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Upper GI bleeding
- 1. “I’M THROWING UP A LOT OF BLOOD!” RAWAN ALSULMI G3
- 2. CONTENT • Introduction • Definition • Mode of presentation • DDx • Approach to patient with upper GI bleeding
- 3. INTRODUCTION The gastrointestinal track extend from the mouth to the anus and divided in to two parts Upper and lower GIT By suspensory muscle of duodenum ( ligment of treitz ) at the duodenojejunal junction
- 4. GI BLEEDING One of the most common cause of hospital admission specially in elderly is bleeding , account for 10 % mortality. Any bleeding proximal to ligament of treitz is upper GI bleeding , distal to the ligament is lower bleeding.
- 7. MODE OF PRESENTATION Presentation Description Indication Hematemesis (50%) Vomiting blood Bright red = significant bleeding. Coffee ground = no active bleeding Melena (80%) Passage of foul smelling black stool Presence in GIT for more than 14 h Hematochezia(20%) Bright blood per rectum Occult bleeding No evidence of visible blood loss but +ve microscopic blood Symptoms of blood loss or iron deficiency anemia Symptoms of anemia Chronic bleeding
- 8. APPROACH TO THE PATIENT WITH UPPER GI BLEEDING • History • P/E • Investigations
- 9. HISTORY Symptoms: Abdominal pain , Hematemesis , Melena , Hematochezia Symptoms of blood loss: anemia , syncope , shock Symptoms of underlying cause : weight loss , dyspepsia Drug history : NSAIDs , anticoagulant . Past medical history of chronic liver , renal , cardiac diseases Past surgical history.
- 10. PE - General : Level of consciousness Vitals : HR, BP , Sign of shock : cold extremities , tachy , hypotension , confusion ,,etc. Skin change : dry , sunken eye - Systemic
- 11. INVESTIGATIONS Lab: • CBC , LFTs • BUN/creatinine ratio • Coagulation profile Imaging • Endoscopy • Angiography if the bleeding persist
- 12. DIFFERENTIAL DIAGNOSIS “PAGE ME!” 1.Peptic ulcer 50% 2. Atrioventricular (AV) malformation 3. Gastritis 4. Esophageal varices 5. Mallory-Weiss tear 6. Esophagitis
- 13. UNCOMMON CAUSES • Boerhaave’s syndrome • Gastric varices • Upper GI tumours • Aortoenteric fistulae (AEF) • Hereditary hemorrhagic telangiectasia (HHT) • Coagulopathy
- 15. CASE SCENARIOS
- 16. CASE 1 An 88-year-old white woman is taking naproxen for osteoarthritis. She has noticed mild epigastric discomfort for several weeks, but has continued the naproxen because of improvement in joint symptoms. She suddenly develops hematemesis and hypotension.
- 17. GASTRIC ULCER
- 18. CASE 2 A 42-year-old white woman with a history of alcohol abuse develops nausea and vomiting without abdominal pain. After several bouts of retching, she vomits bright red blood. Physical exam is negative, without spider angiomata or splenomegaly. LFTs are normal.
- 19. 1.MALLORY-WEISS TEAR Linear mucosal tears at the gastroesophageal junction. 2.BOERHAAVE’S SYNDROME • Complete transmural (full-thickness) laceration or perforation of the esophagus, distinct from Mallory-Weiss syndrome, a nontransmural esophageal tear.. • Perforation is almost always on Left side of Lower esophagus • Odynophagia and surgical emphysema in the neck
- 21. CASE 3 A 76-year-old white man presents with painless hematemesis and hypotension. He has no previous GI symptoms but did have resection of an abdominal aortic aneurysm 12 years previously. EGD shows no bleeding source in the stomach or duodenum.
