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  1. 1. Upper GI bleeding DDX Local esophagus stomach General duodenum -Haemophilia -Leukemia -Oesophageal varices-lesser curve gastric ulcers erode left gastric A -Oesophageal CA -Erosive gastritis -Reflux oesophagitis Commom in alcoholic. -Mallory-Weiss syndrome -Gastric CA -gastric lymphoma -complicated Duodenal ulcer erode gastroduodenal A -Thrombocytopenia -Anti-coagulant therapy -Duodenitis -Periampullary tumour -Aorto-duodenal fistula -gastric leiomyoma -Dielafoy’s syndrome -rare a)History taking :: a)History taking 1-when? -what is the color, the appearance of the vomited blood? -redDark red? Brown? Black? -coffee ground appearance(suggests more limited bleeding)? -bright red (suggests moderate to severe bleeding)? & frothy? -have u vomited blood only once/several times? -has the bleeding been abrupt/massive? 2-have u passed black tarry stools with vomited blood(DDX : 90%UGIB or LGIB)? -what is the color of the stool? Bright red(most are LGIB or massive UGIB)? -have u had, bleeding from the nose? Bloody expectoration? A dental extraction? -have u had >1 black, tarry stool within a 24-h period?
  2. 2. -for how long have the tarry stools persisted? Help in DDX 3-Specific symptoms of most common causes of upper GI bleeding ●Peptic ulcer: Epigastric or right upper quadrant pain ●Esophageal ulcer: Odynophagia, gastroesophageal reflux, dysphagia ●Mallory-Weiss tear: Emesis, retching, or coughing prior to hematemesis ●Variceal hemorrhage or portal hypertensive gastropathy: Jaundice, weakness, fatigue, anorexia, abdominal distention ●Malignancy: Dysphagia, early satiety, involuntary weight loss, cachexia 4- other symptoms and sign: -retching & severe nonbloody vomiting? -lightheadedness? Nausea? Thirst? Sweating? Hypovolemic shock -faintness when lying down/when standing/syncope? -following the haemorrhage did you have diarrhea? -Symptoms that suggest the bleeding is severe include orthostatic dizziness, confusion, angina, severe palpitations, and cold/clammy extremities. # systemic review 5-Risk factors (drug and social ): - aspirin or (NSAIDs)? anticoagulant or antiplatelet therapy? iron preparation(black stool)? - age of the patient? - what is your smoke/alcohol intake? 6-Past medical and surgical Hx: - have there been similar episode in the past? When? Diagnosis? - were u hospitalized on this occasion? Did u receive a transfusion? -Potential bleeding sources suggested by a patient's past medical history include: ●Varices or portal hypertensive gastropathy in a patient with a history of liver disease or alcohol abuse ●Aorto-enteric fistula in a patient with a history of an abdominal aortic aneurysm or an aortic graft ●Angiodysplasia in a patient with renal disease, aortic stenosis, or hereditary hemorrhagic telangiectasia ●Peptic ulcer disease in a patient with a history of Helicobacter pylori, nonsteroidal anti-inflammatory drug (NSAIDs) use, or smoking ●Malignancy in a patient with a history of smoking, alcohol abuse, or H. pylori infection
  3. 3. ●Marginal ulcers(ulcers at an anastomotic site) in a patient with a gastroenteric anastomosis 7-FHx: are there any other members of your family who have same conditions , intestinal disease/bleeding tendency/peptic ulcer/liver disease, History of Malignancy? b) Physical b) Physical examination: examination: Assessment of hemodynamic stability( Signs of hypovolemia ). c)Management c)Management 1 -Resuscitation and Risk Assessment ِِ -Resuscitation and Risk Assessment 1 Resuscitate : crystalloid and blood product if indicated. Assess BASELINE vitals INVESTIGATION (BP,HR, orthostatic -FBC ( Hb, Wbc) changes) -liver function test – cirrhosis Endoscopy (within 24 hrs) -coagulation profile -renal profile -RBC morphology -endoscopic variceal injection with sclerosant or banding. Or sengstaken tube Endoscopy Immediate 2- other 2- other INVESTIGATIONS INVESTIGATIONS Micro:chroni bleeding Peptic Ulcer(PPI And if) TTT: Major SRH somatostaten and vasopressure. Endoscopic Treatment + Preceded with ABx Nitroglycerin in CAD pt. Failure Other mangement : unstable Normo:acute bleeding -OGDS Varices stable Surgical Minor SRH Eradicate H.pylori & Risk Reduction No obvious cause Minor Bleed Major Bleed Other colonoscopy or angiography CXR: aspiration pneumonia; pleural effusion, perforated oesophagus. -Erect and supine AX ray:perforated viscus and ileus. CT scan and US: -Liver disease. -Cholecystitis with haemorrhage. -Pancreatitis with haemorrhage and pseudocyst. -Aortoenteric fistulae. Nuclear medicine scans have been used to identify areas of active haemorrhage. Angiography: may be useful if endoscopy fails to identify site of bleeding.
  4. 4. Major SRH : (visible vessel, fresh clot) RESUSCITATION in details:  airway and oxygen  Insert 2 large-bore (14-16G) IV cannulate take blood  IV colloid - crossmatched.  In a dire emergency, give O Rh-ve blood.  haemodynamically stable.  Correct clotting abnormalities  Monitor  Insert urinary catheter and monitor hourly urine output if shocked.  Consider a CVP line to monitor CVP and guide fluid replacement.  Organize a CXR, ECG, and check arterial blood gases in high-risk patient.  Arrange an urgent endoscopy.  Notify surgeon of all severe bleeds on admision. INDICATION OF BLOOD TRANSFUSION : 1.Systolic BP < 110 mmHg 2.Postural hypotension 3.Pulse > 110/min 4.Haemoglobin <8g/dl 5.Angina or cardiovascular disease with a Haemoglobin <10g/dl . UPPER GI BLEEDING RISK FACTORS FOR DEATH : 1. Advanced AGE 2. SHOCK on admission(pulse rate >100 beats/min; systolic blood pressure < 100mmHg) 3. COMORBIDITY (particularly hepatic or renal failure and disseminated malignancy) 4. Diagnosis (worst PROGNOSIS for advanced upper gastrointestinal malignancy) 5. ENDOSCOPIC FINDINGS (active, spurting haemorrhage from peptic ulcer; non-bleeding visible vessel) 6. REBLEEDING (increases mortality 10 fold)