Upper Gastrointestinal Bleeding

Anthony Alexander University of the West Indies at Mona

Overviewy Loss of blood from the upper gastrointestinal tract y Clinical spectrum ranging from haematemesis to

circulatory collapse y Occurs at any agey Particularly between the ages of 40-79 y Mortality greatest in patients above 60

y 50-150/100,000 adults/year (US), 50-120/100,000 (UK)

Relevant Anatomy

Ligament of TreitzRuns from crus of diaphragm to DJ flexure Bleeds originating above this point are classified as UGIB

Aetiologyy Common y Peptic ulcer (35-50%) y Gastritis & gastric erosions (10-20%) y Oesophagitis (10%) y Bleeding varices (2-9%) y Drugs: NSAID, aspirin, steroids, thrombolytics, anticoagulants y No obvious cause

Aetiologyy Less common y Mallory-Weiss tear (5%) & Boorhaave s y Vascular malformations (5%) y Cancer of oesophagus/duodenum (2%) y Aortoenteric fistula (0.2%)

PathophysiologyDepends on the aetiology, but y Most commonly:y Mucosal erosion into blood vessels y Strong association with:y y

haemorrhage

y

H. pylori: inflammatory effect on gastric mucosa NSAIDS: COX activity thus impaired mucosal protection against acid Alcohol consumption

Pathophysiologyy Oesophageal varicesy Portal hypertension leads to dilated submucosal

veins in lower oesophagusy

y

Blood that would flow through the portal circulation is redirected to areas of lower venous pressure These dilated vessels are susceptible to bleeding

Pathophysiologyy Mallory-Weiss tear y Retching against closed LES increased intragastric pressure y There is now a gradient between intragastric and intrathoracic pressures y If a shearing force is generated longitudinal laceration

PresentationHistory y Haematemesisy Red with clots with severe bleeding y Coffee grounds when less

y Melaena/Haematochezia y Dark, tarry foul smelling stool y Estimated blood loss and symptoms of hypovolaemia y Pain y Duration y Vomiting/retching y Past Mx Hx: Previous GI bleed, coagulopathy, known liver disease/varices y Comorbidities: cardiovascular, respiratory, hepatic/renal y Past Sx: AAA y Drugs y Social: alcohol consumption

Examinationy General y Mucous membranes y Cool, clammy, pale skin y Decreased conscious level y Respiratory distress

Examinationy Signs of circulatory compromise y Altered consciousness hepatic encephalopathy y Reduced urine output y Tachycardia y Hypotension (SBP 20 mmHg, systolic)

Examinationy Signs of chronic liver disease y Leukonychia y Clubbing y Palmar y Asterixis y Jaundice y Gynaecomastia y Ascites y Spider Naevii y Distended veins y Signs of hepatic encephalopathy

Examinationy Abdomen y Distension y Tender epigastrium, tender/enlarged liver, AA y Abdominal scars: aneurysm repair? y Caput medusae, distended veins y Ascites y Rectal y Melaena y Haemathochezia

Managementy Secure airway y Sever haematemesis from bleeding varix/ulcer y conscious level due to extensive blood loss loss of airway protective reflexes y May need to intubate

Management:y Secure breathing y Supplemental oxygen

Management Secure circulationy

y y

y

2 large bore IV cannulae CBC U+E LFT Clotting studies Group and crossmatch Crystalloid bolus: 2L or 20ml/kg Blood: type O if necessary before results of crossmatch U cath to monitor U/O

Monitory Vitals y U/O y CVP indicated in severe bleed

Indications for Transfusiony Low blood pressure y Evidence of volume depletion after crystalloid bolus y Severe distress, cardiac ischaemia, massive blood loss y Platelets 2mg/dl admit

For dischargey Historically, all patients admitted y However, stable UGIB patients with a normal Hb, few

or no comorbidities, and a small amount of bleeding that has resolved may be discharged if close followup(1 2 days) is available. y Advised to return immediately if any symptoms return

COMPLICATIONS y Shocky DIC y Azotemia

y Endoscopy

COMPLICATIONSy Aspiration pneumonia y Perforation (1% for the first endoscopic therapy, 3% for the second) y Bleeding can be caused by drilling into the vessel with the laser, by

perforating the vessel with an injection, or by removing the clot with a failure to coagulate the vessel.y Surgeryy Ileus y Sepsis y Poor wound healing y Myocardial infarction

Prognosisy 10 % die

Summaryy UGIB is the most common GI emergency y PUD is the commonest cause y ABC s, monitoring y PPI s y Arrange for urgent endoscopy