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Upper GI Hemorrhage (UGIH)

UGIB is bleeding derived from a source proximal to the Ligament of Treitz.

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Acute Upper G.I. Bleeding

  • Haematemesis
  • Melaena
  • Haematochezia

Haematemesis

  • The vomiting of blood.
  • It indicates that the bleeding is from a cause proximal to the (LOT).
  • The colour of the vomited blood is dependent on the concentration of HCL and its admixture with the blood .If the vomiting occurs soon after the UGIB , then haematemesis will be bright red in colour. IF there is a time lag then haematemesis will be dark red brown or black.

Melaena

  • The passage of black and tarry stools.
  • Usually due to UGIH.
  • It results from more then 60-100 ml of blood with moderate transit time.
  • Can be a result of LGIH if the GI transit time was sufficiently  prolonged to about  8hrs.

Haematochezia

  • The passage of fresh blood per rectum due to bleeding from the lower GIT.
  • Rarely due to UGIB. Requires more than 1000ml.

GASTROINTESTINAL BLEEDING

  • Hematemesis
  • Melena
  • Hematochezia
  • Occult bleeding

Summary

  • Vomiting of blood
  • Bright red or dark
  • Proximal to the ligament of Treitz
  • Differentiate from hemoptysis, bleeding from mouth & pharynx
  • 80-95% cases – Mucosal abnormalities, Varices, Spontaneous resolution

Causes of UGIH

  1. Esophageal  Varices
  2. Duodenal ulcer
  3. Gastric ulcer
  4. Gastritis
  5. Other rare causes are:
  • Mallory-Weiss tear.
  • Boerhaave syndrome.
  • Vascular  Ectasia
  • Aortoenteric fistula.
  • Neoplasm
  • Portal hypertensive gastropathy.
  • Hemobilia.

CLINICAL PRESENTATION

  • Clinical manifestations of GI bleeding depends upon extent & rate
  • Postural hypotension suggests acute hemorrhage & intravascular volume depletion
  • Fatigue & exertional dyspnea typical symptoms  with slow, chronic blood loss

Symptoms and Signs

  • Hematemesis – 40-50%
  • Melena – 70-80%
  • Hematochezia – 15-20%
  • Syncope – 14.4%
  • Presyncope – 43.2%
  • Dyspepsia – 18%
  • Epigastric pain – 41%
  • Heartburn – 21%
  • Diffuse abdominal pain – 10%
  • Dysphagia – 5%
  • Weight loss – 12%
  • Jaundice – 5.2%

Clinical Features

History

Differentiate hematemesis from hemoptysis

Amount of blood loss (drops, tablespoonful, clots)

Recently ingested foods (food colors, beets, drugs)

Source of bleed (upper GIT, nose, mouth pharynx)

Prolonged, forceful vomiting (Mallory-Weiss)

Abdominal pain & vomiting (esophagitis, gastritis)

Cracked nipples, Jaundice & Liver disease

Umbilical vein catheterization (portal vein thrombosis)

Familial bleeding diathesis

PHYSICAL

  • Orthostatic changes in pulse & BP
  • Cardiopulmonary
  • Skin
  • Examine oral cavity & nasopharynx
  • Lymph nodes
  • Abdomen
  • Digital rectal

Physical signs

  • Petechiae, Ecchymosis
  • Icterus, Palmar erythema, Spider angioma
  • Hepatosplenomegaly, Ascites
  • Active nasopharyngeal bleed
  • Occult blood in stools

Approach to the patient

GOAL —   Determine the cause & treat

Phase – 1 Differentiate (blood, food color, Beets etc)

Phase – 2 Assess severity (Hematocrit, Capillary refilling, Vital signs)

Phase – 3 Determine the site ( Epistaxis simulates Upper G I bleed)

Imaging, Endoscopy

Clinical Approach

  • Confirm bleeding
  • Assess Severity
  • Resuscitate
  • Medical Intervention
  • Liaison with surgical/ ITC Team
  • Diagnosis of site
  • Surgical hand over

Hints for Screening

Make sure – vomited material: is it really blood ?

NG aspirate –ve for blood doesn’t rule out ‘UGIB’

Competent pylorus may mask a duodenal bleed

Bright red blood – active bleed

Dark ‘Coffee grounds’ – denatured  by gastric acid

Rapid bleed – a medical emergency

Slower bleed – anemia, occult blood in stools, melena

Hypotension – may not be seen even in a large bleed

Initial Hb – values may be unreliable

Acute U.G.I. Bleeding

Clinical approach:

–1.   if small amount, no immediate Tx,   because   CVS can compensate

–2.   85% stop bleeding during 48 hrs –

–3.   Criteria for low risk

  • Age less then 60 years
  • Coffee ground without malena
  • Alcohol induced
  • Hemodynamically normal

4. Criteria for Hospitalization

  • –recent (24 hrs),
  • –age (60 +)
  • –Continuing visible blood loss.
  • –Hemetemsis with malena
  • –Cardio-respiratory disease
  • –Signs of chronic liver disease
  • –Shock
  1. P>100,BP<100
  2. Poor peripheral circulation
  3. JVP<1cm (from sternal angle when Patient is flat)

Immediate management:

** Emergency management:

History.

(Dyspeptic symptoms, Vomiting preceding blood, Alcohol, Drugs, Previous episode of bleeding, History of jaundice, peptic ulcer, surgery )

  • Monitor: pulse & BP /30 min
  • Blood sample: haemoglobin, urea   electrolytes, grouping & cross-matching
  • I.v. access

**Shock management:

  • ABC
  • Airway: endotracheal tube,   oropharyngeal airway.
  • *Give oxygen
  • Breathing: support respiratory function
  • * Monitor: resp. rate, blood gases, chest radiograph
  • – Circulation: expand circulating volume: blood, colloids, crystalloids support CVS function: vasodilators
  • * Monitor: skin color, peripheral temp., urine   flow, BP, ECG

Blood transfusion in case of:

1) shock

2) haemoglobin <10 g/dl

  • Urgent endoscopy
  • Surgery when recommended

Rationale for Endoscopy

To identify the source of bleeding

To determine the risk of re-bleeding

To render endoscopic therapy

  1. Band ligation
  2. Injection sclerotherapy
  3. Cautery
  4. Heater probe
  5. Endoclip

General Investigations:

1. Hb, PCV

2. CBC (WBC … etc)

3. Bld glucose

4. Platelets, coagulation

5. Urea, creatinine, electrolytes

6. Liver biochem.

7. Acid-base state

8. Imaging: chest & abd. radiography, US,   CT

Laboratory Aids

1. Bleeding scans – Inconclusive Endoscopy

Technitium sulfur colloid (detects rapid bleed)

Tagged RBCs (for small bleeds)

2. Angiography

General management:

–Drug therapy

1. H2 – receptor antagonists

2. proton pump inhibitors

3. octreotide

4. Vasopressin/Terlipressin

Factors in reassessment

1. age: 60 + indicates  greater mortality

2. recurrent hemorrhage: +++ mortality

3. re-bleeding: mostly within the 1st 48 hrs

Further Evaluation

Re-bleeding Signs:

–Rise in pulse

–Decreased urinary output

–General condition deterioration

–Continued bleeding after 6-8 units of blood

–Spurting vessel at endoscopy

Treatment of Uncontrolled Bleeding

  • Sengastaken– Blakemore tube
  • TIPSS
  • Surgical shunts

Prognosis

Overall mortality =8-12%

can be reduced to 6-9%

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