8. Acute bleeding of the upper GIT - diagnosis and treatment

Question 1

where does the bleeding of the upper GI originate from ?

Answer 1

esophagus , stomach and duodenum

Question 2

what are the causes for upper gastrointestinal tract bleeding ?

Answer 2

esophagus 
esophageal variceal 
esophagitis 
esophageal cancer 
mallory weiss tear - laceration at the junction of cardia and esophagus (vomitting due to alcohol , bulimia) 

stomach 
portal hypertensive gastropathy 
peptic ulcers 
gastric cancer - rare 
gastritis 

duodenum
peptic ulcer
aortoeneteric fistula

any form of malignancy

NSAIDS , SSRI , anti-platelet agents such as clopidrogel

Question 3

how do we diagnose acute bleeding which is from the UPPER GI ?

Answer 3

black stool

initially check blood pressure , heart rate

blood count - findings of anemia , coagulopathy , elevated BUN to creatine ratio of 30 or more

and age of less than 50

in the absence of this do a nasogastric aspiration to find source of bleeding - if positive an upper GI bleeding likelihood of more than 50 percent
accuracy increased by gastroocult test

nasogastric lavage and aspiration - no real benefits in regard to mortality , length of hospital stay , surgery or transfusion
used when it is unclear if the patient has ongoing bleeding and therefore indicate and early endoscopy check and it has shown that endoscopy can be done quicker as it clears the clot and blood

endoscopy if only there is no rebound tenderness suggesting perforation within the first 24 hours with pro kinetic factors to improve visualisation

Question 4

what are the signs and symptoms for acute upper GI bleeding

Answer 4

hematemesis -coffee ground vomiting
moderate to severe bleeding is going on

hematochezia - marron coloured stool if the bleeding is severe or usually indicated with bleeding fro the lower GIT

melena

anemia
chest pain
syncope
shortness of breath

increased heart rate

orthostatic hypotension - blood volume loss of atleast 15 percent
more than 40 recent supine hypotension

Question 5

what is the treatment for acute bleeding in the upper GIT

Answer 5

airway managmnet

fluid replacement - colloids and albumin for liver cirrhosis and variceal bleeding

varicose veins
vasopressin and nitroglycerin to reduce portal pressure
endoscopic banding or sclerotherapy
beta blockers and nitrates used for the prevention of rebleeding
balloon tamponade - followed by transjugular intrahepatic portosystemic shunt for esophageal varicose
vasoactive medication - somatostatin for vatical bleeding

blood transfusions
not for moderate bleeding and not to correct anemia
important to avoid over transfusion inonly if haemoglobin below 7g/DL in vatical bleeding can there be transfusion
and less than 8g/dl in normal cases

transfuion of platelets and FFP if if INR is greater than 1.5 - 1.8 only proceed with endoscopy if the INR is less than 2.5

proton pump inhibitors - do not reduce the death rate , or later bleeding evens or need for surgery

tranexamic acid (antifibrinolytic) - reduce mortality but evidence is very weak

Question 6

what type of scoring system is used to asses the that a person with upper GI would need intervention

Answer 6

glasgow Blatchford score

Question 7

when is the glasgow blatchford score equal to 0 when no intervention is needed ?

Answer 7

hemoglobin level higher than 12.9g/dl for men
11.9 for women

systolic blood pressure of more than 109mmhg

pulse less tha 100 bpm

blood urea nitrogen level of less than 6.5mmol/L

no melon or syncope

no past or present liver diseases and heart failure

Question 8

in the glasgow blatchford score which passes the 50 percent risk managmnet of needing an intervention

Answer 8

6

Question 9

how does gastroocult test work ?

Answer 9

based on the reaction of alpha guaiaconic acid with hydrogen peroxide in the presence of heme to produce a highly conjugated blue quinone compound.
The Gastroccult pH test is based on changes in the color of dyes due to changes in hydrogen ion concentration.

Question 10

which are the glasgow blatchford scores that does not need hospital admittance ?

Answer 10

less than 2

Question 11

which factors prove that bleeding occurred from anything proximal to the ligament treitz?

Answer 11

hematemesis

black tarry stools

Question 12

why is there elevated BUN to creating ratio in acute UPGI bleeding?

Answer 12

because blood is absorbed as it passes though the intestines and patients may have decreased renal perfusion