Introduction
Common medical Emergency
- Predominantly seen in elderly 68% over 60 and 27% over 80Years of age
- 7-10 % die mostly in elderly (patients with severe and persistent bleeding have high mortality rates)
- 80-85% of upper GI bleeding stops spontaneously
PRESENTATION
Depends on its acuity and the source
Blood loss from the GI tract is manifested in five ways.
- Hematemesis
- Melena
- Hematochezia
- Occult bleeding
- Obscure bleeding
Predisposing Factors for Bleeding
- Gastric Acid
- Helicobacter Pylori
- NSAID
- Underlying Medical and Clinical factors
- Stroke
- Cirrhosis
- Other Pharmacological agents like doxycycline, bisphosphonates
- Hospitalization
Etiology of GI Bleeding
A. Duodenal Ulcer
B. Gastric Ulcer
C. Esophageal Varices
D. Gastritis or duodenitis
E. Esophagitis or esophageal ulcer
F. Mallory-Weiss tear
G .Gastrointestinal malignancy
H.Dielafoy’s Lesion
I.Gastric antral vascular ectasia
J.Arteriovenous malformation
K.Angiodysplasia of stomach or duodenum
Management of Upper GI Bleeding
Diagnostic Approach
A.History and Physical Examination
B.Endoscopy
C.Radionuclide Scanning
D.Angiography
Management of Upper GI Bleeding
Management
- The goals of managing the patient with gastrointestinal bleeding have not changed since 1970s
- patient’s hemodynamic status must be rapidly assessed
- resuscitative measures initiated
- determine the source of the hemorrhage
- stop the bleeding
- prevent recurrent bleeding
When GI bleeding is suspected
Rapid assessment to gauge the urgency of the situation
Is bleeding acute or chronic?
Hemodynamically stable or unstable?
the first goal is to stabilize
- air way
- breathing
- circulation.
Continued
Vital signs are recorded
Blood Pressure and Heart Rate
the patient’s skin and mucous membranes are inspected for pallor or signs of shock,
blood is sent to the laboratory
Treatment of patients with GI bleeding always begins with resuscitation measures
- Resuscitation begins in the admitting area
- Insertion of two large-bore intravenous cannulas
- Saline or lactated Ringer’s solution should be infused as rapidly
- Measurement of central venous or pulmonary capillary wedge pressure
- Oxygen by nasal cannula or face mask
- Vital signs and urine output are monitored frequently.
Specific treatment
pharmacologic agents
endoscopic
angiographic control
surgery
Specific treatment for
A. Peptic Ulcer bleeding
*acid inhibitory agents
- H2 receptor antagonists
- proton pump inhibitors
* agents that reduce splanchnic blood flow
- vasopressin
- octreotide
Specific treatment continued
*. Endoscopic therapy
injection
Thermocoagulation
* Surgery.
B. Variceal Haemorrhage
Fresh frozen plasma or platelets
Balloon temponade: Sengstaken-Blakemore tube (three tubes), Minnesota tube (four tubes)
Endoscopic treatment
Banding
Sclerotherapy
*Somatostatin and its long-acting synthetic analog octreotide
*Transjugular Intrahepatic Portosystemic Shunts (TIPS)
Adverse Prognostic Variable in Acute Upper GI Bleeding
- Increasing Age
- Increasing number of comorbid conditions
- Cause of bleeding
- Red blood in the emesis and/or stool
- Shock or hypotension on presentation
- Increased number of blood transfusion
- Active bleeding during endoscopy
- Bleeding from large >2cm ulcer
- Emergency surgery
