Upper GI bleed

Question 1

What is an upper GI bleed?

Answer 1

Upper GI bleed involves:
0  mouth, 
0 oesophagus
0 Stomach
0 Duodenum 

Can cause :
0 Hemoptysis - vomiting blood
0 melena - black tarry stools

Question 2

Causes of Upper GI bleed? - relating to oesphagus

Answer 2

Oesophagitis - inflammation of Oesophagus
0 Severe GORD - irritate the lining and cause bleeding.
0 Infective
0 Chemical
0 eosinophilic
0 Barretts oesophagus - cells in the cell lining change in morphology ( grow abnormally)and can lead to adenocarcinoma - oesophageal cancer - but not common.

0 oesophageal varices - dilated veins of esophagus which can rupture
- diagnostic tool - endoscopy
symptoms - bleeding,no pain
Causes - portal Hypertension secondary to liver cirrhosis.
Very dangerous - cause internal hemmorage.

• esophagus drained by left gastric vein + oesophageal vein which anastomose. Portal hypertension will interrupt drainage and lead to blood pooling in the veins of oesophaus.

0 Oesophageal tear - prolonged retching caused bleeding

  - Mallory Weiss Syndrome - tear/ laceration in mucous membranes - normally located in junction btw esophagus and stomach.

Symptoms -

• Severe vomiting
• abdomainal pain
• Hematemesis - appearence of coffee grounds.
• retching
• melena
• severe blood loss can cause shock, collapse. - rare and life-threatening.

Causes - ( chronic retching, vomiting, coughing, straining) chronic alcoholism, severe trauma to chest/abdomen, oesophagitis, gastritis, chemotherapy, etc.

0 Mass lesions e.g Polyps or tumours
- Oesophageal Adenocarcinoma or
squamous cell carcinoma

Question 3

Causes of Upper GI bleed relating to stomach ?

Answer 3

Erosive gastritis - erosion in gastic mucosa causing bleeding ( can hae few or no symptoms )

Treatment ; PPI , H2 blockers - inhibit gastic secretion

CAUSES : alcohol , NSAID use , stress

Diagnosis - endoscopy

Mass lesions e.g Polyps or tumours

            - Benign - Gastric adenomas
            - Fundic gland polyps - polyps located into the fundus of the stomach - most common stomach polyp - usually occur in groups. 
            - inflammation and Hyperplastic Polyps. 

• polyps - abnormal tissue growths - look like small flat bumps.
  can happen in colon, bowel, stomach, uterus, oesophagus, cervix etc.

Benign polyps classified into 2 ;
- adenoma- potential to become cancerous

• hyperplastic/inflammatory polyps - rarely become cancerous.

Malignant

0 Gastric Carcinoma - most common
0 Gastric Lymphoma
0 Carcinoid tumour
0 Stromal cell tumour

Dieulafoy’s lesion - RARE - life-threatening - abnormally large artery, bulging - rupture and cause haemorrhage and internal bleeding.

Angiodysplasia - elastic dilated thin-walled vessels lined by epithelium alone.

( fragile , leaky blood vessels - i think it is more linked to lower GI bleed as most common in the colon - 2nd most common cause of lower GI bleed in > 60 ) - cause GI bleeding and anaemia .

Symptoms - intermittent GI bleeding without pain.

Ulceration - Gatric

P

Question 4

Causes of Upper GI tract - Duodenum ?

Answer 4

Duodenal Ulcer.

Question 5

Drainage to Liver ?

Answer 5

Dual blood sulpply

0 Hepatic portal vein - made up of the joining of Splenic , inferior and superior mesenteric vein (can be some variation - but usual pattern of convergence) -
75 % of blood (Portal System )

• Inferior mesenteric drains into splenic which joins superior mesenteric .

0 Hepatic Artery Proper - derived from Coeliac trunk - 25 % of blood supply - provides 40 % of oxygen

1 -2 L / min of blood flows through Liver.

Liver uses 20% of Oxygen at rest.

Question 6

What is the Porta Hepatis - what does it contain ?

Answer 6

Deep fissure in inferior surface of liver- entrace and exit for neurovasculature.

• separates Caudate from Quadrate Lobe.

Main Contains : -
   0 Hepatic Portal vein
  0 Common Bile duct 
  0 Hepatic artery proper
0 Lymphatics 
0 Hepatic Nervous Plexus
0 hepatic ducts 

• Not veins.

Question 7

Significance of the Hepatorenal space

Answer 7

Hepatorenal recess separates liver from right kidney. - Potential space - so under normal circumstance should not be filled by fluid e.g fluid (edema) - acities, blood

if filled will be seen on ultrasound - near black stripe.

Question 8

What is Portal Hypertension causes ?

Answer 8

Increase in pressure in the portal venous system.

CAUSES :

Pre- hepatic
0 portal /splenic vein thrombosis
0 Congenital atresia / stenosis - narrowing of portal vein
0 External pressure e.g tumor

Hepatic 
   0 Cirrhosis - common
   0 hepatitis
   0 schistosomiasis/    bilharzia ( infection caused by a parasitic worm that lives in fresh water in subtropical/ tropical regions - can remain in body for long time and damage organs - liver , bladder etc. 
   0 Idopathic portal hypertension

Post -hepatic - Budd - Chiari syndrome - occlusion of hepatic veins - rare

Question 9

`Importance of Portocaval anastomoses ?

also signs of Portal hypertension.

Answer 9

porto - portal vein

Caval - Systemic veins

examples -
0 Oesohagael - btw oesophageal branches of left gastric and of azygous vein

0 rectal - btw superior rectal and middle/ inferior rectal veins

0 Para - umbilical - btw para umbilical veins and superior epigastric veins

In portal hypertension, back flow to blood here causing distention and bulging ———> varices ——–> increased pressure also causes ascites (fluid build-up in peritoneal cavity

• cirrhosis - does not produce albumin , reduced onocotic pressure.

Cirrhosis - reduced aldosterone metabolism - so more aldosterone with cirrhosis which retains salt and water. )

Cirrhosis - causes splanchnic vasodilation - blood vessels in abdomen so kidney gets reduced blood flow and responds by retaining more fluid.
- vicious circle )

Hepatorenal syndrome - serious complication of cirrhosis - type of liver failure type of liver failure.

0 increased splenic pressure - Splenomegaly

Rectal varices —–> lead to Hemorrhoids - can bleed.
( treat underlying condition )

Para - umbilical varices —-> CAPUT MEDUSA

Oesophagelal varices - prone to very bad rupture

*Varices - happen secondary to portal hypertension
vs hemorrhoids - can happen to anyone

• note - altered blood flow - blood drained from GI bypass liver ——> toxins not filtered ——-> can cause hepatic enecephopathy

Question 10

Treatment of Portal Hypertension ?

Answer 10

TIPS Procedure

Transjugular intrahepatic portosystemic shunt

Go through jugular vein ——> into IVC—–> Hepatic vein —–>through liver -
place a stent , bypassing liver and cirrhosis.

shunting blood to bypass liver