I. INTRODUCTION UPPER GASTROINTESTINAL BLEEDING Originates in the GI tract from the mouth to the ligament of Treitz where the duodenum, the first part of the small intestine, ends. Bleeding from the esophagus may occur from esophageal varices, dilation of the veins in the esophagus. One of the symptoms of upper GI bleeding is vomiting of blood (hematemesis).If the blood travels through the GI tract, the stool may appear tarry and black (melena) because of digested blood, though the stool can still be stained with red blood (hematochezia). About 75% of patients presenting to the emergency room with GI bleeding have an upper source. The diagnosis is easier when the patient has hematemesis. In the absence of hematemesis, 40% to 50% of patients in the emergency room with GI bleeding have an upper source. Determining whether a patient truly has an upper GI bleed versus lower gastrointestinal bleeding is difficult. Mortality is about 11% in patients admitted with an UGIB.2 It is as high as 33% in patients who develop bleeding whilst in hospital. A score of less than 3 using the Rockall system above is associated with an excellent prognosis, whereas a score of 8 or above is associated with high mortality.3 Most deaths occur in elderly patients with co- morbidity. Mortality is reported to be lower in specialist units possibly because of adherence to protocols rather than because of technical advances.2 The prognosis in liver disease relates significantly to the severity of the liver disease rather than to the magnitude of the haemorrhage Upper gastrointestinal bleeding is commonly caused by bleeding varices (varicose veins) in the esophagus, peptic ulcers or a
Transcript
I. INTRODUCTION
UPPER GASTROINTESTINAL BLEEDING
Originates in the GI tract from the mouth to the ligament of Treitz where the duodenum, the first part of the small intestine, ends. Bleeding from the esophagus may occur from esophageal varices, dilation of the veins in the esophagus. One of the symptoms of upper GI bleeding is vomiting of blood (hematemesis).If the blood travelsthrough the GI tract, the stool may appear tarry and black (melena) because of digested blood, though the stool can still be stained with red blood (hematochezia). About 75% of patients presenting to the emergency room with GI bleeding have an upper source. The diagnosis is easier when the patient has hematemesis. In the absence of hematemesis, 40% to 50% of patients in the emergency room with GI bleeding have an upper source. Determining whether a patient truly has an upper GI bleed versus lower gastrointestinal bleeding is difficult. Mortality is about 11% in patients admitted with an UGIB.2 It is as high as 33% in patients who develop bleeding whilst in hospital. A score of less than 3 using the Rockall system above is associated with an excellent prognosis, whereas a score of 8 or above is associated with high mortality.3 Most deaths occur in elderly patients with co-morbidity. Mortality is reported to be lower in specialist units possibly because of adherence to protocols rather than because of technical advances.2 The prognosis in liver disease relates significantly to the severity of the liver disease rather than to the magnitude of the haemorrhage
Upper gastrointestinal bleeding is commonly caused by bleeding varices (varicose veins) in the esophagus, peptic ulcers or a Mallory- Weiss tear at the esophageal gastric junction from severe retching .Otherwise, bleeding over time results in anemia, characterized by lower than normal blood hemoglobin and hematocrit with symptoms like weakness, fatigue, and fainting.
The most important step to evaluate upper GI bleeding is upper endoscopy. During this procedure, performed by a gastroenterologist, a tube with a camera (endoscope) is passed into the mouth and down the esophagus. The gastroenterologist can proceed to the stomach and duodenum and localize the source of the bleeding, if possible. Other examination to determine UGIB are Vital signs, in order to determine the severity of bleeding and the timing of intervention. Abdominal and rectal examination, in order to determine possible causes of hemorrhage. Assessment for portal hypertension and stigmata of chronic liver disease in order to determine if the bleeding is from a variceal source.
Laboratory findings include anemia, coagulopathy, and an elevated BUN-to-creatinine ratio.
