11

UPPER GIT BLEEDINGUPPER GIT BLEEDING

44thth YEAR YEAR BYBY

Dr. HAYDER M. ABDULNABIDr. HAYDER M. ABDULNABI CABSCABS

22

DEFINITIONDEFINITION

HEMATESISHEMATESIS VVomiting of blood (fresh , unalterd oromiting of blood (fresh , unalterd or

digested by gastric secretiondigested by gastric secretion--- --- acid hematinacid hematin((

IIt is a manifestation of a bleeding sitet is a manifestation of a bleeding site located between the oropharynxlocated between the oropharynx & &

the ligament of Treitzthe ligament of Treitz TThere may be a simultaneous melenahere may be a simultaneous melena

CLACIFICATION OF CAUSESCLACIFICATION OF CAUSES

11 . .OESOPHAGEALOESOPHAGEAL

a. VARICESa. VARICES

b. PEPTIC ESOPHAGITISb. PEPTIC ESOPHAGITIS

c. CARCINOMAc. CARCINOMA

d. FOREIGN BODYd. FOREIGN BODY

22 . .STOMACHSTOMACH

a. PEPTIC ULCER (ACUTE-CHRONIC)a. PEPTIC ULCER (ACUTE-CHRONIC)

b. EROSIONSb. EROSIONS33

c. GASTRITISc. GASTRITIS

d. CARCINOMAd. CARCINOMA

e. HIATUS HERNIAe. HIATUS HERNIA

f. MALLORY-WEISS SYNDROMEf. MALLORY-WEISS SYNDROME

g. BENIGN TUMOURSg. BENIGN TUMOURS

h. FOREIGN BODYh. FOREIGN BODY

33 . .DUODENUMDUODENUM

a. PEPTIC ULCERa. PEPTIC ULCER

b. DIVERTICULUMb. DIVERTICULUM

c. DUODENITISc. DUODENITIS 44

44 . .MISCELLANEOUSMISCELLANEOUS

a. HEPATIC TRAUMA(HEMTOBILIA)a. HEPATIC TRAUMA(HEMTOBILIA)

b. BLOOD DYSCRASIASb. BLOOD DYSCRASIAS

c. HERIDITARY TELENGIECTASIAc. HERIDITARY TELENGIECTASIA

55

66

MOST COMMON CAUSESMOST COMMON CAUSES 11 . .Peptic ulcerationPeptic ulceration

22 . .Gastritis & ErosionsGastritis & Erosions 33 . .Esophagogastric varicesEsophagogastric varices

44 . .Reflux esophagitis(Hiatus hernia)Reflux esophagitis(Hiatus hernia) 55 . .NeoplasimsNeoplasims

Peptic ulcerationPeptic ulceration --- (1/2-2/3 of cases) --- (1/2-2/3 of cases)) ) duodenal ulcer 4 times moreduodenal ulcer 4 times more

frequent than gastric ulcerfrequent than gastric ulcer(( Due to errosion of a regional arteryDue to errosion of a regional artery..

) ) gastroduodenal , Lt. & Rt. Gastricgastroduodenal , Lt. & Rt. Gastric((

77

Patients with atherosclerosis , persistantPatients with atherosclerosis , persistant bleeding is more likely (failure ofbleeding is more likely (failure of

retraction of vessels wallretraction of vessels wall(( ErosionsErosions --- (not true ulcers)(often --- (not true ulcers)(often

multiple)(does not extendmultiple)(does not extend through the muscularisthrough the muscularis

mucosae)(body or fundus aremucosae)(body or fundus are involvedinvolved((

Tube ulcerTube ulcer --- (suction drawing mucosa --- (suction drawing mucosa into N.G. tubeinto N.G. tube((

88

Stress ulcerStress ulcer --- (secondary to shock --- (secondary to shock& &

sepsis following operationssepsis following operations , ,

trauma & burn)(decrease in thetrauma & burn)(decrease in the

splanchnic blood flow – ischemiasplanchnic blood flow – ischemia

of superficial gastric mucosaof superficial gastric mucosa& &

microcoagulationmicrocoagulation((

Curling ulcerCurling ulcer --- (after burn) --- (after burn)

Cushing ulcerCushing ulcer --- (postcraniotomy) --- (postcraniotomy)

99

0ther causes of upper GIT bleeding0ther causes of upper GIT bleeding

Hepatic traumaHepatic trauma --- hematobilia --- hematobilia

Mallory-weiss syndromeMallory-weiss syndrome --- (linear tears --- (linear tears

of esophagogastric junctionof esophagogastric junction((

) ) severe vomiting in alcoholicsevere vomiting in alcoholic& &

pregnant womenpregnant women((

Heriditary telengiectasiaHeriditary telengiectasia

LeukemiaLeukemia

1010

DIAGNOSISDIAGNOSIS

HistoryHistory --- Active ulcer --- Active ulcer Violent retching or vomitingViolent retching or vomiting

Recent ingestion of drugsRecent ingestion of drugs Bleeding tendencyBleeding tendency

Previous gastric surgeryPrevious gastric surgery Heart burn acentuated byHeart burn acentuated by

recumbancyrecumbancy Upper abdomen or chest traumaUpper abdomen or chest trauma

1111

ExaminationExamination --- --- Skin & mucous membraneSkin & mucous membrane

) ) icterus , spider angioma , livericterus , spider angioma , liver

palms , hair loss) – hepatic causepalms , hair loss) – hepatic cause

) ) melanin spots – Peutz-jeghersmelanin spots – Peutz-jeghers

syndromesyndrome ( (

Lips , tongue , earLips , tongue , ear

) ) hereditary tlangiectasiahereditary tlangiectasia((

Supraclavicular L.NSupraclavicular L.N..

) ) intraabbdominal maignancyintraabbdominal maignancy((

Epigastric tendernessEpigastric tenderness

) ) ulcer or gastritisulcer or gastritis((

1212

Palpable liver,splenomegalyPalpable liver,splenomegaly,,

abdominal veinsabdominal veins

) ) varicesvarices((

N.G. tube aspirationN.G. tube aspiration

) ) presence of blood at thispresence of blood at this

level & extent of bleedlevel & extent of bleed--

inging((

1313

TESTSTESTS

HbHb level decrease ( 4-6 hours) level decrease ( 4-6 hours) LeukocytosisLeukocytosis ( leukemia ) ( leukemia )

Neutrophils & plateletsNeutrophils & platelets decrease(hepatic) decrease(hepatic) ClottingClotting factorsfactors(bleeding tendency)(bleeding tendency)

EndoscopyEndoscopy Radiological studiesRadiological studies

11 . .Radionuclide imaging(Tc 99m sulfurRadionuclide imaging(Tc 99m sulfur colloid or Tc 99m labled erythcolloid or Tc 99m labled eryth--

rocytesrocytes((

1414

22 . .Selective angiography (celiacSelective angiography (celiac& &

superior mesentericsuperior mesenteric((

) ) bleeding rate must be in the rate ofbleeding rate must be in the rate of

3-5ml/min3-5ml/min((

33 . .Barium swallow,enema & followBarium swallow,enema & follow

throughthrough

Explorative laparotomyExplorative laparotomy

1515

Barium swallow (esophageal varices)

1616

FILING DEFECT (Ca stomach)

1717

Erosive gastritis (covered with hematin)

1818

Erosive gastritis

1919

Reflux esophagitis

2020

Reflux esophagitis

2121

Big ulcer crater (stomach)

2222

Gstric ulcer

2323

Healed gastric ulcer

2424

Bleeding DU

2525Clip management

2626Healing

2727

Kissing DU