Acute upper gastrointestinal Bleeding Prof.Dr.Khalid Al-Khazraji MBCHB , MD, CABM , FRCP , FACP Baghdad medical college

Epidemiology The most common gastrointestinal emergency. Overall incidence is approximately 100 hospitalizations per 100 000 adults per year. The incidence among men is approximately double than that among women. Rate increases markedly with age. Mortality rate is 5-12%

Clinical features The two cardinal features are: - 1- Haematemesis: bloody vomitus ; either fresh & bright red or older and “coffee-ground” in character. 2- Melaena: Passage of black, tarry, foul-smelling stools. Following a bleed from the upper GI tract, unaltered blood can appear per rectum, but the bleeding must be massive and is almost always accompanied by shock. The passage of dark blood and clots without shock is always due to lower GI bleeding.

Aetiology Common causes: - Other uncommon causes: 1- Peptic ulcer. 35-50% 2- Gastric erosions. 10-20% 3- Esophagitis (usually with hiatus hernia). 5% 4-Varices. 5-15% 5- Vascular malformation. 2% 6- Mallory - weiss tears. 5% 7- Cancer of stomach or esophagus. 5% Other uncommon causes: 1-Hereditary telangiectasia (osler-weber-rendu syndrome). 2-Pseudoxanthoma elasticum. 3-Blood dyscrasias. 4-Dieulafoy gastric vascular abnormality. 5-Portal gastropathy 6-Aortic graft surgery with fistula.

Causes:

Clinical Assessment -Haematemesis is red with clots when bleeding is profuse, or black (coffee grounds) when less severe. Intravascular volume depletion Hypotension Syncope -Symptoms of anaemia suggest chronic bleeding. - Approximately 85% of patients stop bleeding spontaneously within 48 hours. - Factors affects the risk of rebleeding and death:- 1- age 2- evidence of co-morbidity 3- shock 4- endoscopic diagnosis 5- ulcer with active bleeding 6- clinical signs of chronic liver disease

Calculate after endoscopy Rockall Score Parameter 1 2 3 Age <60 60-79 ≥80 Shock None HR >100 SBP <100 Co-morbidity Nil CCF, IHD , major comorbidity Renal / liver failure Metastatic cancer Calculate after endoscopy Diagnosis M-W tears, or normal All other diagnoses GI malignancy Evidence of Bleed Blood in stomach Adherent clot Visible or spurting vessel Final score 0 - 11

Management Immediate Management The goals of management: First the patient’s hemodynamic status must rapidly assessed & resuscitative measures initiated. Only then should next steps in management be undertaken: determine the source of hemorrhage, stop the Bleeding and prevent recurrent rebleeding. Immediate Management 1- History and examination. Note co-morbidity. 2- Monitor pulse and BP half-hourly. 3- Take blood for: Hb, electrolytes, urea, liver biochemistry, coagulation screen, group and cross-match. 4- IV access (2 large-bore i.v cannulae). Central line if brisk bleed. 5- Give blood transfusion/colloid if necessary. Indications for blood transfusions are: A- shock B- Hb less than 10 g/dL. 6-Oxygen 7- Urgent Endoscopy in shocked patients / liver disease. 8- Continue to Monitor Pulse and BP. 9- Re-endoscope for continued bleeding / hypovolemia. 10- surgery if bleeding persist.

Indication for urgent endoscopy : 1-large initial bleed 2-patients with resting hypotension or orthostatic change 3-repeated hematemesis or bloody nasogastric . 4-requiring blood transfusions

Endoscopy: can detect the cause of bleeding in 80% or more of cases. At first endoscopy: Varices treated with banding, or sclerosing. Bleeding ulcer treated with two haemostatic Methods ( injection with adrenaline ,& thermal Coagulation). Or by endoscopic clipping - Take antral biopsy for H. pylori. Drug therapy After diagnosis at endoscopy; give IV omeprazole 80 mg followed by 8 mg/h 72 hours to all ulcer patients as it reduces the rebleeding rates and the need for surgery. H2-receptor antagonists are of no value.

Atlas DU with clot Therapy with Argon photocoagulation of vessels of DU

Mallory weiss syndrome

Variceal banding

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