UPPER GASTROINTESTINAL HEMORRHAGE

Prof. Feroze Quader Dept. of Surgery BKZMC

 Upper GIT Hemorrhage is a very frequent medical problem. Bleeding Peptic ulcer, Portal hypertension, Gastritis and Oesophageal varices are the common causes for hemorrhage. Hematemesis or melena is usually present unless rate of bleeding is minimum. Acute bleeding stops spontaneously is 75 % cases.

Rest of the patient requires surgery or die out of complications.

Incidence % Common causes Peptic Ulcer Dudenal ulcer Gastric ulcer Esophageal varices Gastritis Mallory-Weiss syndrome Uncommon causes Gastric Carcinoma Esophagitis Pancreatitis Hemobilia Duodenal diverticulum 45

Uncommon causes 5%

20 20 10 5

MalloryWeiss syndrome 10% Peptic Ulcer 45%

Gastritis 20%

Esophageal varices 20%

Gastric Ulcer

Duodenal Ulcer

Ca-Stomach

Esophageal varices

Gastritis

Mallory-Weiss Tear

 Hematemesis Vomiting of blood is common when bleeding originates from Stomach or esophagus. Color of the vomitus will be coffee- ground when gastric acid converts hemoglobin into methemoglobin. Melena Passage of black tarry stools are common when there is bleeding from any part of Upper GIT. The black color of melenic stools is caused by Hematin ,the product of oxidation of Haem by intestinal and bacterial enzymes.

 Hematochezia It is defined as passage of bright-red blood from the ractum. Common in bleeding from Colon, Rectum and Anus. In case of brisk bleeding in the Upper GIT, Bright red blood may come out unchanged in the stool.

Initial assessment and management goals:

Assessment of the status of the circulatory system and

replace blood loss as necessary. Determine the amount and rate of bleeding. Slow or stop the bleeding by ice-water lavage Discover the lesion responsible for the episodes. Specific management for underlying causes.

 Patient may have h/o weakness, dizziness, syncope associated with Hematemesis, melena and hematochezia. Patients may have a history of previous dyspepsia, ulcer disease, early satiety, and NSAIDs use. Smoking and alcohol may have some association.

 The goal of the patient's physical examination is to evaluate for shock and blood loss. signs of shock include cool extremities, oliguria, chest pain, pre-syncope, confusion, and delirium. Hematemesis and melena should be noted.

 Signs of chronic liver disease should be noted, including

spider angiomata, gynecomastia, splenomegaly, ascites, pedal edema

Signs of tumor are uncommon but indicate a poor prognosis. Signs include a nodular liver, abdominal mass, and enlarged and firm lymph nodes.

 Blood grouping and Rh typing and cross matching.

Upper gastrointestinal endoscopy :
In case of massive bleeding Endoscopy should be carried out by an experienced operator as soon as the patient is resuscitated. For patient with mild bleeding, endoscopy should be carried out on the next morning after admission.

Occult Blood Test:

Normally 2.5 blood is lost per day. Blood loss between 50-100 ml /day will produce melaena. OBT detects amount between 10-50 mL/d.

 Specific treatment: Peptic Ulcers: Endoscopic hemostastasis Medical management by H2 antagonist or PIP Surgical treatment Esophageal varices: Endoscopic control by electro-coagulation or injection Medical treatment for Portal hypertension..

 Specific treatment:
Gastric erosions: Endoscopic hemostastasis Medical management by H2 antagonist or PIP Surgical treatment Mallory-Weiss Tear: Endoscopic treatment If fails, gastrostomy and repair of the tear. Malignancy:
Should be treated appropriately

Upper GI Bleeding Massive Hemorrhage Endoscopy Resuscitation Routine Inv Chronic Bleeding

Ulcer

Varices

Erosions

MalloryWeiss

Malignancy

Endoscopic hemostastasis Medical management by H2 antagonist or PIP Surgical treatment

Endoscopic control by electro-coagulation or injection Medical treatment for Portal hypertension.

Endoscopic hemostastasis Medical management by H2 antagonist or PIP Surgical treatment

Endoscopic treatment If fails, gastrostomy and repair of the tear.

Should be treated appropriately