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UPPERUPPERGASTROINTESTINALGASTROINTESTINAL

BLEEDBLEED

UPPERUPPERGASTROINTESTINALGASTROINTESTINAL

BLEEDBLEED


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OutlineIntroductionAetiology of upper GIT bleeding

Diagnosis-history

-physical examination

Management


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Upper gastrointestinal

bleeding (UGIB) UGIB is defined as bleeding derived from a

source proximal to the ligament of Treitz.

A potentially life-threatening abdominalemergency

Incidence is approximately 100 cases per 100,000population per year

Common among males and elderly


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Aetiology ofupper GI bleed

STOMACH

Gastric ulcers

Gastric erosions

Gastric varices

Haemorrhagic gastritis

Gastric CA

Gastric lymphoma

Gastric polyp

Hereditaryhaemorrhagic telangiectasia

Dieulafoy lesion

Gastric antral

vascular ectasia ( GAVE )

Angiodysplasia

DUODENUM

Duodenal ulcer

Duodenal erosions

Vascular malformation

Aorta-

duodenal fistula

Polyps

( Peutz- Jeghers

and Polyposis coli )

CA of ampulla

CA pancreas

Haemobilia

OESOPHAGUS

Esophageal varises

Mallory Weiss tear

Reflux oesophagitis

Oesophageal ulcer

Barrets ulcer

Cameron ulcer withinhiatus hernia

Oesophageal

neoplasm


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Diagnosis

Medical history Extremely helpful in determining thelocation of the GI hemorrhage.

A history of recent nonsteroidal anti-inflammatory drug (NSAID) abuse

Alcohol abuse or a history of cirrhosisshould elicit consideration of portalgastropathy or esophageal varices assources for the bleeding.

History of anticoagulant treatment


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Hematemesis Melena Hematochezia Syncope

Dyspepsia Epigastric pain Heartburn Diffuse abdominal pain Dysphagia

Weight loss Jaundice


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Physical examination

Vital signs-hypotension,tachycardia,dereasedpulse pressure or tachypnea

Sign of shock-cool,clammy skin

Sign of CLD-palmar

eryhema,jaundice,gyneacomastiaAbdominal-tenderness,ascites,organomegaly

Per rectal-malenic stool


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Shock


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Management Resuscitation begins with the DRABCs(airway, breathing, circulation)

Assess blood loss and severity Quick history and physical examination

Investigation

Endoscopy, balloon tamponade

Definite management medical or surgery


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Airways and Breathing Patients with hemorrhagic shock

present with mental status changesand confusion.

They cannot protect their airway andat increased risk for aspiration,patients must be electively, not

emergently, intubated in a controlledsetting.

Oxygen should be given to all patients.


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Circulation Intravenous access must be obtained. Bilateral/two14/ 16-gauge (minimum)

peripheral intravenous lines are

required. Patients with severe coexistingmedical illnesses, may requirepulmonary artery catheter insertionor CVP.

Crytalloids or colloids- 3-for-1 rule.Replace each milliliter of blood loss

with 3 mL of crystalloid fluid.


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Fluids Proper fluid management is crucial. Start with a crystalloid, such as

Hartmann's or Ringer's solution. However,any patient with a significant bleed shouldbe treated together with colloid, althoughblood is obviously better.

Those with a life threatening bleed willneed blood as soon as possible, which canbe achieved by using O negative blood


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Monitoring response to

resuscitation BP, PR, CVP, urine output, Nasogastric

tube

based on evidence of end organperfusion and oxygen delivery; skintemp. serum bicarbonate


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Blood tests Serial Full blood count.

Clotting screen: The coagulopathy could be amarker for advanced liver disease.

Urea and electrolytes. Blood in the stomach willbe digested as protein and will be broken down bythe liver into urea, resulting in an elevated urea

concentration. Azotemia. The BUN-to-creatinine >36 without renal insufficiency is suggestive ofUGIB.

Group and cross match. mild cases 2-4 units ofblood. severe 6-20 units, depending on the

patient's condition.


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Endoscopy For diagnostic and therapeutic

Early intervention to control bleeding and preventrebleeding Timing: within 12 to 24 hrs after presentation of

bleeding Provided that patient is stabilized Try to remove any clot to visualize the site Biopsy of GIT mucosa is taken during scope for

Clo test (to detect H. pylori infection, resultavailable after 24-hr)


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Techniques for hemostasis

Injection vasoactive agents

sclerosing agents

Mechanical Rubber band ligation

Application of hemostatic materials, includingbiologic glue, clips

Coagulation Bipolar electrocoagulation Thermal probe coagulation

Constant probe pressure tamponade

Argon plasma coagulator

Laser photocoagulation


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Drug therapy Infusion of somatostatin and it

synthetic,octreotide are effective in reducingbleeding from varices or peptic ulcer.

-Dose of octreotide:50g iv bolus, followed by 50g8-24hr

Dose of somatostatin:250-500 g iv bolus,followed250-500 g perhour

Proton-pump inhibitors :

Omeprazole ( iv omeprazole 80mg stat followed by

infusion 8mg hourly for 72hrs ) is recommendedfollowing endoscopic therapy

Iv pantoprazole also can be used

Helicobacter pylori eradication


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Helicobacter pylori eradication

therapy Proton-pump inhibitors along with two

antibiotics for 1 week :

- Omeprazole 20mg and metronidazole400mg or amoxycillin 1g andclarythromycin 500mg(all twice daily )


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Ballon Tamponade-sengstaken blakemore tube

-control variceal hemorrhage in 40-80% of patient

Surgery-who do not respond to medical therapy andendoscopic hemostatic


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Indications for surgery Severe life-threatening hemorrhage not

responsive to resuscitative efforts Failure of medical therapy and endoscopic

hemostasis with persistent recurrent bleeding

A coexisting reason for surgery such asperforation, obstruction, or malignancy

Prolonged bleeding with loss of 50% or more ofthe patient's blood volume

A second hospitalization for peptic ulcerhemorrhage


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THANK YOU


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Referrences

Guide to the essentials in emergency medicine:Shirley Ooiand Peter manning

Gastrointestinal emergency: David T.overton

Garden, O. J., W.Bradbury, A., & Forsythe, J. (2002).Principles and Practice of Surgery(Fourth Edition ed.):Churchill Livingstone


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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 overlying clot (no visible vessel) IIc: Ulcer with hematin covered base

III: Clean ulcer ground (no clot, no vessel)

Stigmata of Recent Haemorrhage: Major SRH, Minor SRH


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Common sites of portal-systemic collateral formationLocation Portal circulation Systemic circulationClinical

consequence

Proximal stomach and

distal esophagus

Coronary vein of

stomach

Azygos vein Submucosal

gastroesophageal

varicesAnterior abdominal

wall

Umbilical vein in

falciform ligament

Epigastric

abdominal wall veins

Caput medusae

Retroperitoneal Splenic vein branch

Sappey's veins (around

liver and diaphragm)

Left renal vein

Retzius's vein

Usually none

Anorectal Middle and superior

hemorrhoidal veins

Inferior

hemorrhoidal vein

May be mistaken

for hemorrhoids


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