taking, physical examination, laboratory tests is to access the severity of the bleed, identify potential
sources of bleed, and determine if there are conditions present that may affect subsequent management

Presence of frankly blood emesis suggests moderate to severe bleeding that may be ongoing, coffee ground emesis suggest more
limited bleeding

GI bleeding due to esophageal or gastric varices and peptic ulceration carry the highest mortality. Need to have Exclusion of other
bleeding sources ( pulmonary and intranasal sources )

Non- variceal bleed - Peptic ulcer disease

- Acute erosive gastritis
- Carcinoma of stomach and
esophagus
- Mallory- weiss syndrome
- Bleeding disorders
- Oesophagitis
- Angiodysplasia

Variceal bleed - complication of end stage Portal hypertension

liver disease.
Approach on Gastrointestinal bleed
Upper GI bleed Lower GI bleed

Site Proximal to ligament of Distal to ligament of Treitz

Treitz

History Haematemesis, melena Haematochezia

Nasogastric aspiration Blood present Blood not present

Causes Duodenal causes:
Esophageal causes:
- Duodenal ulcer
-Esophageal varices - Vascular malformation
- Esophagitis including
- Esophageal cancer aorto-enteric fistulae
- Esophageal ulcers - Hematobilia, or bleeding
- Mallory-Weiss tear from the
biliary tree
Gastric causes: - Hemosuccus
- Gastric ulcer pancreaticus, or
- Gastric cancer bleeding from the
- Gastritis pancreatic duct
- Gastric varices - Severe superior
- Dieulafoy's lesions mesenteric artery
syndrome
Erosive or ● Peptic ulcer disease (∼ 30% of cases)
inflammatory ● Esophagitis
● Erosive gastritis and/or duodenitis

Vascular ● Esophageal varices or gastric varices

● Gastric antral vascular ectasia: a dilation of small blood vessels in the antrum
● of the stomach
● Dieulafoy lesion: minor mucosal trauma to an abnormal submucosal artery
(usually located in the proximal stomach) leads to major bleeding (acute upper
GI bleeding)
○ It can be hard to visualize a Dieulafoy lesion on endoscopy because
it is missing an ulcer base.
○ Treatment includes endoscopic hemostasis (injection therapy,
hemoclips, etc.) or excision of the susceptible mucosa

Tumors ● Esophageal cancer

● and/or gastric carcinoma

Traumatic or ● Hiatal hernias

iatrogenic ● Mallory-Weiss syndrome
● Boerhaave syndrome

Other causes ● Portal hypertensive gastropathy

● Coagulopathies
Clinical Presentation
Hematemesis: vomiting of blood. Vomitus may contain digested blood
in the stomach (coffee-ground emesis that indicate slower rate of bleeding) or fresh/unaltered blood
(gross blood and clots, indicates rapid bleeding)

Melena: stool consisting of partially digested blood (black tarry, semi solid, shiny and has a distinctive
odor, when its present indicative that blood has been present in the GI tract for at least 14 hours.
The more proximal the bleeding site, the more likely melena will occur.

***Hematochezia usually represents a lower GI source of bleeding, although an upper GI lesion may bleed so
briskly that blood does not remain in the bowel long enough for melena to develop.
 Description Cause

Hematemesis ● Vomiting blood, which may be red ● Most commonly due to bleeding
or coffee-ground in appearance in the upper GI tract (e.g.,
esophagus, stomach)

Melena ● Black, tarry stool with a strong ● Most commonly due to bleeding
offensive odor in the upper GI tract
● Can also occur in bleeding from
the small bowel or the right
colon

Hematochezia ● The passage of bright red (fresh) ● Most commonly due to bleeding
blood through the anus in the lower GI tract (e.g., in the
● (with or without stool) distal colon
○ Colonic bleeding:
maroon, jelly-like traces
of blood in stools
○ Rectal bleeding: streaks
of fresh blood on stools
History Taking
History:
• Abdominal pain
• Haematamesis
• Haematochezia
• Melena
• Features of blood loss: shock, syncope,
anaemia
• Features of underlying cause: dyspepsia,
dysphagia, weight loss
Drug history: NSAIDs, Aspirin, corticosteroids, anticoagulants, (SSRIs) particularly fluoxetine and
sertraline.
• History of epistaxis or hemoptysis to rule out the GI source of bleeding.
• Past medical : previous episodes of upper gastrointestinal bleeding, diabetes mellitus,
coronary artery disease, chronic renal or liver disease or chronic obstructive pulmonary disease.
• Past surgical: previous abdominal surgery
Pathophysiology of common
causes of upper GI bleeding.
Duodenal/ gastric ulcer
 Erosions

● Esophageal erosion signifies the gradual deterioration of the

esophagus
● Commonly caused by GERD/ Esophagitis
Esophageal varices

extremely dilated sub-mucosal

veins in the lower third of the
esophagus. They are most often
a consequence of portal
hypertension, commonly due to
cirrhosis
 Mallory-Weiss syndrome

Caused by any conditions which causes violent vomiting and

retching
Management
1.The goal of medical therapy in upper gastrointestinal bleeding (UGIB) is to correct shock and
coagulation abnormalities and to stabilize the patient so that further evaluation and treatment
can proceed.
2.Resuscitation of a hemodynamically unstable patient begins with assessing and addressing
the ABCs
-haematemesis and patients with altered mental status require airway protection.
Preparation for endoscopy
3.intravenous access must be obtained. Bilateral, 16-gauge (minimum), upper extremity,
peripheral intravenous lines are adequate for volume resuscitative efforts.