Emergency treatment for upper GI bleeds includes aggressive replacement of volume with intravenous solutions, and blood products if required. As patients with esophageal varices typically have coagulopathy, plasma products may have to be administered. Vital signs are continuously monitored.Early endoscopy is recommended, both as a diagnostic and therapeutic approach, as endoscopic treatment can be performed through the endoscope. Therapy depends on the type of lesion identified, and can include:injection of adrenaline or other sclerotherapy, electrocautery, endoscopic clipping, or banding of varices. Stigmata of high risk include active bleeding, oozing, visible vessels and red spots. Clots that are present on the bleeding lesion are usually removed in order to determine the underlying pathology, and to determine the risk for rebleeding. Pharmacotherapy includes the following: Proton pump inhibitors (PPIs), which reduce gastric acid production and accelerate healing of certain gastric, duodenal and esophageal sources of hemorrhage. These can be administered orally or intravenously as an infusion depending on the risk of rebleeding. Octreotide is a somatostatin analog believed to shunt blood away from the splanchnic circulation. It has found to be a useful adjunct in management of both variceal and non-variceal upper GI hemorrhage. It is the somatostatin analog most commonly used in North America. Terlipressin is a vasopressin analog most commonly used in Europe for variceal upper GI hemorrhage. Antibiotics are prescribed in upper GI bleeds associated with portal hypertension.
If Helicobacter pylori is identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI is suggested.
II. OBJECTIVES
General objectives:
This case study focuses on the advancement of my skills in managing and administering the extensive range of my intervention to my client with Upper Gastrointestinal Bleeding (UGIB). This study will further help me to expand my knowledge about the said disease.
Specific objectives:
1. To established good rapport to the client and to get the physical assessment.
2. To define what is Upper Gastrointestinal Bleeding (UGIB).
3. To trace the pathophysiology of UGIB.
4. To enumerate the different signs and systems of UGIB.
5. To formulate and apply necessary nursing care plans utilizing the nursing process.
III. DEMOGRAPHIC DATA
Name: Mrs. E.M.C
Age: 47 y/o
Gender: Female Spouse: Armando A. Cacho
Status: Married Chief Complaint: Change in Sensoruim
Nationality: Filipino Date admitted: November 11, 2010
Religion: INC Time admitted: 10:30 am
Blood type: O+
Address: BKL3 LOT 10 PH Dela Costa Homes 3, SJDM, Bulacan
Final Diagnosis: Upper Gastrointestinal Bleeding (UGIB)
CLINICAL ABSTRACT
This is the case of EMC 47 y/o female from BKL3 LOT 10 PH Dela Costa Homes 3, SJDM, Bulacan. She was born on September 15, 1963. She is married for 22 years now and has 6 children. Mrs. EMC is a non smoker and non alcoholic beverages drinker.
Mrs. EMC was admitted to East Avenue Medical Center on November 11, 2010, 10:30 in the morning. She was admitted due to dizziness, loss of consciousness and change of sensorium.
HISTORY OF PRESENT ILLNESS
One week prior to admission the patient had experienced dizziness and vomiting of previous ingested food but still conscious and able to communicate. Three days prior to admission Mrs. EMC had experienced anorexia and abdominal pain. Few hours prior to admission Mrs. EMC still in the previous symptoms, and rushed to the ER of EAMC.
November 11, 2010 the physician ordered CBG monitoring, serum glucose control which revealed type 2 DM, start of empiric antibiotic which revealed complicated UTI and had her laboratory examinations like blood chemistry, hematology test and urinalysis. On the same day she undergone upper endoscopy with biopsy which revealed gastric ulcer. On the 13 th day of Nov. she had her cross matching which revealed her blood type which is type ”O” positive. Nov. 21 she had undergone to IJ catheter insertion for dialysis.
PAST MEDICAL HISTORY
According to the patient she has a hypertension, DM and BA (last attack 20 vq). She is negative to PTB and thyroid disease. She had no maintenance on her HPN, for her DM she took Metformin.
FAMILY MEDICAL HISTORY
(+) Hypertension (-) PTB
(+) DM (-) Thyroid disease
(+) BA
LIFE STYLE
A. Personal Habit
The patient does not smoke nor drinks alcoholic beverages.
B. Diet
She eats three times a day and drinks 6-8 glass of water per day and sometimes she also drinks soft drinks. The patient’s usual diet includes rice, meats like pork, beef, chicken and fish. According to the patient, she seldom eats vegetables. She is fond of eating sweets and lechon. She also drinks coffee often (4x a day).
