Upper Git Bleeding Presentation

OBJECTIVESOBJECTIVES

History & Examination & portal system History & Examination & portal system Definition & Related terms Definition & Related terms Clinical presentationClinical presentation Differential DiagnosisDifferential Diagnosis Hematemesis VS Hemoptysis Hematemesis VS Hemoptysis Management Management

Anatomy of the Portal System

Reason for question Reason for question Question askedQuestion askedCommentComment

Was it blood, and if so Was it blood, and if so was it coughed or was it coughed or vomited?vomited?

Where did the blood Where did the blood come from?come from?

Allow the patient to describe his Allow the patient to describe his symptoms. symptoms.

It seems almost unnecessary to ask these It seems almost unnecessary to ask these questions, but a lot of time and effort will questions, but a lot of time and effort will be saved if it is established that what the be saved if it is established that what the patient has brought up is blood and not, patient has brought up is blood and not, for example, red wine. Avoid words like for example, red wine. Avoid words like coffee-grounds, which may misleadcoffee-grounds, which may mislead

The form and severity The form and severity of the blood loss. of the blood loss. Health immediately Health immediately before bleedingbefore bleeding

Have you vomited Have you vomited blood before?blood before?

Previous history of bleedings, e.g. from DU Previous history of bleedings, e.g. from DU

About a third of patients with peptic ulcers About a third of patients with peptic ulcers do not have symptoms before they bleed. do not have symptoms before they bleed. Almost half of the patients who bleed have Almost half of the patients who bleed have no symptoms to suggest the cause of the no symptoms to suggest the cause of the bleeding.bleeding.

The patient is better able to describe The patient is better able to describe volume of blood lost in familiar measures, volume of blood lost in familiar measures, rather than in millilitres. Remembers rather than in millilitres. Remembers however that even a little blood seems a however that even a little blood seems a lot to a frightened patient or relatives. lot to a frightened patient or relatives. There is almost always more lost than There is almost always more lost than appears in vomit.appears in vomit.


Rectal blood lossRectal blood lossWhat has the colour of What has the colour of your motions been? your motions been? Please describe your Please describe your motionsmotions

Blood in the rectum in a patient Blood in the rectum in a patient with haematemesis indicates with haematemesis indicates severe bleedingsevere bleeding

Symptoms Symptoms accompanying accompanying blood lossblood loss

Have you felt giddy or light Have you felt giddy or light headed?headed?

Have your felt your heart Have your felt your heart thumping inside your thumping inside your chest? (Palpitations)chest? (Palpitations)

Have you felt an pain in Have you felt an pain in your chest? (describe)your chest? (describe)

These may give an indication of These may give an indication of the severity of blood loss.the severity of blood loss.

Angina and palpitations may Angina and palpitations may accompany severe anaemia.accompany severe anaemia.

Possible cause of Possible cause of bleeding Drugsbleeding Drugs

Ask about tablets for Ask about tablets for backache or headaches backache or headaches (aspirin), tablets for (aspirin), tablets for arthritis (phenylbutazone, arthritis (phenylbutazone, indomethacin); and indomethacin); and steroidssteroids

Do you take blood thinning Do you take blood thinning tablets (anticoagulants)tablets (anticoagulants)

These drugs cause gastric These drugs cause gastric erosionserosions


Benign upper GITBenign upper GITAny history of indigestion, Any history of indigestion, heartburn, or pain in the heartburn, or pain in the upper part of y our tummy? upper part of y our tummy? Do you wake up in the Do you wake up in the middle of the night with middle of the night with tummy pain?tummy pain?

Peptic ulcer, reflux oesophagitis, Peptic ulcer, reflux oesophagitis, hiatus herniahiatus hernia

MalignancyMalignancyWhat has your appetite What has your appetite been like?been like?

Enquire about weight loss. Enquire about weight loss. If yes, how much and over If yes, how much and over how long?how long?

Carcinoma of stomach a rare Carcinoma of stomach a rare cause of haematemesis (see cause of haematemesis (see above)above)

Cirrhosis of liverCirrhosis of liverHow much alcohol do you How much alcohol do you drink? How long have you drink? How long have you been drinking?been drinking?