Fluid resuscitation
- Colloid or crystalloids solution should be used to maintain blood pressure more than 100
mmHg systolic.
- Volume required is in 3:1 ratio
- Blood transfusion to be necessary if active haematemesis and haemarrhagic shock.
PPI
- The relative efficacy of the PPIs may be due to their superior ability to maintain a gastric pH
at a level above 6.0 and cause acid suppression thereby protecting an ulcer clot from
fibrinolysis. The ideal pharmacologic therapy for patients with acute ulcer bleeding appears to
be an intravenous PPI

Somatostatin and analogs

-decreased gastric acid and pepsin

Prokinetic agents
-improves gastric visualisation 3mg/kg IV erythromycin over 20-30 minutes prior to endoscopy

Antibiotics
-reduces mortality in patients who develop acute upper GI bleeding + chronic liver disease.
-IV 3rd generation cephalosporin (ceftriazone and ciprofloxacin)
Endoscopic and surgical management of bleeding peptic ulcer.

● Peptic ulcer disease is the most common cause of upper gastrointestinal (GI) bleeding. In most of the cases,
bleeding from a peptic ulcer stops spontaneously. Arterial diameters in bleeding ulcers can measure up to 3.45 mm,
but in most cases the diameter of the bleeding artery is small (< 2 mm).

High-dose intravenous proton pump inhibitors after endoscopic therapy for a bleeding ulcer reduce recurrent bleeding risk
and surgery

● Nature of the blood loss can preclude accurately in identifying the lesion
● Diagnosis can be made endoscopically

Major stigmata of hemorrhage (an adherent clot, a visible vessel, or active bleeding) are associated with high rebleeding
risks. Endoscopic treatment in patients with high-risk stigmata results in improved outcomes. Common endoscopic
techniques and the devices used to treat upper GI ulcer bleeding, including injection therapy, thermal coagulation, endoclip
application, and hemostatic powder spray
Indication for surgery is confined to the following cases:, failure to stop bleeding endoscopically, and to prevent further
life‐threatening rebleeding, particularly in high‐risk patients.

The surgical procedures for a bleeding peptic ulcer can generally be classified into minimal or definitive approaches.

● The sole achievement of surgical ulcer hemostasis is a minimal approach, includes under‐running the ulcer (so‐called
simple intraluminal ligature or undersewing), plication, or an ulcerectomyand may also include ligation of the vessel
around the stomach or duodenum
● whereas the addition of acid reduction procedures is classified as a definitive approach. Also includes local
procedures for primary hemostasis with either vagotomy and pyloroplasty or a partial or total gastrectomy.
ROLE OF ENDOSCOPY IN UPPER GI
BLEEDING
DIAGNOSTIC THERAPEUTIC

1. Allows excellent visualization of the The source of UGIT bleeding may be

mucosa of oesophagus, stomach and treated endoscopically via:
duodenum
a. Mechanical therapy – e.g. hemoclip,
1. Allow us to determine the site and bands
source of bleeding
a. Injection therapy – with sclerosants or
1. Allow us to diagnose unusual sources epinephrine
and causes of bleeding
a. Thermal coagulation
1. Allow us to obtain biopsy samples for
histological examination (H.pylori) a. Combination
Most of the bleeding occurs in duodenum

Definitive approach

1. The duodenum should be fully mobilised before it is opened.

● Makes the ulcer much more accessible
● The surgeon can place his hand behind the gastroduodenal artery (source of major bleeding)
1. Following mobilisation, the duodenum & usually the pylorus are opened longitudinally as in pyloroplasty → to achieve
good access to ulcer (found posteriorly or superiorly)
2. Bleeding is from the vessel inside the ulcer. It should be controlled with → well-placed sutures that under-run the
vessel
3. Following under-running, mucosa over the ulcer is closed.
4. The pyloroplasty is closed with interrupted sutures in a transverse direction.
5. Management of gastric ulcers is the same as that of duodenal ulcers.
6. The stomach is opened anteriorly and the vessel in the ulcer under-run.
7. If the ulcer is not excised → perform biopsy of edge → to exclude malignancy
8. Sometimes bleeding can be from splenic artery
● → If there is a lot of fibrosis, operation can be challenging
Oesophageal varices
From: https://healthjade.com/esophageal-varices/