C. Recreational Activity
She watch television during her free time after she had finish the household choirs.
D. Sleep and Rest
She said that she spends 6 hours of sleep every night and she takes naps if she had free time. She usually sleeps at 11:00 in the evening and wakes up at 5:00 in the morning she said that it is continuous and she feels refreshed after waking up.
E. Activities of Daily Living
The patient works everyday in their house and sometimes she accepts laundry. Every weekend she allotted time to rest and to have bonding with her family. She said she do the household choirs before she starts washing her accepted laundry from her neighbors.
PATIENT’S SOCIAL HISTORY
A. Family Relationship and Friends
The patient’s family is nuclear type together with her husband Armando A. Cacho, her six children. According to her she has a good relationship with each member of her family and also with her friends. She allotted time to bond with her family.
B. Occupational History
The patient is self employed.
C. Economic History
According to the patient her husband is a constructor and an OFW before. Her husband is the one who brings income in their family. According to her husband work is enough to support their children’s need. Her accepted laundry from their neighbors helps them in their needs and it is an additional income to them and it satisfies their needs.
IV. PHYSICAL ASSESSMENT
Actual Findings Normal Findings Interpretation Head
Skull
Scalp
Hair
Face
Eyes
Eyebrows
Eyelashes
Eyelids
-Normocephalic-No lumps
-No nits, lice and dandruff-no baldness
-Straight, Black with white hair, oily hair
-Symmetrical with movement-Expressions appropriate to situations
-Symmetrical-No cloudiness-No Lacrimation
-Symmetrical
-Equally distributed-Curved slightly outward
-Skin intact-No discharge-No discoloration-Lids close symmetrically
-Normocephalic-Smooth-No lumps-Absence of modules or masses-No area of tenderness-Symmetrical with protrusions on the lateral part of parietal forehead and occipital bone.
-Whitish -No nits, lice and dandruff-no baldness
-Black or brown in color-Hair is evenly distributed-No area of baldness-Thick-Fine-Curly/kinky/straight-Dry/oily/shiny hair
-Symmetrical with movement-Expressions appropriate to situations
-Symmetrical-No protrusions-Dear or no Cloudiness-No excessive Lacrimation
-Yellowish-Dry/waxy cerumen-Presence of cilia-No foreign body
-With good hearing acuity in both ears
-Symmetric and straight-No discharge or flaring-Uniform color-No tenderness-No lesions-Presence of cilia
-Uniform pink color(darker, e.g,Bluish hue, in Mediterranean groups and dark-skinned clients)-Soft, moist, smooth texture-Symmetry of contour-Ability to purse lips-No tenderness
-Pink, moist-No swelling-No tenderness-No discharges-No retraction(lower and upper)
-32 in number-White-Upper teeth over-rides lower teeth
-Pink, even, rough dorsal surface and moist
-Normal
-Normal
-Normal
-Decrease of oxygen supply
-Normal
-Normal
-Normal
Soft Palate
Hard Palate
Uvula
Tonsils
Neck
Upper Extremities Skin
-Midline-pinkish-With visible veins
-Pink, moist, no swelling/No tenderness
-Bony, Light pink in color, moist
-Midline moves when the client says “Aah”
-Pinkish-No discharge-No inflammation
-Same as the skin color-No lymphs, No mass
-No abrasions or other lesions-When pinched, skin springs back to previous state- with edema
-Midline-pinkish-With visible veins
-Pink, moist, no swelling/No tenderness
-Bony, Light pink in color, moist
-Pink, moist-Midline moves when the client says “Aah”
-Pinkish-No discharge-No inflammation
-Erect & midline-Same as the skin color-No tenderness-No lymphs, No mass-Symmetrical-Muscles equal in size; head centered-Coordinated, smooth movements with no discomfort
-Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive-No edema-No abrasions or other lesions-Freckles, some birthmarks, some flat and raised nevi-When pinched, skin springs
-Normal
-Normal
-Normal
-Normal
-Normal
-Normal
-accumulation of excess fluid
Nails
Chest and back Posterior
Thorax
Anterior Thorax
Abdomen
-Convex curvature-white
-No tenderness-No masses
-Full expansion-Tachypnea
-Unblemished skin-Uniform color
back to previous state
-Convex curvature-Smooth texture-Highly vascular and pink in light-skinned clients; dark-skinned clients may have brown or black pigmentation in longitudinal streaks-Intact epidermis-Prompt return of pink or usual color(generally less than 4 seconds)
-Chest symmetric-Skin Intact; uniform temperature-Chest wall intact-No tenderness-No masses-Full and symmetric chest expansion-Vesicular and bronchovesicular sounds
