Upper GIT Bleeding

Question 1

What is upper gastrointestinal bleeding?

Answer 1

refers to blood loss within the intraluminal gastrointestinal tract from any location between the upper oesophagus to the duodenum at the Ligament of Treitz

Question 2

Whats more common: UGIB and LGIB?

Answer 2

UGIB is more common than bleeding from the lower GI tract, accounting for 70% of all gastrointestinal bleeding.

Question 3

Local causes of UGIB?

Answer 3

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)

Question 4

General/Systemic Causes of UGIB?

Answer 4

Bleeding Diathesis
1. Haemophilia, Leukaemia, Thrombocytopaenia
2. Hereditary haemorrhagic telangiectasia
3. Anticoagulant therapy

Question 5

What is portal hypertension?

Answer 5

Obstruction in the portal tree
1. Pre-hepatic
2. Hepatic
3. Post-hepatic

Question 6

Causes of portal hypertension?

Answer 6

Cirrhosis is by far the commonest cause of portal hypertension
- May not be true in Malawi!
> Shistosomiasis – periportal fibrosis

Question 7

Portosystemic shunts in portal hypertension?

Answer 7

1. Left gastric vein and oesophageal veins
2. Superior and inferior rectal veins
3. Obliterated umbilical vein & epigastric veins
4. Retroperitoneal & diaphragmatic anastomoses

Question 8

Describe left gastric vein and oesophageal veins?

Answer 8

• Largest & clinically the most important connections
• Bleeding oesophageal varices is the most serious complication of PHTN

Question 9

Presentation of portal hypertension?

Answer 9

1. With portal congestion
   - Splenomegaly
   - Often associated with hypersplenism
2. Umbilical vein recanalization
   - which leads to the caput medusae
3. Ascites
4. Anorectal varices

Question 10

What is peptic ulcer disease?

Answer 10

An imbalance between acid secretion and mucosal defense mechanisms

Question 11

Causes of peptic ulcer disease?

Answer 11

1. Helicobacter pylori (H. pylori) infection
   - 90% - 95% DU & 70% - 90% GU
2. Nonsteroidal anti-inflammatory drug (NSAID)
3. Cigarette smoking
4. Acid hypersecretion

Question 12

Peptic ulcer disease and H. Pylori?

Answer 12

• 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.

Question 13

Leading cause of death in PUD?

Answer 13

Hemorrhage is the leading cause of death due to PUD ~ 5% to 10% mortality

Question 14

Most common cause of UGIB?

Answer 14

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

Question 15

Clinical presentation of UGIB?

Answer 15

1. Dysphagia/Odynophagia
2. Haematemesis (Haemorrhagic shock)
3. Abdominal pains
4. Chronic anaemia symptoms
5. Stigmata of liver disease
6. Malaena

Question 16

Treatment of UGIB?

Answer 16

resuzcitation

Question 17

General measures in UGIB?

Answer 17

Airways, Breathing, Circulation
Give oxygen
Large bore cannula
Commence rapid fluid iv (N saline)
Assess for shock

Question 18

Management of UGIB?

Answer 18

1. Assessment and replacement of blood (volume) loss
2. Diagnosis of source of bleeding
3. Treatment and control of source of bleeding

Question 19

Describe bleeding in UGIB?

Answer 19

80% of UGIB will stop spontaneously !
- Risk of rebleeding (25%)
Look Up Rockall Score and Complete Rockall Score

Question 20

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?

Answer 20

1. Hypotension or tachycardia, oliguria, hematemesis, low hemoglobin
2. Significant chronic cardiac, pulmonary, renal, or liver disease
3. Patient on antiplatelet or anticoagulant medications, including aspirin and NSAIDs, or those on immunosuppressive medications like steroids
4. 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)
5. Age over 60
6. Elevated BUN or creatinine

Question 21

What you need to come up with the diagnosis of UGIB?

Answer 21

1. Patient’s history
2. Clinical examination
3. General and specific investigations
   - FBC & G, Xmatch
   - LFTs
   - U&Es, ABGs
   - UGI endoscopy

Question 22

Class I hemorrhagic shock?

Answer 22

1. blood loss <750 mls
2. pulse rate <100/min
3. blood pressure normal
4. pulse pressure normal
5. respiratory rate 14-20/min
6. urine output >30ml/hr
7. mental status slightly anxious

Question 23

Class II hemorrhagic shock?

Answer 23

1. blood loss 750-1500 mls
2. pulse rate >100/min
3. blood pressure normal
4. pulse pressure decreased
5. respiratory rate 20-30/min
6. urine output 20-30ml/hr
7. mental status slightly anxious

Question 24

Class III haemorrhagic shock?

Answer 24

1. blood loss 1500-2000
2. pulse rate >120/min
3. blood pressure decreased
4. pulse pressure decreased
5. respiratory rate 30-40/min
6. urine output 5-25 ml/hr
7. mental status anxious + confused

Question 25

Class IV haemorrhagic shock?

Answer 25

1. blood loss >2000
2. pulse rate >140/min
3. blood pressure decreased
4. pulse pressure decreased
5. respiratory rate >40/min
6. urine output negligible
7. mental status lethargic

Question 26

Mechanical management of UGIB?

Answer 26

1. Nasogastric tube
2. Sengstaken- Blakemore tube
3. Endoscopic therapy
   - Injection Sclerotherapy, Banding
4. Surgery