Duodenal Ulcer
https://library.med.utah.edu/WebPath/GIHTML/GI2
56.html
Surgical approach to the management of portal hypertension

Surgical shunts

● Prevent rebleeding
● Reduce pressure in portal circulation by diverting blood into the low-pressure systemic circulation

Oesophageal stapled transection

● Use a stapling device

● Staple and resect the donut ring of the lower oesophagus

Endoscopic Sclerotherapy

● Inject a scleroscent agent into the varices using a freehand technique

HEMOCLIP
Injection therapy

https://www.jhmicall.org/GDL_Disease.aspx?CurrentUDV=31&
GDL_Cat_ID=AF793A59-B736-42CB-9E1F-
E79D2B9FC358&GDL_Disease_ID=80AD1118-6659-4B04-
Thermal Coagulation
Oesophageal balloon tamponade

● Sengstaken-Blakemore tube is inserted

● Gastric balloon inflated with 300ml of air & retracted to fundus
● Oesophageal balloon inflated to a pressure of 40mmHg
● Two channels allow gastric & oesophageal aspiration
● Radiograph confirms position of the tube
● Balloons are deflated after 12hrs to prevent pressure necrosis of oesophagus
Transjugular intrahepatic portosystemic stent shunts (TIPSS)

● Indicated for:

● Varices not responding to drug and endoscopic therapy , Child’s B or C cirrhosis

● Shunts are inserted under local anaesthetic, analgesia & sedation using fluoroscopic guidance & ultrasonography
● Guidewire is inserted via Internal Jugular vein and Superior vena cava
● Towards hepatic vein → hepatic parenchyma → branch of portal vein
● Track through parenchyma is dilated with a balloon catheter to allow insertion of metallic stent
OTHER TREATMENTS

a. Transgastric oesophageal stapling

a. Porto-systemic shunting operations

- High mortality and morbidity
- Selective shunts (splenorenal) or Non-selective (portocaval)

c. Liver transplant
Statistics in Hospital Seberang Jaya

Based on OGDS done in HSJ in 2021:

Total cases of 502 was done, further divide into:
Epigastric pain = 224 Others included:
Heartburn
Esophageal varices = 71 Anemia
Gastric ulcer = 48 HCV
Coffee ground vomiting
Malaena = 47
Duodenal ulcer = 47
Dysphagia = 18
Statistics in Hospital Seberang Jaya

According to data given in HSJ from 2013 – 2022:

Gastric cancer cases:
● Total = 123
● Chinese = 46, Malay = 34, Indians = 33, Others = 7
● Total death : Indians 8, Malay = 3, Chinese = 0
Esophageal varices with bleeding:
● Total cases = 157
● Malay = 85, Chinese = 34, Indian = 23, Others = 15
● Total deaths : Malay = 23, Indian = 9, Chinese = 2, Others = 2

Mallory Weiss tear

● Total cases = 42
● Malay = 34, Indian = 22, Chinese = 13, Others = 3
● No death recorded
Gastric ulcer:
● Total = 190
● Malay = 112, Chinese = 111, Indians = 47, Others = 20
● Total deaths : Chinese = 5

Duodenal ulcer:
● Total = 132
● Malay = 62, Chinese = 54, Indian = 9, Others = 7
● Total deaths: Malay = 10