Cirrhosis of the liver presents Cirrhosis of the liver presents with upper GIT bleeding in 25% of with upper GIT bleeding in 25% of patients known to have this liver patients known to have this liver disorder.disorder.

ROSROSRest of GITRest of GIT

RS, CVS, CNS, GUSRS, CVS, CNS, GUS

Think of intercurrent disease, Think of intercurrent disease, which will have to be taken into which will have to be taken into account in management. An account in management. An example is ischaemic heart example is ischaemic heart disease.disease.


PMHPMHDU, gastric, ulcer, cirrhosis of liver, DU, gastric, ulcer, cirrhosis of liver, hepatitishepatitis

Arthritis, chronic pain requiring Arthritis, chronic pain requiring analgesicsanalgesics

Recent major operationRecent major operation

Deep venous thrombosis or Deep venous thrombosis or pulmonary embolismpulmonary embolism

Suggests stress Suggests stress ulcerationulceration

Requiring Requiring anticoagulant anticoagulant treatment treatment

DRUGSDRUGSAs mentioned earlier As mentioned earlier

SHSHAlcohol intake: document type of Alcohol intake: document type of drinks, quantities in an average week, drinks, quantities in an average week, how long the patient has been how long the patient has been drinking.drinking.

Drug abuseDrug abuse

SmokingSmoking

Do not forget cirrhosis Do not forget cirrhosis of the liverof the liver

Risk of hepatitis Risk of hepatitis

Increased risk of Increased risk of peptic ulcerpeptic ulcer

General ExaminationGeneral ExaminationTake time now to assess the patient more thoroughly. He may Take time now to assess the patient more thoroughly. He may look ill from an underlying disease such as malignancy or look ill from an underlying disease such as malignancy or simply from blood loss. He may be anaemic and dehydrated simply from blood loss. He may be anaemic and dehydrated from bleeding. Enlarged lymph nodes should alert you to the from bleeding. Enlarged lymph nodes should alert you to the possibility of malignancy.possibility of malignancy.

Bruising and purpura suggest platelet deficiencyBruising and purpura suggest platelet deficiency

General signs of General signs of chronic liver disease chronic liver disease

Spider naevi, palmar erythema, gynaecomastia, clubbing of the Spider naevi, palmar erythema, gynaecomastia, clubbing of the fingers, testicular atrophy in males.fingers, testicular atrophy in males.

Reason for Reason for question question

Question askedQuestion askedCommentComment

ABDOMENABDOMENInspection: Scars from Inspection: Scars from previous operations Distenionprevious operations Distenion

E.g. for peptic ulcer, varices, carcinomaE.g. for peptic ulcer, varices, carcinoma

May be due to ascites from liver failure or May be due to ascites from liver failure or secondary carcinoma.secondary carcinoma.

My be enlarged liver, spleen or tumour My be enlarged liver, spleen or tumour deposit deposit

Think of portal hypertensionThink of portal hypertension

Palpation: Enlarged liverPalpation: Enlarged liver

Enlarged spleenEnlarged spleen

Abnormal massesAbnormal masses

Tenderness Tenderness

Consider portal hypertension and liver Consider portal hypertension and liver secondariessecondaries

Portal hypertensionPortal hypertension

Tumour deposits Tumour deposits

Epigastric tenderness suggests peptic Epigastric tenderness suggests peptic ulcerulcer

To detect ascitesTo detect ascites

Percussion: Shifting dullnessPercussion: Shifting dullness

Auscultation:Auscultation:

PR: melaena, bloodPR: melaena, blood

Masses felt on rectal Masses felt on rectal examination examination

The presence of blood or melaena The presence of blood or melaena supports the history of bleeding. Back supports the history of bleeding. Back tarry stools may be due to oral iron.tarry stools may be due to oral iron.

