1. Acute Upper GIT bleeding

2. Lecture outline Definition Epidemiology Causes Clinical presentation
Diagnosis
Treatment
Complications
Prognosis

3. 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.

4. 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.

5. 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

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

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

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

9. 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.

10. 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.

11. 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.

12. 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!

13. 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

14. 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

15. 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

16. 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.

17. 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 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.

18. 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.

19. 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.

20. Thank you