Diuelafoy’s lesion
● Total = 60
● Chinese = 41, Malay = 16, Indians = 2, Others = 1
● Total deaths: Chinese = 7
Statistics in Hospital Seberang Jaya
PATIENT_AGE_GROUP_ PATIENT_ETHNICITY_NAM
DIAGNOSIS DISCH_TYPE_DESC PATIENT_GENDER 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 NO_OF_DIAGNOSIS
5YEAR E
Bukan Warganegara Balik Ke Rumah LELAKI 0 0 0 1 0 1 0 0 0 0 2
30 - 34 years
India Balik Ke Rumah LELAKI 0 0 0 0 0 4 0 0 0 0 4
Engkar Nasihat Doktor
Bukan Warganegara (DAMA) / Dengan Risiko LELAKI 0 1 0 0 0 0 0 0 0 0 1
Sendiri (AOR)
35 - 39 years India Dipindah Ke Fasiliti Lain PEREMPUAN 0 0 0 0 0 0 1 0 0 0 1
Engkar Nasihat Doktor
Melayu (DAMA) / Dengan Risiko LELAKI 0 0 0 0 0 0 0 0 0 1 1
Sendiri (AOR)
India Balik Ke Rumah PEREMPUAN 0 0 0 0 0 0 2 2 0 0 4
40 - 44 years LELAKI 0 1 0 0 0 0 0 0 0 0 1
Melayu Balik Ke Rumah
PEREMPUAN 0 0 2 0 0 0 0 0 0 0 2
Cina Dipindah Ke Fasiliti Lain PEREMPUAN 0 0 1 0 0 0 0 0 0 0 1
45 - 49 years Balik Ke Rumah PEREMPUAN 0 0 1 0 0 0 0 0 0 0 1
Melayu
Dipindah Ke Fasiliti Lain PEREMPUAN 0 0 1 0 0 0 0 0 0 0 1
LELAKI 1 0 0 0 0 0 0 0 0 0 1
Balik Ke Rumah
50 - 54 years Melayu PEREMPUAN 0 0 0 0 0 0 1 0 0 0 1
Dipindah Ke Fasiliti Lain PEREMPUAN 0 0 0 0 0 0 1 0 0 0 1
Cina Balik Ke Rumah LELAKI 0 0 0 0 0 2 0 5 0 0 7
India Balik Ke Rumah LELAKI 1 0 0 0 0 0 0 0 0 0 1
55 - 59 years
LELAKI 0 1 0 0 0 0 0 0 0 0 1
Melayu Balik Ke Rumah
PEREMPUAN 0 1 0 0 0 0 0 0 0 0 1
Dipindah Ke Fasiliti Lain PEREMPUAN 0 1 0 0 0 0 0 0 0 0 1
Cina LELAKI 2 0 0 0 0 0 0 0 0 0 2
Mati
PEREMPUAN 2 0 0 0 0 0 0 0 0 0 2
Lain-lain Balik Ke Rumah LELAKI 0 0 0 0 1 0 0 0 0 0 1
Gastric cancer
60 - 64 years Balik Ke Rumah LELAKI 0 1 0 1 0 0 0 0 0 2 4

Melayu LELAKI 0 0 0 0 0 0 0 2 0 0 2
Dipindah Ke Fasiliti Lain

PEREMPUAN 0 0 0 0 0 0 0 1 0 0 1
LELAKI 0 0 0 0 0 0 0 0 3 0 3
Balik Ke Rumah
Cina PEREMPUAN 1 0 0 0 0 0 0 0 0 0 1
Dipindah Ke Fasiliti Lain PEREMPUAN 0 0 0 0 0 0 5 0 0 0 5
Balik Ke Rumah LELAKI 0 0 0 0 0 0 0 8 0 0 8
65 - 69 years India
Dipindah Ke Fasiliti Lain PEREMPUAN 0 0 1 0 0 0 0 0 0 0 1
LELAKI 0 0 2 0 0 0 0 0 6 0 8
Balik Ke Rumah
Melayu PEREMPUAN 0 0 0 0 1 0 0 0 0 0 1
Dipindah Ke Fasiliti Lain PEREMPUAN 0 0 0 0 0 0 4 0 0 0 4
Balik Ke Rumah LELAKI 0 0 0 1 0 0 0 0 0 0 1
Cina Dipindah Ke Fasiliti Lain PEREMPUAN 0 0 1 0 0 0 0 0 0 0 1
70 - 74 years Mati PEREMPUAN 0 0 0 2 0 0 0 0 0 0 2
LELAKI 0 0 0 0 0 0 1 0 0 0 1
India Balik Ke Rumah
PEREMPUAN 0 0 0 0 0 0 0 0 0 7 7
LELAKI 5 0 0 0 5 4 0 0 0 0 14
Balik Ke Rumah
PEREMPUAN 1 0 0 0 0 0 0 0 0 0 1
Cina
Dipindah Ke Fasiliti Lain LELAKI 1 0 1 0 0 0 0 0 0 0 2
Mati LELAKI 0 2 0 0 0 0 0 0 0 0 2
75 - 79 years
India Balik Ke Rumah PEREMPUAN 0 0 0 0 0 0 0 0 6 0 6
Balik Ke Rumah PEREMPUAN 0 0 0 2 0 0 0 0 0 0 2
Melayu Dipindah Ke Fasiliti Lain PEREMPUAN 0 0 0 0 0 0 0 0 0 3 3
Mati LELAKI 0 0 0 0 0 3 0 0 0 0 3
 25 - 29 years Melayu Balik Ke Rumah PEREMPUAN 0 1 0 0 0 0 0 0 0 0 1
30 - 34 years Bukan Warganegara Balik Ke Rumah LELAKI 0 0 0 0 0 0 0 2 0 0 2
India Balik Ke Rumah LELAKI 0 0 0 0 0 0 0 0 1 0 1
35 - 39 years
Melayu Balik Ke Rumah LELAKI 0 0 0 0 0 3 3 0 0 0 6
Bukan Warganegara Balik Ke Rumah LELAKI 0 0 0 0 3 0 0 0 0 4 7
Dipindah Ke Fasiliti Lain LELAKI 0 0 0 0 0 0 6 0 0 0 6

Engkar Nasihat Doktor (DAMA)