-Quiet, rhythmic, and effortless respirations-Full symmetric excursion-Bronchial and tubular breath sounds in the trachea-Vesicular and bronchovesicular breath sounds
-Brown in color- with edema- No abrasions or other lesions- with edema
- Concave curvature -Brown pigmentation in longitudinal streaks
- Repeatedly and rhythmically touches the nose- Rapidly touches each finger to thumb with each hand- Can readily determine the position of fingers and toes
by respiration- Audible bowel sounds - No tenderness- Relaxed abdomen with smooth, consistent tension
- Varies from light to deep brown; from ruddy pink to light pink; from yellow overtones to olive- No edema- No abrasions or other lesions- Freckles, some birthmarks, some flat and raised nevi- when pinched, skin springs back to previous state
- Concave curvature - Smooth texture- highly vascular and pink in light-skinned clients; dark-skinned clients may have brown or black pigmentation in longitudinal streaks- Intact epidermis- Prompt return of pink or usual color (generally less than 4 secs.)
- Has upright posture and steady gait with opposing arm swing; walks unaided, maintaining balance- May sway slightly but is able to maintain upright posture and foot stance.- Maintain stance for at least 5 secs- maintains heel-toe walking along straight line- Repeatedly and rhythmically
- accumulation of excess fluid
-Normal
-Normal
touches the nose- Rapidly touches each finger to thumb with each hand- Can readily determine the position of fingers and toes
GORDONDS
Before hospitalization
During hospitalization
Interpretation Analysis
a. activity-exercise pattern- hobbies
Elimination pattern
According to her she does the household choirs and at the same time it is her way of exercising and she can perform different activities.
Prior to hospitalization she defecates every day. She urinates normal amount and normal color. urinates
During her hospitalization she is in complete bed rest.
For the period of hospitalization her defecation does not vary but her urine
output decreases.
She was not able to perform the activities because of the disease process.
The patient’s elimination pattern changed during hospitalization because she is under medication.
Exercise is very important to our body because it promotes good health and helps us build and maintain healthy muscles, bones, and joints and it reduces depression and anxiety.
Good elimination pattern reduces the risk of having cancer. It helps us to detoxify waste in our body to free ourselves from complications
Sleep and rest pattern
Cognitive-perceptual pattern
Self –perception and self-concept pattern
Role-relationship pattern
Before she sleeps 6 hours every day
The patient is a 2nd year college undergraduate. She is literate.
Prior to hospitalization she is a happy person and positive thinker.
The patient’s family is nuclear type. They are 8 in the family. They have 6 children and she allotted time for her family to bond. She is sociable to everyone.
Throughout her hospitalization sleeps 12 hours and can take naps.
Same
During her hospitalization she is still a positive thinker.
Throughout her hospitalization her family is with her side at all times to support her.
Due to confinement the patient has no problem with her sleep.
Due to confinement the patient has no problem with understanding
Even she is in the hospital herself perception does not change. She stayed the same as she was before.
Due to her hospitalization the family becomes closer to one another and become stronger.
Enough and good sleep and rest pattern can reduce stress, helps us to think better.
Good education is important to overcome poverty.
Good self-perception and self-concept pattern helps us to overcome problems and trials.
Good relationship to each member of the family creates unity and compact relationship with each other. Good relationship with other people can gain trust, acceptance, support, and someone to Call On When You Need a Hand.
Coping-stress tolerance pattern
Health perception
Sexuality- reproductive pattern
Values- belief pattern
Ever time she encounters difficulties she asks guidance and help from God.
According to her health is very important because it is wealth.
Before hospitalization she menstruates regularly.
She is an INC. They go to church every Thursday and Sunday.
During her hospitalization she just prays every time she’s in pain.
During her hospitalization she still believes that health is wealth.
Same
During her hospitalization her husband and her always prays for her health.
