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: Patient X
Age: 14 y/o
Gender: Male
Status: Single
Nationality: Filipino Date admitted: September 20,2011
Religion: Catholic Time admitted: 04:30pm
Blood type: O+
Address:
Final Diagnosis: Upper Gastrointestinal Bleeding Anemia (UGIB Anemia)
CHIEF COMPLAINT
The patient was admitted at Gat Andres Bonifacio Memorial Medical Center on September 20 2011 at 4:30pm in the afternoon due to tarry stool. He was attended at the Emergency department and had taken a clinical history and physical assessment. He was transferred at the Medical Ward particularly in the Gastro Intestinal Room of the hospital for further evaluation of the complaint. He was attended by Dr. Feipe, a resident physician of the said hospital.
HISTORY OF PRESENT ILLNESS
2 Days- BM Black in color
PAST MEDICAL HISTORY
-None
FAMILY MEDICAL HISTORY
-None
IV. PHYSICAL ASSESSMENT
Actual Findings Normal Findings Interpretation
Head Skull
Scalp
Hair
-Normocephalic
-No lumps
-
-no baldness
-Straight, Black hair, oily hair
-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
-Normal
-Normal
-Normal
Face
Eyes
Eyebrows
Eyelashes
Eyelids
-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
-approximately 15-20 involuntary blinks per minute; bilateral blinking
-Curly/kinky/straight
-Dry/oily/shiny hair
-Symmetrical with movement
-Expressions appropriate to situations
-Symmetrical
-No protrusions
-Dear or no Cloudiness
-No excessive Lacrimation
-Moves symmetrically
-Hair evenly distributed
-Skin Intact
-Equally distributed
-Curved slightly outward
-Skin intact
-No discharge
-No discoloration
-Lids close symmetrically
-Normal
-Normal
-Normal
-Normal
-Normal
Lid margins
Lower palpebral conjunctiva
Sclera
Iris
-No secretions
-No erythema
-No redness
-Pink, shiny, with visible blood vessels
-No discharges
-White in color
-Clear
- No redness
-Flat
-Brown
-Round
-Transparent/Shiny
-PERRLA
-approximately 15-20 involuntary blinks per minute; bilateral blinking
-No scaling
-No secretions
-No erythema
-No redness
-Pink, shiny, with visible blood vessels
-No discharges
-White/yellowish in black Americans
-Clear, No cloudiness
-No redness
-Flat
-Brown
-Even coloration
-Symmetrical
-Round
-Transparent/Shiny
-Normal
-Normal
-Normal
-Normal
Pupils
Eye Movement
Field of vision
*Visual acuity
Ear
Ear Canal
-Moves in unison
-coordinated
-Same as the color of the face
-No swelling
-Shell shape
- Waxy cerumen
-Presence of cilia
-PERRLA(Pupils Equally Round, Reactive to Light & Accommodation
-Moves in unison
-coordinated
-Good peripheral vision
-20/20 in both eyes
-Parallel with outer canthus of the eyes
-Same as the color of the face
-No swelling
-No tenderness
-Shell shape
-Firm cartilage
-Yellowish
-Dry/waxy cerumen
-Normal
-Normal
-Normal
-Normal
Hearing acuity
Nose
Lips
Gums
-With good hearing acuity in both ears
-No lesions
-Presence of cilia
-Darker lips
-Ability to purse lips
-Pink, moist
-No swelling
-No tenderness
-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
-Normal
-Normal
-Normal
-Decrease of oxygen supply
Teeth
Tongue
Frenulum
Soft Palate
Hard Palate
Uvula
-No discharges
-white
-Pink, even, rough dorsal surface and moist
-Midline
-pinkish
-With visible veins
-Pink, moist, no swelling/No tenderness
-Bony, Light pink in color, moist
-Midline moves when the client
-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
-Midline
-pinkish
-With visible veins
-Pink, moist, no swelling/No tenderness
-Bony, Light pink in color, moist
-Normal
-Normal
-Normal
-Normal
-Normal
Tonsils
Neck
Upper ExtremitiesSkin
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
-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
-Normal
-Normal
-Normal
-Normal
Nails
Chest and backPosterior Thorax
back to previous state
- with edema
-Convex curvature
-white
olive
-No edema
-No abrasions or other lesions
-Freckles, some birthmarks, some flat and raised nevi
-When pinched, skin springs 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
-accumulation of excess fluid
-Decrease O2 supply
Anterior Thorax
Abdomen
-No tenderness
-No masses
-Full expansion
-Tachypnea
-Unblemished skin
-Uniform color
-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
-Unblemished skin
-Uniform color
-Silver-white striae or surgical scars
-Flat, rounded(convex),or scaphoid (concave)
- Symmetric movements caused by respiration
- Audible bowel sounds
- No tenderness
- Relaxed abdomen with
-Normal
-Difficulty of breathing
Lower extremities
Skin
Nails
-Brown in color
- with edema
- No abrasions or other lesions
- with edema
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.)