India LELAKI 0 0 1 0 0 0 0 0 0 0 1
40 - 44 years / Dengan Risiko Sendiri (AOR)

Mati LELAKI 0 0 0 0 7 0 0 0 0 0 7
Balik Ke Rumah LELAKI 0 0 0 0 0 0 2 0 2 0 4
Melayu
Mati LELAKI 2 0 0 0 0 0 0 0 0 0 2
Bukan Warganegara Mati LELAKI 0 0 2 0 0 0 0 0 0 0 2
Cina Balik Ke Rumah LELAKI 0 0 0 0 0 0 0 0 0 3 3
45 - 49 years
India Balik Ke Rumah LELAKI 0 0 0 0 0 0 0 0 0 1 1
Melayu Balik Ke Rumah LELAKI 2 0 0 0 0 0 0 0 5 0 7
Cina Balik Ke Rumah LELAKI 0 0 0 0 0 0 2 0 0 0 2
50 - 54 years Balik Ke Rumah LELAKI 1 1 0 0 0 5 0 3 4 2 16
Melayu
Mati LELAKI 0 0 0 0 2 0 0 0 0 0 2
Cina Balik Ke Rumah LELAKI 0 0 0 0 0 2 0 0 0 5 7
India Mati LELAKI 0 0 2 0 0 0 0 0 0 0 2
55 - 59 years
Balik Ke Rumah LELAKI 0 1 0 0 0 4 0 0 0 0 5
Oesophageal varices with bleeding Melayu
Mati LELAKI 0 0 0 0 4 0 0 0 0 0 4
LELAKI 0 0 0 0 4 0 0 0 0 0 4
Balik Ke Rumah
Cina PEREMPUAN 0 0 0 0 3 0 0 0 0 0 3
Mati LELAKI 0 0 0 2 0 0 0 0 0 0 2
India Balik Ke Rumah PEREMPUAN 0 0 0 0 0 0 0 0 5 0 5
LELAKI 0 0 1 0 0 0 0 0 0 0 1
60 - 64 years Balik Ke Rumah
PEREMPUAN 0 0 0 0 2 0 0 5 0 0 7

Melayu Engkar Nasihat Doktor (DAMA)

LELAKI 0 0 0 0 1 0 0 0 0 0 1
/ Dengan Risiko Sendiri (AOR)

Mati LELAKI 0 0 0 2 0 0 0 0 0 0 2
Cina Balik Ke Rumah PEREMPUAN 0 0 0 0 0 0 0 0 3 0 3
Lain-lain Balik Ke Rumah LELAKI 0 0 0 0 0 4 0 0 0 0 4
65 - 69 years LELAKI 0 0 0 0 0 1 0 0 2 0 3
Balik Ke Rumah
Melayu PEREMPUAN 0 0 0 0 5 0 0 0 0 0 5
Mati PEREMPUAN 2 0 0 0 0 0 0 0 0 0 2
Balik Ke Rumah PEREMPUAN 0 0 0 0 0 0 5 0 0 0 5
70 - 74 years Melayu LELAKI 0 0 0 0 0 3 0 0 0 0 3
Mati
PEREMPUAN 0 0 0 0 0 0 0 0 0 6 6
Cina Balik Ke Rumah PEREMPUAN 0 0 0 0 0 0 2 8 0 0 10
75 - 79 years Balik Ke Rumah LELAKI 0 0 1 0 0 0 0 0 0 0 1
Melayu
Mati PEREMPUAN 0 2 0 0 0 0 0 0 0 0 2
 LELAKI 0 0 0 0 0 0 0 0 1 0 1
< 1 year Melayu Balik Ke Rumah
PEREMPUAN 0 0 0 0 0 0 0 5 0 0 5
Cina Balik Ke Rumah PEREMPUAN 0 0 1 0 0 0 0 0 0 0 1
India Balik Ke Rumah LELAKI 0 0 0 0 1 0 0 0 0 0 1
1 - 4 years
LELAKI 0 0 2 0 0 0 0 0 0 0 2
Melayu Balik Ke Rumah
PEREMPUAN 0 0 0 0 0 0 0 0 0 3 3
Cina Balik Ke Rumah PEREMPUAN 0 0 0 0 0 0 2 0 0 0 2
5 - 9 years
Melayu Balik Ke Rumah PEREMPUAN 0 0 2 0 1 0 0 1 0 0 4
LELAKI 0 0 0 1 0 0 1 0 0 0 2
10 - 14 years Melayu Balik Ke Rumah
PEREMPUAN 0 0 0 0 0 0 2 0 0 2 4
Cina Balik Ke Rumah LELAKI 0 1 0 0 0 0 0 0 0 0 1
15 - 19 years
Melayu Balik Ke Rumah PEREMPUAN 0 0 0 0 0 0 0 0 0 3 3
Bukan Warganegara Balik Ke Rumah LELAKI 1 0 0 0 0 0 0 0 0 0 1
LELAKI 0 0 0 0 0 1 0 0 0 0 1
Balik Ke Rumah
PEREMPUAN 0 0 0 2 0 1 0 0 0 0 3
20 - 24 years
Melayu
Engkar Nasihat Doktor
(DAMA) / Dengan Risiko PEREMPUAN 1 0 0 0 0 0 0 0 0 0 1
Mallory Weiss tear Sendiri (AOR)