Think of pelvic secondaries from Think of pelvic secondaries from carcinoma of stomachcarcinoma of stomach

DefinitionDefinition

Bleeding derived from aBleeding derived from anyny source source proximal to the proximal to the Ligament of TreitzLigament of Treitz

1 in 1000 in us who experienced upper GI bleedingMen :women 2 : 1Mortality rate 10%

Related Terms

Hematemesis? Vomiting of blood Red or Brown Dark ??? Coffee ground

Hematochezia Upper OR Lower? Blood in the stool

Melena Upper Or Lower? Black, tarry, smelly stool

HPS Portal Hypertension Pressure difference between the portal vein

and the hepatic veins =< 5 mm Hg

Portacaval Anastomosis portal circulation systemic

circulation left gastric vein Azygos vein

Esophageal Varices UGIB

Esophageal varices

Clinical Presentation Hematemesis - 40-50% Hematemesis - 40-50% Melena - 70-80% Melena - 70-80% Hematochezia - 15-20% Hematochezia - 15-20% Syncope - 14.4% Syncope - 14.4% Presyncope - 43.2% Presyncope - 43.2% Dyspepsia - 18% Dyspepsia - 18% Epigastric pain - 41% Epigastric pain - 41% Heartburn - 21% Heartburn - 21% Diffuse abdominal pain - 10% Diffuse abdominal pain - 10% Dysphagia - 5% Dysphagia - 5% Weight loss - 12% Weight loss - 12% Jaundice - 5.2% Jaundice - 5.2%

Peptic Ulcer

A break in the epithelial surface (i.e. A break in the epithelial surface (i.e. ulceration) of the ulceration) of the oesophagus, oesophagus, stomach or duodenum stomach or duodenum ..

PU includesPU includes

Duodenal ulcer. Duodenal ulcer. ((commonestcommonest) )

Gastric ulcer.Gastric ulcer.

Common causes of PUCommon causes of PU Infection with Infection with H.pylori.H.pylori.

NSAIDNSAID and the usual suspects and the usual suspects (Alcohol ,smoking, (Alcohol ,smoking,

stress)stress)

Imbalance between the aggressive Imbalance between the aggressive and protective mechanisms.and protective mechanisms.

Acid hypersecretion due to increase Acid hypersecretion due to increase number of parital cells or as seen in number of parital cells or as seen in ((Zollinger-Ellison syndromeZollinger-Ellison syndrome).).

Clinical Features (PUClinical Features (PU))

M > F ,20-50 yrs.M > F ,20-50 yrs. Epigastric pain during fasting (hunger Epigastric pain during fasting (hunger

pain), relieved by food and Antacids.pain), relieved by food and Antacids. Back pain if ulcer is penetrating Back pain if ulcer is penetrating

posteriorly.posteriorly. Hematemesis from ulcer penetrating GD Hematemesis from ulcer penetrating GD

artery posteriorly.artery posteriorly. Can lead to peritonitis if ulcer occurs Can lead to peritonitis if ulcer occurs

anteriorly.anteriorly. Can lead to pyloric stenosis.how?Can lead to pyloric stenosis.how?

The Forrest classification of PU

Bleeding F-I Active bleeding: F-I/a. Spurting arterial

bleeding F-I/b. Oozing bleeding F-II Signes of recent haemorrhage : F-II/a. Visible vessel on the

base of ulcer F-II/b. Coagulum in the ulcer F-II/c. Coffee ground ulcer base F-III No signe of bleeeding

F 1A

Beheviour of Beheviour of PU BPU Bleedingleeding

Spontaneous stoping: 70-80 % Probability of rebleeding: 30-50 % Rebleeding within 24-48 hours: 70-80 % Mortality among patients operated

because of rebleeding: 20-30 %

Gastric Ulcer

Type I

Type IISame as PU

M>F 3:1 , 50+ yrs.M>F 3:1 , 50+ yrs.Epigastric pain induced by Epigastric pain induced by eatingeating..Weight loss.Weight loss.Nausea and vomiting.Nausea and vomiting.Anaemia from chronic Anaemia from chronic blood loss.blood loss.

Treatment 1-Medical In chronic PU : eradication of In chronic PU : eradication of

H.pylori.H.pylori. General management :General management :

Avoid smoking and food that Avoid smoking and food that cause pain.cause pain.

Antacids for symptomatic Antacids for symptomatic relief.relief.

