Upper Git Bleeding

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Upper Git Bleeding

  1. 1. Upper GIT bleeding By Dr. Osman Bukhari
  2. 2. <ul><li>Upper GIT bleeding is the most common medical GIT emergency . Presentation of upper GIT bleeding </li></ul><ul><li>1- haematemesis </li></ul><ul><li>2- melaena </li></ul><ul><li>3- rectal bleeding (haematochesia) </li></ul><ul><li>4- occult blood loss </li></ul><ul><li>5- symptoms : syncope, palpitation and </li></ul><ul><li>shock </li></ul>
  3. 3. <ul><li>Definitions - Haematemesis is vomiting of blood from a lesion proximal to distal duodenum. It is either red with clots if bleeding is profuse or coffee grounds when bleeding is less severe. </li></ul><ul><li>- Melaena is the passage of black tarry stools from bleeding proximal to and including caecum. Rarely massive bleeding presents as unaltered blood from rapid transit ( haematochesia ). </li></ul>
  4. 4. <ul><li>Etiology </li></ul><ul><li>Relative incidences of the causes depend on the patient population. </li></ul><ul><li>1- Variceal : evidence of PHT. </li></ul><ul><li>2- PU : Chronic dyspepsia, history of PU. Bleeding may be ppted by drugs or alcohol. </li></ul><ul><li>3- Gastric erosions :associated with ASA, NSAIDs and alcohol. </li></ul><ul><li>4- Reflux oesophagitis : bleeding not usually severe. </li></ul>
  5. 5. <ul><li>5- Mallory-Weiss tears . </li></ul><ul><li>6- Carcinomas (esophageal or gastric): chronic blood loss is usually present. </li></ul><ul><li>7- Vascular malformations . </li></ul><ul><li>8- Drugs : Aspirin & NSAIDs cause gastric erosions & ppt. bleeding from PU sp. in elderly. Anticoagulants from any cause. </li></ul><ul><li>9- Bleeding disorders & anticoagulation . </li></ul><ul><li>10- Aorto- enteric fistula : Bleeding in patient after aortic graft surgery. </li></ul>
  6. 6. <ul><li>Clinical approach </li></ul><ul><li>- Admit all patients with significant bleeding within 48 hours. In many no immediate TR is required as CVS can compensate. </li></ul><ul><li>- 85% STOP Bleeding spontaneously within </li></ul><ul><li>48 hours. </li></ul><ul><li>- Cause may be obvious from the history and examination. </li></ul><ul><li>- Age, amount of blood loss, shock, continuing visible blood loss, signs of chronic liver disease and co morbidity affect management </li></ul>
  7. 7. <ul><li>Immediate management </li></ul><ul><li>- IV access using two large-bore canulae. - Take blood for CBC, BUN, electrolytes, LFT, blood grouping & cross matching, clotting profile & start crystalloid or colloids </li></ul><ul><li>- Rapid initial clinical assessment with special look for signs of shock, evidence of liver disease, co morbidity & stop offending drugs. - Blood transfusion Restore blood volume rapidly to normal best using whole blood. Avoid overload and heart failure </li></ul>
  8. 8. <ul><li>- Oxygen by face mask to all shocked patients who should be managed in high dependency units. </li></ul><ul><li>- Monitor the patient half hourly with pulse, Bp, CVP & urine output. </li></ul><ul><li>- NG tube (controversial) </li></ul><ul><li>- Guide lines for BT </li></ul><ul><li>1- Clinical shock </li></ul><ul><li>2- PR >100 </li></ul><ul><li>3- SBP >100 </li></ul>
  9. 9. <ul><li>All patients with organ failure requiring BT & patients with severe hypotension require CVP monitoring. - Endoscopy after adequate resuscitation, usually within 24 hours in most patients. A diagnosis is made in 80%. - Varices are dealt with by EST and EBL, vasopressor therapy, balloon tamponade, TIPSS and surgery.. </li></ul>
  10. 10. <ul><li>- PU with major stigmata of recent hage (active spurt hage, visible vessel, active oozing, fresh or organized clot or black spots) should be dealt with by heat probe, adrenalin, sclerosing agents or with laser therapy. - Endoscopic therapy is also of value in vascular malformations and occasionally in Mallory- Weiss. </li></ul>
  11. 11. <ul><li>- TIPSS or Surgery are considered if bleeding persists (or recurred within 48 hours of the initial bleeding) despite pharmacological therapy and two endoscopic attempts at least 24 h apart. - Indications for surgery : </li></ul><ul><li>- hypovolemic shock after 6 units of BT - bleeding that persist for >2-3 days - patients over 60 y of age with massive bleeding or rebleeding </li></ul><ul><li>- visible vessel inside the crater </li></ul>
  12. 12. <ul><li>- Surgery includes: transection of oesophag </li></ul><ul><li>Varices, devascularization of the stomach, </li></ul><ul><li>Portal systemic shunts and liver transplantation - Ulcer therapy in patients with PU. Avoid NSAID - Colonoscopy if endoscopy is normal </li></ul>
  13. 13. <ul><li>Discharge policy </li></ul><ul><li>- Generally patients who are stable & no sitgmata of recent hemorrhage on endoscopy can be discharged within 24 hours. </li></ul><ul><li>- Patients age, endoscopic diagnosis, co- morbidity & presence or absence of shock should be considered. </li></ul>
  14. 14. <ul><li>Prognosis </li></ul><ul><li>- Mortality depends on the cause of bleeding. Risk factors for death include increasing age , shock, co- morbidity, endoscopic findings & rebleed. </li></ul><ul><li>- Improved mortality is achieved in speciliased units with joint management by physicians and surgeons with agreed </li></ul><ul><li>protocols for transfusion & surgery. </li></ul>

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