Approach to Bleeding Upper GIT Flashcards
Define Upper Gastrointestinal Tract Bleeding
bleeding that occurs proximal to the ligament of Treitz
What is ligament of treitz ?
The ligament of Treitz is the suspensory muscle of the duodenum that connects the DJ flexure to the connective tissue surrounding the celiac axis
and SMA .
Clinical presentation of UGIB
-Hematemesis (vomiting of red blood / coffee ground vomitus)
-melena (black tarry stool)
Nature of bleeding ( compare hemoptysis and hematemesis )
Hemoptysis
- bloody expectoration from larynx , trachea , bronchi and the lungs
- have sensation in their throat followed by expectoration of blood (frothy and bright red)
Hematemesis
-vomited blood might be mixed with food particles
-Colour of vomitus depends on contact time with HCl acid from stomach (red → brown)
- Fresh red blood suggest moderate to severe bleeding
- Coffee grounds vomitus is altered blood due to gastric acid, suggest limited bleeding
What is melena ?
Passage of altered blood (black tarry stool) that originate proximal to the ligament of Treitz (90%)
Important to differentiate it between iron stool – greenish hue on rubbing between gloved fingers, particulate. if gloved finger is stirred in a cup of water, melena will “dissolve” completely with no sedimentation and turn the water black, but iron stool will have sedimentation and turn the water green
Etiology of UGIB classification
Variceal bleeding
- Any previous variceal bleed, ask patient if he/she goes for regular banding or OGD screening and banding
- Any history of chronic liver disease, ask for risk factors (i.e. alcohol ingestion, hepatitis B/C, any regular follow-up for liver disease
– AFP, U/S HBS)
Non variceal bleeding
State the non variceal bleeding etiology
-Peptic Ulcer disease (most common cause)
-Stress ulcer
-Mallory Weiss tear
-Dieulatoy’s Disease
-Malignancy
-Gastric antral vascular ectasia
Peptic Ulcer Disease (most common cause)
● History of dyspepsia (indigestion), previous H. pylori infections, previous endoscopy (OGD) performed
● Drug History – NSAIDs, antiplatelets, steroids, anticoagulants, TCM
● Secondary to cirrhosis-induced hypergastrinemia from decreased hepatic metabolism of GI hormones
Malignancy (gastric / oesophageal carcinoma)
● Early lesions: asymptomatic, epigastric pain, dyspepsia
● Intermediate lesions: anemia, melena, hematemesis, early satiety, dysphagia (difficulty swallowing) , nausea/vomiting, bloatedness
● Late lesions: loss of appetite, loss of weight, palpable epigastric mass, obstructive jaundice (mets to liver)
On clinical examination , what is the most important to check
- Vital Signs (most important)
- Assess hemodynamic stability – blood pressure, heart rate, oxygen saturation , PAIN SCORE ( Prof Sohail)
After checking vital signs , what is the next steps in clinical examination
- Confirm UBGIT
- DRE for melenic stool (differentiate from Fe-laden stools)
- If NGT in-situ, can aspirate on NGT - coffee grounds vomitus - Determine Etiology
- Variceal Bleed: look for stigmata of chronic liver disease, jaundice
- Non-variceal bleed - Look for complications
- Signs of Anemia
● Face – (i) conjunctival pallor (ii) pallor of mucous membrane
● Cardiac Auscultation – short systolic flow murmur at aortic area (rarely assessed)
● Pulse – (i) tachycardia (ii) bounding (iii) collapsing pulse
● Hands – pallor of palmar creases
- Urine output – is patient clinically dehydrated
- Lungs: auscultate for any aspiration pneumonia
- Exclude peritonism – contraindication for endoscopy (ensure no abdominal guarding / rigidity)
What is the principle of management of UGIB
Patients’ hemodynamic status must be immediately assessed. Fluid resuscitation is the first step in the management. Once the patient
is stabilized he can be transferred for further investigations to determine the cause of the bleeding. Escalate to seniors early if the
patient is hemodynamically unstable.
Early medication :
-PPI
-variceal : somatostatin ( to reduce pressure in the portal) , cefrtiaxone (antibiotic)