-Normal
- accumulation of excess fluid
Motor functions:
- 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
- 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 touches the nose
- Rapidly touches each finger to thumb with each hand
- Can readily determine the position of fingers and toes
-Normal
-Normal
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
Enough and good sleep and rest pattern can
Sleep and rest pattern
Cognitive-perceptual pattern
Self –perception and self-concept 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
Throughout her hospitalization sleeps 12 hours and can take naps.
Same
During her hospitalization she is still a positive thinker.
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
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
Role-relationship pattern
Coping-stress
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.
Ever time she encounters difficulties she asks guidance and help from God.
According to her health is very important because it is
Throughout her hospitalization her family is with her side at all times to support her.
During her hospitalization she just prays every time she’s in pain.
the family becomes closer to one another and become stronger.
Her coping stress is the same as what she is doing before.
Her health
other people can gain trust, acceptance, support, and someone to Call On When You Need a Hand.
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
tolerance pattern
Health perception
Sexuality- reproductive pattern
wealth.
Before hospitalization she menstruates regularly.
She is an INC. They go to church every Thursday and Sunday.
During her hospitalization she still believes that health is wealth.
Same
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
and can prevent cancers in reproductive system.
Strong values-beliefs help us to overcome difficulties and trials.
Values- belief pattern
During her hospitalization her husband and her always prays for her health.
stronger.
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 needed.
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 procedureCollect urine from the first voiding in the morning and examine within 30 mins.Label specimen properlyInstruct patient to keep labia majora separated while urinatingInstruct the patient to collect specimen by a midstream catch
Parameters Results
Color Light yellow
Transparency Slightly cloudy
Development of pseudo anuerysms
Weakened wall raptures leading
Peripheral vasoconstriction
Pale nail beds and conjuctivitis
UGIB
Reaction 5.0
Sp gravity 1,020
Albumin + 2
Glucose (-)
RBC count 1-2
WBC count 25-30
Epithelial cells Few
Mucus threads 0 cc’l
Bacteria Moderate
Amorphous
Urates
Casts none
Analysis and interpretation
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 prickLabel the specimen properly.
Parameters Normal Values Results
Hemoglobin M- 130- 180 g/l
F – 120-160 g/l
60
Hematocrit M- 0.42-0.52
F- 0.37- 0.48
0.181
WBC count 4.3-10.8x 10/l
Segments 0.45-.0.74 0.83
Lymphocytes 0.16-0.45 0.15
Eosinophils 0-0.07
Monocyte 0.04-0.10 0.02
Basophils 0-0.02
Bands 0.02-0.04
Platelets 130-400x 10 /l 239
ESR M- 0.15 mm/hr
F- 0.20 mm/hr
RDW= 14.7 Normal MCV= 85.2 Normal MCH-= 28.3 Normal
MCHC= 332 Normal
Interpretation:
This test showed that the hemoglobin is less than the normal value therefore it indicates a decrease of oxygen in the blood.
Blood chemistry
Definition
A blood test is a laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a needle, or via finger prick.
Indication
Blood tests are used to determine physiological and biochemical states, such as disease, mineral content, drug effectiveness, and organ function. They are also used in drug tests. Although the term blood test is used, most routine tests (except for most haematology ) are done on plasma or serum, instead of blood cells.