Cina Balik Ke Rumah PEREMPUAN 0 0 0 0 1 0 0 0 0 0 1

25 - 29 years
Melayu Balik Ke Rumah LELAKI 0 0 0 1 0 0 0 0 0 0 1
Bukan Warganegara Balik Ke Rumah LELAKI 0 0 1 0 0 0 0 0 0 0 1
30 - 34 years Cina Balik Ke Rumah PEREMPUAN 0 0 1 0 0 0 0 0 0 0 1
India Balik Ke Rumah LELAKI 0 0 0 0 0 1 0 0 0 0 1
Bukan Warganegara Balik Ke Rumah PEREMPUAN 0 0 0 0 0 1 0 0 0 0 1
Cina Balik Ke Rumah PEREMPUAN 1 0 0 0 0 0 0 0 1 0 2
35 - 39 years
LELAKI 0 0 0 0 0 0 0 2 0 0 2
Melayu Balik Ke Rumah
PEREMPUAN 0 0 0 0 0 0 2 0 0 0 2
Cina Balik Ke Rumah PEREMPUAN 0 0 0 0 0 0 0 2 0 0 2
40 - 44 years Balik Ke Rumah LELAKI 0 0 0 0 0 0 1 0 0 0 1
India
Dipindah Ke Fasiliti Lain LELAKI 0 0 0 1 0 0 0 0 0 0 1
50 - 54 years India Balik Ke Rumah LELAKI 0 0 0 1 0 0 0 0 0 0 1
60 - 64 years India Balik Ke Rumah LELAKI 0 0 0 0 0 0 0 2 0 6 8
65 - 69 years Cina Balik Ke Rumah PEREMPUAN 0 0 0 0 3 0 0 0 0 0 3
75 - 79 years India Balik Ke Rumah PEREMPUAN 0 0 0 0 0 0 0 0 7 0 7
 < 1 year Melayu Balik Ke Rumah LELAKI 1 0 0 0 0 0 0 0 0 0 1
1 - 4 years Melayu Balik Ke Rumah PEREMPUAN 0 0 0 0 0 0 2 0 0 0 2
15 - 19 years Melayu Balik Ke Rumah LELAKI 0 0 0 0 0 0 0 0 5 0 5
Bukan Warganegara Balik Ke Rumah LELAKI 0 0 0 0 0 0 1 0 0 0 1
20 - 24 years
Melayu Balik Ke Rumah LELAKI 0 0 0 1 0 0 0 0 0 0 1
Bukan Warganegara Balik Ke Rumah LELAKI 0 0 1 1 0 0 0 0 0 0 2
30 - 34 years
Melayu Balik Ke Rumah LELAKI 1 0 1 0 0 0 0 0 0 0 2
Bukan Warganegara Balik Ke Rumah LELAKI 0 0 0 0 0 0 0 0 1 0 1
35 - 39 years Cina Balik Ke Rumah LELAKI 0 0 0 0 0 1 0 0 0 0 1
India Balik Ke Rumah LELAKI 0 1 0 0 0 0 0 0 0 0 1
Bukan Warganegara Balik Ke Rumah LELAKI 0 0 0 0 0 1 0 0 0 0 1
Cina Balik Ke Rumah LELAKI 0 0 0 0 0 0 0 5 0 0 5
India Balik Ke Rumah LELAKI 0 1 0 0 0 0 0 0 0 0 1
LELAKI 0 1 0 1 0 0 0 0 5 0 7
40 - 44 years Balik Ke Rumah
PEREMPUAN 0 0 0 0 2 0 0 0 0 0 2
Melayu
Engkar Nasihat Doktor (DAMA) / Dengan
LELAKI 0 0 1 0 0 0 0 0 0 0 1
Risiko Sendiri (AOR)