- 23. CASE 4 A 23-year-old man develops iron-deficiency anemia and heme-positive stools. His weight is stable. A few telangiectasias are present on the lips. Abdominal exam is negative without hepatosplenomegaly . Past history of nosebleeds
- 25. MANAGEMENT Aim: • To stabilize the patient (ABC) • Identify the source • Treat the cause accordingly
- 26. MANAGEMENT 1- Immediate assessment 2- Stabilization 3- Identify the source of the bleeding 4- Stop the active bleeding 5- Treat the underlying 6- Prevent rebreeding
- 27. 1- IMMEDIATE ASSESSMENT - PE - Amount of blood loss
- 28. ROCKALL SCORE
- 29. ROCKALL SCORE - Low risk ( 0-2 ) : 80% will resolved spontaneously - Intermediate risk (3-5) : hospitalization for 72 hrs. - High risk (>5): ICU
- 30. 2- RESUSCITATION ABC: Ensure patent airway Supplemntal O2 IV crystalloid NG tube Transfusion
- 31. 3- LOCALIZATION NG tube Blood EGD Slow Massive Angio Tagged RBC No Blood
- 32. Suspected GI bleed Admit , resuscitate , stabilize , PPI Variceal (cirrhosis ) Non- Variceal Urgent EGD Octreotide,Antibiotic s , nonselective BB Surgery PU Endoscopic infusion of Epi Esophagitis PPI
- 34. REFERENCES • C&K • BMJ • Webmed
- 35. THANK YOU
Editor's Notes
- anticoagulant although doct caousr per se
- high in upper
- hx of NSAID use (often with concomitant use of corticosteroids) or past ulcers is common; ingestion of food often transiently improves abdominal pain; coffee-ground emesis and haematemesis are very common
- classically, patients note haematemesis following retching or vomiting, but any increase in intra-oesophageal pressure (e.g., from seizures, hiccups, or straining) can cause a tear; some tears develop spontaneously; alcohol use, advanced age, and presence of hiatal hernias are common underlying features Gastric contents enter the mediastinum and pleural cavity, if one were to perform a pleural fluid aspirate; one is likely to aspirate gastric contents!
- usually painless and, as such, are often asymptomatic until they cause overt bleeding; associated with cirrhosis, end-stage renal disease, advanced age, and von Willebrand's disease The erosion of the proximal end of a woven aortic graft into the distal duodenum or proximal jejunum can occur many years after the initial surgery. Often the patient will have a smaller herald bleed which is fol- lowed by catastrophic bleeding catastrophic complication of aortic surgery
- Patients with HHT usually have low-grade GI blood loss without obvious hematemesis; frequent nosebleeds may occur. The physical finding of small matlike telangiectasias of the mouth, lips, and fingertips points to this autosomal dominant disease and may prevent unnecessary endoscopy.
- Score < 3 poor 8 good To detect the high mortality and rebleeding
- Reduces portal venous pressure,
- 1-Angiodysplasia = associated with vWf 2-Ischemic colitis = abd.pain + ischemic heart disease 3-Investigation of Upper or lower GI bleed: CBC Coagulation factors Endo 4-What are the endoscopic findings that suggest rebreeding? Clot Visible bleeding Visible Vessels 5-Ranson criteria 6-Analgesia better to be avoided in pancreatitis? Morphine is avoided because it increases sphincter of Oddi pressure and may aggravate pancreatitis. 7-- When we should give antibiotics in pancreatitis ? In Infected necrosis -When CT? Sign of infection or moderate to sever Ranson. 8-Necrosis, calcification in chronic pancreatic 9-When stare feeding the patient of pancreatitis? After 72 h from presentation if sever give total parental nutrition Or NG tube 10-DDx of pancreatitis: Perforated peptic ulcer why? Epigastria pain , duodenal ulcer radiate to back 11-Chronic pancreatitis complication? Abscess, DM, fat malabsorbtion , chronic diarrhea 12-Infection with streateohrea ? Gardiasis 13- Kerlly B line = horizontal fluid . 14-Non liver disease in ascites ? What is the investigations ? Heart failure: Lab : BNP = not specific may be High in liver in obesity. Chest X ray = cardiomegaly Confirmatory = Eco Renal: Urin output increase early decrees later Uremic : urmic encephalomy , pericarditis , gasstritis . Bleeding tency . Anemia . Neropathy , itching Investigations : kidney function . If normal Bun , do urin analysis 24 h urin collection Urin albumin raio = if the prev need time. Next : GFR 14- 50% of renal function need to be lost . SBP Netrophil 250 Total WBC 500 Dialysis = 100 Acute pancreatitis 2nd high triglycrid= milky Pancritis induced drug : sulpha Thyroglossal vs thyroid = prtrusion of toungue Mediction lead to gynrzlized lyphmo = phtnotoin Hiv and lympha , sle = genrlized lymphodeno