Her coping stress is the same as what she is doing before.
Her health perception is the same as what she believes before.
Her reproductive system works properly.
Her values- belief pattern does not change and her faith to God become stronger.
Having a good coping to stress can overcome stressors and depressions.
Good health perception can maintain health, the body can function properly and it acts as personal strength.
Good sexuality- reproductive can easily determine the fertilization and can prevent cancers in reproductive system.
Strong values-beliefs help us to overcome difficulties and trials.
V. ANATOMY AND PHYSIOLOGY
UPPER GI
The upper GI tract consists of the mouth, pharynx, esophagus, and stomach. This is where ingestion and the first phase of digestion occur.
MOUTH
The mouth includes the tongue, teeth, and buccal mucosa or mucous membranes containing the ends of the salivary glands, continuous with the soft palate, floor of the mouth and under side of the tongue. Chewing (mastication) is the mechanical process by which food, constantly repositioned by muscular action of the tongue and cheeks, is crushed and ground by the teeth through the muscular action of the lower jaw (mandible) against the fixed resistance of the upper jaw (maxilla).
Saliva excreted in the oral cavity by three pairs of exocrine glands (parotid, submandibular, and sublingual) is mixed with chewed food to form a bolus, or ball-shaped mass. There are two types of saliva: a thin watery secretion that wets the food and a thick mucous secretion that lubricates and causes the food particles to stick together to form the bolus.
Digestive enzymes in saliva begin the chemical breakdown of food, primarily starches at this point, almost immediately.
PHARYNX
The pharynx is contained in the neck and throat and functions as part of both the digestive system and the respiratory system. The human pharynx is divided into three sections: the nasopharynx behind the nasal cavity and above the soft palate;
The oropharynx behind the oral cavity and including the base of the tongue, the tonsils, and the uvula; the hypopharynx or laryngopharynx includes the junction with the esophagus and the larynx, where respiratory and digestive pathways diverge. The swallowing reflex is initiated by touch receptors in the pharynx as the bolus of chewed food is pushed to the back of the mouth.
Swallowing automatically closes down the respiratory or breathing pathway as an anti-choking reflex. Failure or confusion of reflexes at this point can result in aspiration of solid or liquid food into the trachea and lungs.
ESOPHAGUS
The esophagus is the hollow muscular tube through which food passes from the pharynx to the stomach. It is also lined with mucous membrane continuous with the mucosa of the mouth and into which open the esophageal glands.
The esophagus is surrounded by relatively deep muscles that move the swallowed bolus of masticated food through peristaltic action, piercing the thoracic diaphragm to reach the stomach.
STOMACH
The stomach is a hollow muscular organ, located below the diaphragm and above the small intestine that receives and holds masticated food to begin the next phase of digestion. Two smooth muscle valves, the esophageal sphincter above and the pyloric sphincter below, keep stomach contentscontained.
The stomach is surrounded by stimulant (parasympathetic) and inhibitor (orthosympathetic) nerve plexuses which regulate both secretory and muscular activity during digestion. With a volume of as little as 50 mL when empty, the adult human stomach may comfortably contain about a liter of food after a meal, or uncomfortably as much as 4 liters of liquid.
DUODENUM
The duodenum precedes the jejunum and ileum and is the shortest part of the small intestine, where most
chemical digestion takes place. The nameduodenum is from the Latin duodenum digitorum, or twelve
fingers' breadths.
In humans, the duodenum is a hollow jointed tube about 10–12 in long connecting the stomach to
the jejunum. It begins with the duodenal bulb and ends at the ligament of Treitz.
The duodenum is largely responsible for the breakdown of food in the small intestine, using
enzymes. Brunner's glands, which secrete mucus, are found in the duodenum. The duodenum wall is
composed of a very thin layer of cells that form the muscularis mucosae. The duodenum is almost entirely
retroperitoneal.