Cina Balik Ke Rumah LELAKI 0 1 0 1 0 2 0 0 1 0 5

45 - 49 years
Melayu Balik Ke Rumah LELAKI 0 0 0 0 2 0 1 0 0 0 3
Balik Ke Rumah LELAKI 1 0 0 0 0 0 0 0 0 0 1
Bukan Warganegara
Dipindah Ke Fasiliti Lain PEREMPUAN 0 0 0 0 0 0 0 0 8 0 8
Cina Balik Ke Rumah LELAKI 0 0 0 1 1 6 0 8 0 0 16
50 - 54 years
India Balik Ke Rumah LELAKI 0 0 0 0 0 3 2 0 3 0 8
LELAKI 0 0 1 0 0 0 0 3 0 0 4
Melayu Balik Ke Rumah
PEREMPUAN 1 0 0 0 0 0 0 0 4 0 5
LELAKI 0 0 1 2 1 4 0 0 0 0 8
Gastri ulcer Cina Balik Ke Rumah
PEREMPUAN 0 0 0 0 0 3 0 0 0 0 3
LELAKI 0 0 0 1 0 0 0 0 0 0 1
55 - 59 years India Balik Ke Rumah
PEREMPUAN 0 0 0 0 0 2 0 0 0 0 2
LELAKI 0 0 0 1 0 0 0 0 7 0 8
Melayu Balik Ke Rumah
PEREMPUAN 0 0 0 0 0 0 2 0 0 0 2
Cina Balik Ke Rumah LELAKI 0 1 1 0 0 2 4 0 0 0 8
LELAKI 0 0 0 0 6 9 0 0 0 0 15
Balik Ke Rumah
India PEREMPUAN 0 0 0 0 0 4 0 0 0 0 4
60 - 64 years
Dipindah Ke Fasiliti Lain LELAKI 0 0 1 0 0 0 0 0 0 0 1
LELAKI 1 0 1 2 0 0 0 2 0 0 6
Melayu Balik Ke Rumah
PEREMPUAN 0 0 0 0 2 0 2 0 0 0 4
LELAKI 0 1 1 1 0 0 0 0 0 4 7
Cina Balik Ke Rumah
PEREMPUAN 1 1 0 1 0 4 1 0 0 0 8
65 - 69 years India Dipindah Ke Fasiliti Lain LELAKI 0 0 0 0 0 0 0 4 0 0 4
LELAKI 0 0 0 2 2 0 4 3 0 0 11
Melayu Balik Ke Rumah
PEREMPUAN 1 0 0 0 4 4 0 0 1 0 10
LELAKI 0 0 0 4 1 0 11 2 0 0 18
Cina Balik Ke Rumah
PEREMPUAN 0 1 1 0 8 3 3 0 0 0 16
70 - 74 years Lain-lain Balik Ke Rumah PEREMPUAN 0 0 0 0 5 0 0 0 0 0 5
LELAKI 0 0 0 2 0 0 0 8 1 0 11
Melayu Balik Ke Rumah
PEREMPUAN 1 0 1 0 9 0 0 0 0 0 11
LELAKI 1 0 0 1 3 11 0 0 0 0 16
Balik Ke Rumah
Cina PEREMPUAN 0 0 1 0 0 2 3 0 0 0 6
Mati LELAKI 0 0 0 0 0 5 0 0 0 0 5
75 - 79 years
Lain-lain Balik Ke Rumah LELAKI 0 0 0 1 0 0 0 0 0 0 1
LELAKI 1 0 0 1 5 0 7 0 0 0 14
Melayu Balik Ke Rumah
PEREMPUAN 0 1 1 0 0 0 0 0 0 0 2
 20 - 24 years Bukan Warganegara Balik Ke Rumah LELAKI 0 0 0 0 2 0 0 0 0 0 2
25 - 29 years Bukan Warganegara Balik Ke Rumah LELAKI 1 0 1 1 0 0 0 0 0 0 3
LELAKI 1 0 0 0 0 0 0 0 0 0 1
30 - 34 years Melayu Balik Ke Rumah
PEREMPUAN 0 0 1 0 0 0 0 0 0 0 1
35 - 39 years Melayu Balik Ke Rumah LELAKI 0 0 0 0 3 0 0 0 0 0 3
40 - 44 years Melayu Balik Ke Rumah PEREMPUAN 0 0 0 0 0 0 3 0 0 0 3
Bukan Warganegara Balik Ke Rumah PEREMPUAN 0 0 0 0 1 0 0 0 0 0 1
45 - 49 years Cina Balik Ke Rumah LELAKI 0 0 0 0 1 7 0 0 0 0 8
India Balik Ke Rumah LELAKI 1 0 0 0 0 0 0 0 0 0 1
LELAKI 0 0 0 1 0 0 0 0 0 0 1
Balik Ke Rumah
Cina PEREMPUAN 0 0 0 0 0 0 0 0 0 1 1
50 - 54 years Dipindah Ke Fasiliti Lain LELAKI 0 0 0 0 0 0 0 0 0 3 3
India Balik Ke Rumah LELAKI 0 0 0 0 1 0 0 0 0 0 1
Melayu Balik Ke Rumah PEREMPUAN 0 0 0 0 0 0 0 0 0 4 4
Cina Balik Ke Rumah LELAKI 0 1 1 0 0 0 0 0 0 0 2
55 - 59 years India Balik Ke Rumah LELAKI 0 0 0 0 0 0 0 0 3 0 3
Melayu Balik Ke Rumah LELAKI 0 0 0 1 0 0 0 0 0 0 1
LELAKI 0 1 0 1 2 0 0 6 0 0 10
Cina Balik Ke Rumah
PEREMPUAN 0 0 0 0 2 0 0 0 0 0 2
India Balik Ke Rumah LELAKI 0 1 0 0 0 0 0 0 0 0 1
LELAKI 0 0 1 0 0 0 0 0 0 0 1
Duodenal ulcer 60 - 64 years Balik Ke Rumah
PEREMPUAN 0 2 0 0 0 0 3 0 0 0 5
Melayu
Engkar Nasihat Doktor (DAMA) /
LELAKI 1 0 0 0 0 0 0 0 0 0 1
Dengan Risiko Sendiri (AOR)

