Upper Gastrointestinal Bleeding
Dr;Basim RassamUpper GIT BleedingG.I.T bleeding acute,chronic;upper,lower;active,non-active.Some DefinitionsUpper GIT Bleeding;refers to bleeding from esophagus,stomach,duodenum(to ligament of trietz);variceal,non-variceal.Haematemesis;MalaenaHaematocheziaOccult Bloodcoffee-ground;brown fleckes vomitus.
Causes of Upper GIT Bleeding(1) Chronic PU. 60%(2) Acute PU, Multiple erosions. 26%(3) Miscellaneous. 14% 1- Esophageal varices or Gastric varices. 4%-10%. 2- Mallory-Weiss Syndrome. 4% 3- Tumours. 0.5% (Gastric, Esophageal) 4- Dieulafoy’s vascular malformation. 0.5% 5- PU in Meckel’s diverticulum. 6- Aorto-Enteric fistula. 7- Haematobilia. 8- Bleeding Tendency. 9- Nosebleeds or Nasopharyngeal bleeding. 10- Hiatus Hernia with severe Reflux Esophagitis.
Clinical Presentation of patients with upper GIT bleeding(1) Haematemesis and/or Malaena.(2) Fainting attacks, sweating, pallor and collapse.(3) Anaemia.(4) Epigastric pain.(5) Fresh bleeding per Rectum.(6) Hepatic Encephalopathy..(7)did non-bloody emesis proceed bloody emesis.
Questions to be asked in the History of patients with upper GIT bleeding1- Color and consistency of the vomitus.2- Color and consistency of the stool.3- Did it start as malaena and then became bright red blood per-rectum?4- Frequency of the Malaena and/or Haematemesis.5- History of medications.6- History of alcoholism.7- History of PU.8- Initial vomitus was bloodless but subsequently the vomiting was with pain and blood.9- Heartburn and epigastric substernal pain.
Signs in physical examination which helps in reaching the cause of Upper GIT Bleeding1- Presence of spider naevi, palmar erythema, dupuytren’s contracture, caput medusa, ascites, jaundice.2- Melanin pigmentation of the mucous memebranes of the mouth and anus.3- Palpable neck mass.4- Red spots on the lips, tongue and ears.5- Virchow’s sign.6- Abdominal auscultation.7- Petichae, ecchymosis, epistaxis and haematuria.
Investigations in Upper GIT Bleeding(1) CBC and Film.Hb & PCV, WBC count and differential, Platelet count and Blood film.(2) Clotting Studies (PT, PTT, INR, TT).(3) Renal function and electrolytes.(4) Endoscopic examination (OGD).(5) Barium studies (Ba Swallow, Meal and Follow through).(6) Radionuclide Scanning.(7) Angiograhy.
Management of Upper GIT Bleeding(1) Resuscitation.1- Large bore short length i.v. line.2- Blood should be aspirated,3- Blood transfusion.4- Chart monitoring of the Vital signs and Urinary output.5- Central venous catheter insertion.6- Nasogastric tube insertion.7- Correction of correctable causes.8- Life saving Manoeuvres.
(2) Medical (Conservative) Treatment.1- Bed Rest.2- Blood transfusion.3- Antiacids.4- Analgesia.5- Tranexamic acid (cyclocaprone).6- diet.7- Prevention of Pulmonary complications.
(3) Minimal Endoscopic Interventional Techniques.1- Injection Sclerotherapy (98% Alcohol).2- Ligation (Banding).3- Injection of Vasoactive agent (Adrenaline 1:10000).4- Laser Photo-Coagulation.5- Electro-Coagulation (Diathermy).
(4) Surgical Intervention.Indications of Surgical intervention in Upper GIT bleeding:1- Failure of conservative treatment. -Patient requires more than 4-6 pints of blood. -Bleeding recurs.2- Long standing History of chronic PU disease.3- At Endoscopy: - Visible artery at the ulcer base. - Spurting artery at the ulcer base. - A large clot over the ulcer crater.4- Elderly patients (Over 60 years).
Operative TechniquesAim of Surgery: Stop Bleeding.* Bleeding Chronic DU:Under-running the bleeder by suture material followed by Pyloroplasty and/or Truncal Vagotomy.* Bleeding Chronic GU:- Under-running the bleeder by suture material followed by Pyloroplasty and/or Truncal Vagotomy. (in Mild cases)- Partial Gastrectomy followed by a gastrojejunostomy (Billroth 2 procedure). (in severe uncontrolable bleeding)*Bleeding esophageal Varices:-TIPSS(Transjugular intrahepatic portosystemic shunting).- Emergency PortoCaval shunt.* Severe Bleeding with no identifiable cause:- Long GastroDuodenotomy.