H2 blockers .H2 blockers .

Treatment

2 -Endoscopic

Topical treatment Injection treatment Mechanical treatment Thermal treatment

Topical treatment

Tissue adhesives (cyanoacrylat) Blood clotting factors

(thrombin,fibrinogen) Vasoconstricting drugd

(epinephrin) collagen Ferromagnetic tamponade

Injection therapy

Sclerotizing drugs (Aethoxysklerol)

Alcohol (96-99.5 %) Epinephrin (Tonogen) Thrombin

Mechanic treatment

Loops Sutures Balloon treatment Haemostatic clips

Thermal treatment

Laser fotocoagulation Heater probe Electrocoagulation Monopolar Bipolar Electrohydrothermo sond

3-Surgical treatment

Local operation? Suture Stiching of ulcer Local operation + vagotomy resection type operation

Local operation

The rebleeding rate is very high, 70-80 %, Insufficient solution Today is not advised!!!

Local operation with vagotomy

Quicker than resection Rebleeding rate 17 % Suture insufficiency 3 %

Resection type operations

Rebleeding only in 3 % Insufficency of duodenal stump

13 % The duration of operation is the

most longer

Oesophageal varicosity

dilated sub-mucosal veins in the esophagus

portal hypertension

left gastric vein + Azygos vein

Treatment

Balloon tamponade Sengstaken-Blakemore Linton

Sclerotherapy

Oesophageal transsection

Variceal ligation, or banding TIPS (

transjugular intrahepatic portosystemic shunt)

Mallory-Weiss syndrome (tear)

The cause: the sudden increase of intragastric pressure

Alcohol intoxication

Pathology: Rupture of the mucosa in the cardia

Treatment: Conservative treatment usually sufficient, no need of operation

MWS

Erosive inflammation in the upper GIT

Regular or incidental alcohol intake

Side effect of a medicine NSAID Salycil containing drugs Steroids Other illnesses cardio-respiratory, cardio-

vascular, trauma, burning & postoperative conditions

Treatment nasogastric intubation and

irrigation with alkaline fluid H2RA, PPI Electrolyt and blood replacement Sedation Operative treatment is often

avoidable

Where is it from?

GI TRACT RESPIRATORY TRACT Dark red or brown

Bright red

In clumps Foamy, runny & bubbly

Mixed with food mixed with mucous

Acidic pH alkaline pH

Stomachache, abdominal discomfort chest pain, warmth

Nausea, retching before and after episode persistent cough

Differentiation

mild bleeding severe bleeding

Normal Pulse Weak & Rapid

Normal BP BP>10HgNormal breathing Deep & Tach

Mucosa slightly dry ParchedSlightly Urine OP Anuris

Conscious Fainting>15%< 15%

Summary

DefinitionHematemesis is vomiting of gross blood.

Causes:

Esophagus Stomach Duodenum hepatic

Hepatic Portal System

system of veins that comprises the hepatic portal vein and its tributaries

Hepatic portal vein Splenic vein celiac trunk superior mesenteric vein inferior mesenteric vein

Assessment

resuscitation nasopharyngeal tube lab assessment (CBC-Coagulation

Factors) Radiology. endoscopy within 48hrs medical therapy / surgery

MANAGMENT

Minimal blood loss If this is not the case, the patient is generally administered a

proton pump inhibitor (e.g. omeprazole), given blood transfusions (if the level of hemoglobin is extremely low, that is less than 8.0 g/dL or 4.5-5.0 mmol/L), and kept nil per os(nil by mouth) until endoscopy can be arranged. Adequate venous access (large-bore cannulas or a central venous catheter) is generally obtained in case the patient suffers a further bleed and becomes unstable.

Significant blood loss In a "hemodynamic ally significant" case of Hematemesis,

that is hypovolemic shock, resuscitation is an immediate priority to prevent cardiac arrest. Fluids and/or blood is administered, preferably by central venous catheter, and the patient is prepared for emergency endoscopy, which is typically done in theatres. Surgical opinion is usually sought in case the source of bleeding cannot be identified endoscopically, and laparotomy is necessary.

Documents

Upper Git Bleeding Presentation