Upper G. I. Bleeding By D. Mohammad Alhawarat
Definition Bleeding originating proximal to the ligament of Treitz (oesophagus, stomach, duodenum) *Catastrophic upper GI bleed may result in massive bleeding per rectum.
Present as : Haematemesis , haematochezia , maleana , or occult blood. May be acute or chronic.
Causes of upper gastrointestinal bleeding 1. Peptic ulcer disease : the most common A: duodenal ulcers B: gastric ulcers
2. Erosive gastritis, esophagitis, duodenitis.
3. Esophageal and gastric varices: Caused by portal hypertention.
4. Mallory weiss syndrome: Longitudinal mucosal tear in the cardioesophageal region caused by repeated retching. # it result from prolonged vomiting or retching. # patient is usually male alcoholics.
5. Less common : #Oesophagitis. #Malignant gastric tumours. #Benign gastric tumours. #Oesophageal ulcers. #Oesophageal tumours. #A-V malformation.
6. Rare : # duodenal tumours. # pancreatic tumours. # arterial aneurysm.
7. Malignancy: # Esophageal ca. # Gastric ca. 8. Arteriovenous malformation.
Resuscitation Initial mgt has 4 primary goals : # quick assessment with attention to hemodynamic status. # appropriate resuscitation and monitoring. # identifying major source of bleeding. # specific therapeutic intervention.
What we have to do : # air way clear of clots. # O 2 may have to be administered. # 2 wide-bore cannulae. # sample to blood bank to GXM blood. # class Ⅰ, Ⅱ hemorrhage replaced with crystalloid. # class Ⅲ, Ⅳ hemorrhage replaced with crystalloid and blood.
# NPO. # urethral catheter is passed, urine monitored. #NGT passed for diagnostic and therapeutic. # blood transfusion as soon as available. # if stable following resuscitation , pt is prepared for upper G. I. endoscopy. # endoscopy done within 24 hrs. # if pt could not be stabilized, an emergency laparotomy may be necessary to prevent exsanguination.
Investigation Questions to ask in history : # any hematemesis , coffee ground emesis , melena , or hematochezia. # any weight loss or changes of bowel habits. #any vomiting and ritching. #any history NSAIDs, steroids.
Physical exam #vital sings may show hypotension and tachycardia. #cool , clammy skin in shock. #spider angiomata , palmer erythema , jaundice. #abdominal exam and rectal exams.
Investigation # upper G. I. endoscopy. # Arteriography. # Baruim swallow. # USS. #Lab investigation.
Endoscopy # most important initial investigation. # for diagnosis and intervention. # establishes diagnosis in 90% of pts. # may need to be done more than once. # it contra indicated in : 1. Acute M. I. unless bleeding life threatening. 2. Perforated viscus.
Arteriography # in pts who continue bleeding & site not identified. # has accuracy 50 -90%. # accuracy is increased if there is active bleeding during investigation. # embolisation may be done at the same time.
Barium swallowmeal # used when endoscopy is not available # may show varices , esophagitis , peptic ulcer , gastric tumours …. etc
Abdominal USS # to access both liver architecture & portal circulation. # more widely available than arteriography. # should be performed before more invasive procedures.
Lab. Investigation # CBC # Electrolytes # Glucose # Coagulation studies # Liver function studies # Type and cross-match
Treatment Peptic ulcer disease : a. if Helicobacter pylori founded: a seven day twice a day course of treatment consisting of two antibiotics (either metronidazole 400 mg and clarithromycin 250 mg, or amoxicillin 1 g and clarithromycin 500 mg) and a full-dose proton pump inhibitor.
b. If no Helicobacter pylori founded: proton pump inhibitor or h 2 antagonist.
Varices : Treatment consists of vasoactive drugs, endoscopic band ligation and antibiotics prophylaxis. Transjugular intrahepatic portosystemic shunt (TIPS) is reserved for those who do not respond or are unlikely to respond to initial standard management.
Mallory weiss syndrome: cauterization or injection of epinephrine to stop the bleeding may be undertaken during the index endoscopy procedure. Very rarely embolization of the arteries supplying the region may be required to stop the bleeding.
Specific treatment Open surgery for uncontrolled bleeding.
Thank You