The duodenum also regulates the rate of emptying of the stomach via hormonal
pathways. Secretin and cholecystokinin are released from cells in the duodenal epithelium in response to
acidic and fatty stimuli present there when the pylorus opens and releases gastric chyme into the duodenum
for further digestion. These cause the liver and gall bladder to release bile, and the pancreas to release
bicarbonate and digestive enzymes such as trypsin,lipase and amylase into the duodenum as they are
Inflammatory effect on gastric mucusa Neutrophils – 86%
Ulcers burrows deep
Weakening and necrosis of arterial
Development of pseudo anuerysms
Weakened wall raptures leading
Peripheral vasoconstriction
Pale nail beds and conjuctivitis
UGIB
Is an array of tests performed on urine and one of the most common methods of medical diagnosis.
Indication:
It is used to detect the presence of UTI, Proteinuria,Glucosuria, Ketonuria, presence of urinary sediments which indicates renal pathology.
Nursing Responsibility:
Instruct the patient perform perineal care prior to the procedure Collect urine from the first voiding in the morning and examine within 30 mins. Label specimen properly Instruct patient to keep labia majora separated while urinating Instruct the patient to collect specimen by a midstream catch
Laboratory results revealed that there is presence of Albumin in the blood, this indicates that the glomerular cannot filter large molecules such as that of Albumin. It also revealed that there is infection as evidence by presence of bacteria and red cells in the urine.
Hematology
Definition
Is the branch of internal medicine, physiology, pathology, clinical laboratory work, and pediatrics that is concerned with the study of blood, the blood-forming organs, and blood diseases. Hematology includes the study of etiology, diagnosis, treatment, prognosis, and prevention of blood diseases. The laboratory work that goes into the study of blood is
frequently performed by a medical technologist. Hematologists physicians also very frequently do further study in oncology - the medical treatment of cancer.
Indication
This test determines the concentration of hemoglobin in whole blood.
Nursing responsibility:
Explain the procedure to the patient
Collect blood sample by extraction from the vein in arm using needle or finger prick Label the specimen properly.
Parameters Normal Values ResultsHemoglobin M- 130- 180 g/l
Pang and colleagues assessed the two scoring systems prospectively in 1,087 patients presenting with UGIB. Endoscopic therapy was given to 297 (27.3%) of the patients. The decision to apply endoscopic treatment was made by the individual endoscopist, who was guided by an in-hospital protocol that required such treatment for all actively bleeding lesions, as well as for visible vessels and adherent clots.
Patients requiring endoscopic treatment were divided fairly equally over all the Rockall score categories. The pre-endoscopic
Rockall score was thus unable to predict the need for endoscopic treatment. By contrast, the Blatchford score was able to
make this prediction, as none of the patients with a score of 0 needed endoscopic intervention. The investigators conclude
that the Blatchford score, but not the pre-endoscopic Rockall score, is a useful predictor of the need for endoscopic
intervention. The Blatchford score can, therefore, be used to immediately discharge the subgroup of patients that present
with UGIB who are at low risk and so can return to the hospital at a later date for outpatient endoscopic treatment.3
The results of this study provide valuable confirmation of the usefulness of the Blatchford score for the identification of low-
risk patients, enabling the targeted use of resources. Pang et al.'s findings support the recommendation of the latest
international guidelines that strongly advise the use of pre-endoscopic risk assessment scores in patients with nonvariceal
UGIB. Several other reports also confirmed that patients with a Blatchford score of 0 rarely require endoscopic intervention.
The clinical impact of these important observations is, however, limited by two closely related factors. First, a minority of
cases have a Blatchford score of 0. In Pang et al.'s study, 4.6% (n = 50) of patients were given this score.3 In other studies the
proportion of patients given a Blatchford score of 0 varied between 1% and 15%.Second, the positive predictive value of a
Blatchford score >1 for the need for intervention is low. For these reasons, the next question that needs to be addressed is
whether the clinical impact of the Blatchford score can be augmented. In contrast to the pre-endoscopic Rockall score, the
probability of the need for intervention increases with increasing Blatchford scores.
