Acute Upper GIT bleeding

Lecture outline Definition Epidemiology Causes Clinical presentation Diagnosis Treatment Complications Prognosis

Definition Upper GIT bleeding can be defined as bleeding occuring from the gastrointestinal tract from any point proximal to the duodeno-jejunal (DJ) flexure at the ligament of Trietz.

Epidemiology Cases of Upper GIT bleeding have been reported globally. Incidence varies from region to region and depends on the predominant aetiology. Male and female affected. Gender disparity also hinges on aetiology.

Causes of upper GIT bleeding Prevalence (%) Bleeding peptic ulcer disease Erosive Gastritis/oesophagitis Variceal bleeding (Liver cirrhosis) Mallory-Weiss tear Upper GIT tumour (Oesophageal,gastric,duodenal) Inflammatory bowel diseases-Crohn’s, UC Vascular abnormalities-Angiodysplasia,Gastric atral vascular ectasia Stress Ulcer- following ay severe illness. 35-50 15-20 5 2 1

Clinical presentation Features of blood loss Hematemesis-fresh blood or coffee grounds Malena Hematochizia Pallor

Clinical presentation Features of underlying cause Liver cirrhosis-ascites,jaundice,wasting,parotid fullness etc

Clinical presentation Features of haemodynamic instability (occurs in the setting of severe blood loss) Hypotension Tachycardia Bradycardia Anaemic heart failure

Diagnosis Diagnosis is based on History,PE and investigations. Establishing aetiology usually secondary to patient resuscitation. Initial management and resuscitation is preemient in patients with severe upper GIT bleeding.

History History of blood loss- Hematemesis(fresh blood or coffee groud),Malena,Haematochizia History to ascertain haemodynamic instability- amount of blood loss (volume, clots, frequency),postural dizziness, fatique, lack of urine, altered conscious level.

History History to ascertain aetiology Peptic ulcer disease Drug intake-Aspirin,NSAIDs,Steroids Alcohol int- Mallory Weiss syn- hx of protracted vomitting Liver cirrhosis- Hx of previous jaundice,blood trasfusion,liver disease.

Examination Ascertain the extent of blood loss-Pallor,hypotesion,tachycardia,bradycardia. Look out for possible aetiology,eg- stigmata of chronic liver disease. Dont forget to do a rectal examination!

Investigations Urgent Blood grouping and cross matching- The 1st and unarguably the most important. FBC + Diff Anaemia-becomes evident after resuscitation. If anaemic at presentation-suggests massive bled. WBC- increased WBC sugggestive of sepsis as a possible aetiology. Platelets- reduced counts may be indicative of hypersplenism due to liver cirrhosis. Clotting profile- usually deranged In liver cirrhosis

Investigations contd Abdominal ultrasound-may reveal cirrhotic liver, intra-abdominal mass lesion. Upper GI endoscopy-gold standard investigation. Should be done within 6 hours of presentation in high risk pts and within 24 hours In low risk patients. Endoscopy helps to answer 4 questions viz: 1. site of bleeding,2. activity of bleeders, 3.cause of bleeding, 4. suitability for endoscopic management. Liver function test Renal function test Septic work up

Treatment- Stratify all patients High risk patient Low risk patient *Age >60 years *Presence of shock-SBP<100,HR>100,postural hypotension *Hb < 10g/dl *Severe intercurrent illness-Liver,cardiac,renal ,respiratory disease or suspected variceal bleeding. *Age < 60 years *No evidence of Hypovolaemia *Hb> 10g/L *No underlying illness

Supportive treatment Admit patient in High dependency Unit or ICU ABC of life. A-Ensure airway is patent ,remove artificial dentures and other foreign bodies,lie patient of the lateral side to forestall aspiration. B-Ensure patient is breathing freely. If not,support respiration. Circulation-Transfuse patients with severe anaemia,those with hypotension and those with active (on –going) bleeding.

Definitive treatment Dependent of the cause of upper GIT bleeding. In cases of erosive gastritis- withdraw offending agents-NSAIDs, Alcohol, Herbal medications. Bleeding PUD-give IV Omeprazole 80mg stat,then 8mg hourly for 48-72 hours. Variceal bleeding- give vasopressin, terlipressin or octreotide, lower portal pressure after resuscitation,endoscopic injection sclerotherapy or banding,balloon tamponade. Stress Ulcer – Give PPIs Mallory Weiss syndrome-give PPI,antiemetics.

Complications of upper GIT bleeding Complications of bleeding Severe anaemia with anaemic heart failure Acute kidney injury/failure Aspiration syndrome Hepatic encephalopathy Complications of treatment Blood transfusion reactions Endoscopy complications.

Prognostic factors-Rockall score Cliical Variable Point score 1 2 3 Age (years) Shock Comorbidity Cause Stigmata of recent bleeding Total score<3=Good prognosis. 60 No shock Nil MW syndrome None or dark spot 60-79 HR>100,SBP >100 All other >80 HR>100,SBP <100 Cardiac. GIT malignancy Blood in the upper GIT,adherent clot,spurter. Liver,Renal,malignancy. Total score >8, High risk of death.

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