Upper Gastrointestinal Bleeding

by

prof/ gouda ellabban

Definition:

Bleeding in the digestive tract is a symptom of disease rather than a disease itself.

Upper gastrointestinal bleeding is a hemorrhage originating proximal to the ligament of treitz.

Pathophysiology:

UGIB occurs from a variety of etiologies, it is often related to mucosal erosion with subsequent hemorrhage.

The disease usually manifests it’s self as being acute or chronic.

Differential diagnosis:

Acute UGIB: Gastric & Duodenal ulcers Esophageal varices Mallory-Weiss tear Esophagitis Hemorrhagic gastritis Neoplasm Dieulafoy lesion

D Dx of AUGIB Continued…

Angiodysplasia Hemoblia Pancreatic pseudocyst Pancreatic pseudoaneurysm Aortoenteric fistula Trauma

D Dx of CUGIB Continued…

Chronic UGIB:

Chronic blood loss can occur with any lesion of the gastrointestinal tract that produces acute bleeding. However it should be remembered that hook worm is the most common cause of chronic gastrointestinal blood loss.

Clinical presentation:

History & physical examination finding in acute UGIB:

Hematemesis Melena Hematochezia Syncope Presyncope

Findings Continued…

Dyspepsia Epigastric pain Heartburn Weight loss Jaundice

Findings in chronic UGIB: Iron deficiency anemia.

Management

The major factor determining the diagnostic and therapeutic approach is the amount & rate of bleeding.

Although 75% of patients stop bleeding spontaneously a significant % require further investigations involving the combined efforts of gastroenterologists, surgeons, & interventional radiologists.

Initial management:

Resuscitation(ABC, intubations & intravenous access)

Assess response to resuscitation(serum lactate or mixed venous oxygen saturation, foley catheter)

Nasogastric tube(aspirate & lavage)

Admission(history and physical examination)

Lab studies:

Hemoglobin value Blood type & crossmatch BUN-to-creatinine ratio Coagulation profile LFT Plasma fibrinogen level Serum electrolyte values

Diagnosis:

Endoscopy Diagnostic Therapeutic

Other procedures Angiography Barium X-ray CT scan

Therapeutic endoscopy:

Injection of vasoactive agent

Injection of sclerosing agent

Bipolar electrocoagulation

Thermal probe coagulation

Castant probe pressure tamponad

Argon plasue coagulater Laser photocoagulator Rubber band ligation Biologic glue

Management of Specific Conditions Peptic ulcer:

Eradication of H-pylori Proton pump inhibitor Endoscopy Surgery Transcatheter angiographic embolization

Variceal bleeding: Vasopressin Injection sclerotherapy & Variceal banding Balloon tamponade

Continued…

Mallory-Wiess tear: Bleeding ceases spontaneously Thermal probe Over sewing

Dieulafoy lesion: Thermal probe Surgical

Angiodysplasia: Thermal probe & band ligation surgical

Prognosis

Age Hematemesis vs.melena Continuing blood loss Amount of blood loss (units of blood) Recurrent hemorrhage Chronic liver disease Co-morbidity

Conclusion

UGIB has been a surgical problem, yet today endoscopic & angiographic methods are used to help diagnose and control the bleeding. Although these technologies have advanced, surgical intervention is necessary to manage some specific & life threatening situations.

References

Short practice of surgery, Bailey & love’s Current surgical diagnosis &treatment, lange Clinical medicine, by Kumar & clark eMedicine, gastrointestinal bleeding: surgical

perspective by James De Caestecker

Thanks!