Upper GIT Bleeding Flashcards
What is upper gastrointestinal bleeding?
refers to blood loss within the intraluminal gastrointestinal tract from any location between the upper oesophagus to the duodenum at the Ligament of Treitz
Whats more common: UGIB and LGIB?
UGIB is more common than bleeding from the lower GI tract, accounting for 70% of all gastrointestinal bleeding.
Local causes of UGIB?
Best considered anatomically
1. Oesophagus
- Oesophagitis, Varices, Oesophageal Tumours
2. Stomach
- Erosive Gastritis, Gastric Ulcers, Gastric Tumours, Isolated Gastric Varices, Dieulafoy’s Lesion
3. Mallory-Weiss Syndrome
4. Duodenum
- Severe Duodenitis, Duodenal Ulcers, Duodenal Erosion (Pancreatic Tumour)
General/Systemic Causes of UGIB?
Bleeding Diathesis
1. Haemophilia, Leukaemia, Thrombocytopaenia
2. Hereditary haemorrhagic telangiectasia
3. Anticoagulant therapy
What is portal hypertension?
Obstruction in the portal tree
1. Pre-hepatic
2. Hepatic
3. Post-hepatic
Causes of portal hypertension?
Cirrhosis is by far the commonest cause of portal hypertension
- May not be true in Malawi!
> Shistosomiasis – periportal fibrosis
Portosystemic shunts in portal hypertension?
- Left gastric vein and oesophageal veins
- Superior and inferior rectal veins
- Obliterated umbilical vein & epigastric veins
- Retroperitoneal & diaphragmatic anastomoses
Describe left gastric vein and oesophageal veins?
- Largest & clinically the most important connections
- Bleeding oesophageal varices is the most serious complication of PHTN
Presentation of portal hypertension?
- With portal congestion
- Splenomegaly
- Often associated with hypersplenism - Umbilical vein recanalization
- which leads to the caput medusae - Ascites
- Anorectal varices
What is peptic ulcer disease?
An imbalance between acid secretion and mucosal defense mechanisms
Causes of peptic ulcer disease?
- Helicobacter pylori (H. pylori) infection
- 90% - 95% DU & 70% - 90% GU - Nonsteroidal anti-inflammatory drug (NSAID)
- Cigarette smoking
- Acid hypersecretion
Peptic ulcer disease and H. Pylori?
- The prevalence ofH. pyloriinfection within sub-Saharan Africa is quite high, with epidemiologic studies showing infection rates of 60-100% in many areas of the region.
- Because of the high prevalence, a positive screening test forH. pylorishould be considered to represent an infection if the patient has not been treated.
Leading cause of death in PUD?
Hemorrhage is the leading cause of death due to PUD ~ 5% to 10% mortality
Most common cause of UGIB?
peptic ulcer bleeding is the most common cause of upper gastrointestinal bleeding
- responsible for about 50% of all cases, followed by oesophagitis and erosive disease worldwide, some studies in Africa indicate esophageal varices as the most common cause
Clinical presentation of UGIB?
- Dysphagia/Odynophagia
- Haematemesis (Haemorrhagic shock)
- Abdominal pains
- Chronic anaemia symptoms
- Stigmata of liver disease
- Malaena
Treatment of UGIB?
resuzcitation
General measures in UGIB?
Airways, Breathing, Circulation
Give oxygen
Large bore cannula
Commence rapid fluid iv (N saline)
Assess for shock
Management of UGIB?
- Assessment and replacement of blood (volume) loss
- Diagnosis of source of bleeding
- Treatment and control of source of bleeding
Describe bleeding in UGIB?
80% of UGIB will stop spontaneously !
- Risk of rebleeding (25%)
Look Up Rockall Score and Complete Rockall Score
Patients are stratified as to their risk of persistent bleeding requiring repeat endoscopic intervention or surgery. The following criteria should be used to classify patients as high-risk?
- Hypotension or tachycardia, oliguria, hematemesis, low hemoglobin
- Significant chronic cardiac, pulmonary, renal, or liver disease
- Patient on antiplatelet or anticoagulant medications, including aspirin and NSAIDs, or those on immunosuppressive medications like steroids
- Endoscopy showing bleeding varices, active bleeding from any source, a visible vessel in an ulcer, stigmata of recent bleeding, such as clot on an ulcer bed (obviously, this is only known once the initial endoscopy is performed)
- Age over 60
- Elevated BUN or creatinine
What you need to come up with the diagnosis of UGIB?
- Patient’s history
- Clinical examination
- General and specific investigations
- FBC & G, Xmatch
- LFTs
- U&Es, ABGs
- UGI endoscopy
Class I hemorrhagic shock?
- blood loss <750 mls
- pulse rate <100/min
- blood pressure normal
- pulse pressure normal
- respiratory rate 14-20/min
- urine output >30ml/hr
- mental status slightly anxious
Class II hemorrhagic shock?
- blood loss 750-1500 mls
- pulse rate >100/min
- blood pressure normal
- pulse pressure decreased
- respiratory rate 20-30/min
- urine output 20-30ml/hr
- mental status slightly anxious
Class III haemorrhagic shock?
- blood loss 1500-2000
- pulse rate >120/min
- blood pressure decreased
- pulse pressure decreased
- respiratory rate 30-40/min
- urine output 5-25 ml/hr
- mental status anxious + confused