Nursing responsibility
Explain the procedure to the patient
Collect blood sample by extraction from the vein in arm using needle or finger prick.
E- Exercise should be promoted in a way by stretching hand and feet every
morning. Encourage the patient to keep active to adhere to exercise program and to remain as self –sufficient as possible
- bed rest
T- Treatment after discharge is expected for patients and watcher with UGIB to
fully participate in continuous treatment.
H- Health teachings regarding the importance of proper hygiene and hand
washing, intake of adequate water and vitamins especially vitamin C-rich foods to strengthen the immune response and increasing of oral fluid intake should be conveyed. Avoid spicy foods, carbonated beverages and coffee.
O- OPD such as regular follow-up check-ups should be greatly encouraged to
clients with UGIB as ordered by physician to ensure the continuing management and treatment.
D- Diet which is prescribed should be followed.
S- Pray for faster healing and don’t losses hope.
Endoscopy: Risk assessment in upper gastrointestinal bleeding
Ernst J. Kuipers About the author
Abstract
Endoscopy is the mainstay for diagnosis and therapy of upper gastrointestinal bleeding. Early risk assessment is crucial for effective timing of endoscopy and determination of the need for other measures to be taken—scoring systems should be used for this purpose. A new prospective study suggests that the Blatchford score can identify patients who do not need endoscopic intervention.
Acute upper gastrointestinal bleeding (UGIB) is the gastrointestinal tract condition most likely to result in a medical emergency. The estimated incidence of acute UGIB is 50–150 per 100,000 population per year: 40–60% of these bleeds are caused by a peptic ulcer, 10% are related to varices, 10% are attributable to erosive esophagitis and the remainder are caused by a variety of conditions. Endoscopic treatment is the main therapy for patients with UGIB. However, risk assessment is necessary to determine whether endoscopic treatment is required; a study by Pang et al. has now assessed the predictive value of two risk assessment scoring systems.
Endoscopic treatment, either with clips or thermocoagulation with or without epinephrine injection, can stop the initial bleed and reduce the risk of rebleeding considerably. This treatment improves outcome, as it can shorten the hospital stay, decrease the need for a blood transfusion, further endoscopic or surgical intervention, and reduce mortality. After adequate endoscopic therapy, the outcome for high-risk patients (such as those with a visible vessel) can be further improved by profound acid suppressive therapy by means of a PPI given intravenously.
Early risk assessment is crucial in patients presenting with UGIB to ensure optimal timing of endoscopy, and to determine whether other measures (such as hospital admission, blood transfusion and treatment in an intensive care unit) are required. Several risk assessment scales have been developed over the past 15 years that are based on retrospective analyses of cohorts of patients presenting with UGIB. Prospective cohort studies are required to assess the validity and usefulness of these scoring systems. For that purpose, Pang and colleagues compared two frequently used risk assessment scales—the Blatchford and pre-endoscopic Rockall scoring systems—for their ability to predict the need for endoscopic therapy.3
Early risk assessment is crucial in patients presenting with UGIB...
Both the Blatchford and pre-endoscopic Rockall scoring systems are based on parameters that can be assessed during first presentation. The pre-endoscopy Rockall scoring system is based on the patient's age, comorbidities, and signs of shock on presentation. By contrast, the Blatchford scale does not consider age, but does assess urea and hemoglobin levels. The Blatchford scale is also more focused on symptoms than the Rockall scoring system.
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
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)
Article
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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).
Pub Med
Pang, S. H. et al. Comparing the Blatchford and pre-endoscopic Rockall score
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.
Nowadays there are many technologies discovered to treat diseases like the Upper Gastrointestinal Bleeding. Before UGIB is difficult to treat because of lack of equipments and high technology equipments and because of that the mortality of UGIB is very high. Until they discovered endoscopy (means looking inside and typically refers to looking inside the body for medical reasons using an endoscope an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices,
endoscopes are inserted directly into the organ) to treat UGIB. It is easier now to treat UGIB with the new way while maintaining the medications prescribed, but still there is disadvantage with endoscopy like risk for infection due to sepsis. The mortality of UGIB now is low unlike before.