In a UK study to validate the Blatchford scoring system, approximately 20% of the participants had a score of 1 or 2, and 5%
of these patients required intervention.5Similarly, Pang and colleagues found that one-fifth of patients had a score of 1 or 2,
but 16% required endoscopic treatment.3 This difference in the need for endoscopic treatment is remarkable because Pang
and colleagues' study only used endoscopic intervention as the outcome parameter, whereas the UK study also included
other interventions, such as blood transfusion, in their outcome parameter. None of the available studies provided more
detailed information regarding the endoscopic appearance of the bleeding lesion and the type of intervention provided. Such
information is needed from future studies to enable the selection of a more sizable proportion of patients with UGIB for
endoscopy on an outpatient basis. This strategy would better reflect the fact that only a minority of patients with UGIB
require endoscopic treatment.3,5
Together, these data support the use of prognostic scores for rapid assessment of patients with UGIB, as recommended by
international guidelines. Unfortunately, this strong recommendation is not routinely followed. In a nationwide survey of
6,750 patients with UGIB in more than 200 UK hospitals, pre-endoscopic risk assessment did not influence timing of
endoscopy in hospitalized patients and 42% of high-risk patients did not undergo endoscopy within 24 h, as recommended
by the international guidelines.9The results of this audit probably reflect the situation in many other countries around the
world. These results also show that studies, such as the one by Pang et al., are urgently required to assess the performance
of prognostic scales and stress the need for their use in the treatment of patients with UGIB—a condition associated with
serious comorbidity and mortality.
In conclusion, international guidelines strongly recommend the use of pre-endoscopic risk assessment scores to stratify
patients as either low-risk or high-risk, and thus determine the use of resources and timing of endoscopy. Pang and
colleagues' findings suggest that the Blatchford score is more useful for this purpose than the pre-endoscopic Rockall score.
A low Blatchford score is adequate for the selection of patients who are unlikely to require endoscopic intervention. In some
series, these patients are identified by a score of 0, in others by a score of <2. Further studies are now required to improve
the predictive value of the Blatchford scoring system.
Competing interests statement
The author declares no competing interests.
References
1. van Leerdam, M. E. et al. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of acute upper GI bleeding between 1993/1994 and 2000. Am. J. Gastroenterol. 98, 1494–1499 (2003)
2. Article 3. PubMed 4. ChemPort 5. Barkun, A. N. et al. International consensus recommendations on the management of patients with nonvariceal upper
gastrointestinal bleeding. Ann. Intern. Med. 152, 101–113 (2010).6. Pub Med7. Pang, S. H. et al. Comparing the Blatchford and pre-endoscopic Rockall score
SUMMARY
Originates in the GI tract from the mouth to the ligament of Treitz where the duodenum, the first part of the small intestine, ends. Bleeding from the esophagus may occur from esophageal varices, dilation of the veins in the esophagus. One of the symptoms of upper GI bleeding is vomiting of blood (hematemesis).If the blood travelsthrough the GI tract, the stool may appear tarry and black (melena) because of digested blood, though the stool can still be stained with red blood (hematochezia). About 75% of patients presenting to the emergency room with GI bleeding have an upper source. The diagnosis is easier when the patient has hematemesis. In the absence of hematemesis, 40% to 50% of patients in the emergency room with GI bleeding have an upper source. Determining whether a patient truly has an upper GI bleed versus lower gastrointestinal bleeding is difficult. Mortality is about 11% in patients admitted with an UGIB.2 It is as high as 33% in patients who develop bleeding whilst in hospital. A score of less than 3 using the Rockall system above is associated with an excellent prognosis, whereas a score of 8 or above is associated with high mortality.3 Most deaths occur in elderly patients with co-morbidity. Mortality is reported to be lower in specialist units possibly because of adherence to protocols rather than because of technical advances.2 The prognosis in liver disease relates significantly to the severity of the liver disease rather than to the magnitude of the haemorrhage
Upper gastrointestinal bleeding is commonly caused by bleeding varices (varicose veins) in the esophagus, peptic ulcers or a Mallory- Weiss tear at the esophageal gastric junction from severe retching .Otherwise, bleeding over time results in anemia, characterized by lower than normal blood hemoglobin and hematocrit with symptoms like weakness, fatigue, and fainting.
The most important step to evaluate upper GI bleeding is upper endoscopy. During this procedure, performed by a
gastroenterologist, a tube with a camera (endoscope) is passed into the mouth and down the esophagus. The
gastroenterologist can proceed to the stomach and duodenum and localize the source of the bleeding, if possible. Other
examination to determine UGIB are Vital signs, in order to determine the severity of bleeding and the timing of intervention.