LELAKI 0 0 0 0 3 6 0 0 0 0 9
Cina Balik Ke Rumah
PEREMPUAN 0 1 1 0 0 0 0 0 0 0 2
65 - 69 years India Balik Ke Rumah PEREMPUAN 1 0 0 0 0 0 0 0 0 0 1
Lain-lain Balik Ke Rumah LELAKI 0 1 0 0 0 0 0 0 0 0 1
Melayu Balik Ke Rumah LELAKI 2 1 0 0 0 0 0 0 0 0 3
LELAKI 1 3 1 0 0 0 0 8 0 0 13
Cina Balik Ke Rumah
PEREMPUAN 0 0 1 0 3 0 0 0 0 0 4
LELAKI 0 0 0 0 0 0 0 0 4 0 4
70 - 74 years Balik Ke Rumah
PEREMPUAN 0 0 1 1 2 0 0 0 0 0 4
Melayu
Dipindah Ke Fasiliti Lain LELAKI 0 0 0 0 7 0 0 0 0 0 7
Mati LELAKI 0 0 0 0 0 0 0 0 9 0 9
LELAKI 0 1 0 0 0 0 0 0 0 0 1
Cina Balik Ke Rumah
PEREMPUAN 0 0 0 1 0 0 0 0 0 0 1
India Balik Ke Rumah PEREMPUAN 0 0 0 0 1 0 0 0 0 0 1
75 - 79 years
LELAKI 2 2 0 0 0 0 0 0 0 0 4
Balik Ke Rumah
Melayu PEREMPUAN 0 1 0 0 2 0 4 0 0 0 7
Mati PEREMPUAN 1 0 0 0 0 0 0 0 0 0 1
 < 1 year Melayu Balik Ke Rumah LELAKI 0 0 1 0 0 0 0 0 0 0 1

Bukan Warganegara Balik Ke Rumah LELAKI 0 0 1 0 0 0 0 0 0 0 1

20 - 24 years
Melayu Balik Ke Rumah LELAKI 0 0 0 1 0 0 0 0 0 0 1

45 - 49 years Melayu Balik Ke Rumah LELAKI 0 0 0 0 0 0 0 0 8 0 8

50 - 54 years Cina Balik Ke Rumah LELAKI 0 0 0 0 0 0 5 0 0 0 5

55 - 59 years Cina Balik Ke Rumah LELAKI 0 0 0 0 5 0 0 0 0 0 5

LELAKI 0 0 0 0 0 0 0 1 0 0 1
Balik Ke Rumah
Dieulafoy's lession Cina PEREMPUAN 0 0 0 0 0 0 0 0 7 0 7
60 - 64 years
Dipindah Ke Fasiliti Lain PEREMPUAN 0 0 0 0 0 0 0 0 5 0 5

India Balik Ke Rumah LELAKI 0 0 0 0 2 0 0 0 0 0 2

65 - 69 years Melayu Balik Ke Rumah LELAKI 0 0 0 0 0 0 0 0 5 0 5

LELAKI 0 0 0 1 0 0 4 0 0 2 7
Cina Balik Ke Rumah
70 - 74 years PEREMPUAN 0 0 0 0 4 0 0 0 0 0 4

Melayu Balik Ke Rumah PEREMPUAN 0 0 0 1 0 0 0 0 0 0 1

75 - 79 years Cina Mati PEREMPUAN 0 0 0 0 0 0 7 0 0 0 7

TOTAL 63 52 70 90 259 260 241 194 235 145 1,6

REFERENCES

● Bailey and Love’s Short Practice of Surgery

● Essential Surgery : Problems, Diagnosis and Management

● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4130885/’

● http://gut.bmj.com/content/early/2015/05/12/gutjnl-2015-309262
● https://emedicine.medscape.com/article/182098-medication

● https://www.nice.org.uk/guidance/CG141/chapter/1-Guidance#risk-assessment

● https://academic.oup.com/bjaed/article/17/4/117/2666343

● https://www.aafp.org/afp/2012/0301/p469.html

● https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4107701/