Upper GI tract bleed

Upper GI bleed presents with hematemesisHematemesis means vomiting of bloodThe appearance of hematemesis

resembles coffee groundsIt indicates bleeding from upper GI usually

from esophagus, stomach and duodenum above ligament of treitz

Conditions which cause hematemesis can also cause melena

Causes of Upper GI bleedPeptic ulcerEsophageal varicesErosive gastritisEsophagitisMallory weiss syndromeCarcinoma stomachHereditary hemorrhagic telengeictasiaBleeding disorders

Peptic ulcerIt means ulcers in those parts of the gut which

are exposed to acid.Common sites are duodenum , stomach and

can also occur in lower esophagus.Causes: Increase acid secretion(duodenal ulcer) Decrease mucosal resistance(gastric ulcer) NSAIDs ingestion H.Pylori infection Zollinger Ellison syndrome (uncommon)

Peptic ulcer pain is felt in the epigastrium and is well localized. Patient points with one finger to the site of pain- the ‘pointing sign’-

Duodenal ulcer Occurs in the 1st part of duodenum. Symptoms include Pain epigastrium aggravated by empty stomach(hunger

pain), relieved by food and antacids Nocturnal pains occur Pain in the morning is not due to peptic ulcer History of periodicity may be present. Signs Localized tenderness in the epigastrium

Investigation

Barium meal shows duodenal deformity/ulcer crater.

Endoscopy confirms ulcer presence.

Gastric ulcer SymptomsRelation of pain to meals and timings is variableMay be relieved or aggravated by foodNocturnal pain is uncommon SignsEpigastric tenderness InvestigationBarium meal shows ulcer craterEndoscopy confirms Every gastric ulcer must be biopsied to exclude

malignancy

Treatment

1st line therapy includesPPI ,Antibiotics( clarithromycin and amoxicillin) 2nd line therapy includes quadruple therapyPPI ,Antibiotics(clarithromycin and amoxicillin)

bismuth For long term ulcer use only PPI Complications of peptic ulcer Bleeding Perforation Chronicity Gastric outlet obstruction

Esophageal varicesThese are dilated tortuous veins in the

esophagusThese are communication channels

between the portal and systemic venous systems and become dilated in portal hypertension

Most common cause of portal hypertension is hepatic cirrhosis

Symptoms Hematemesis is massive and recurrent Distention of abdomen due to ascites History of jaundice Hematemesis may be the first manifestation of cirrhosis Signs Jaundice Dependent edema Gynecomastia and testicular atrophy Palmar erythema, dupuytren’ contracture, Spider

angiomas, parotid swelling (common in alcoholic cirrhosis)

Veins of abdominal wall may be prominentLiver may be enlarged/shrunkenPalpable spleenAscites in advanced diseaseInvestigationEndoscopy

treatmentI.V fluid replacement with 0.9% salineVasopressorProphylactic antibiotics (cephalosporin)Variceal band ligationPPILactulose

Erosive gastritis In addition to inflammation of stomach, there are multiple

mucosal erosions and petechiae. Causes A. drugs Aspirin and NSAIDS Theophylline Potassium chloride B. stress Head injury Shock Trauma Burns Sepsis Hepatic encephalopathy

SymptomsHematemesis with or without epigastric

painh/o drug intakeSignsTenderness in the epigastriumInvestigationEndoscopy

EsophagitisAbnormal reflux of gastric contents into

lower esophagus is the most common cause of esophagitis

Smokers and obese are more proneSymptomsRetrosternal burning and pain(heart burn),

increases on bending forward or lying flatRelieved by antacids

History of regurgitationWater brashBitter taste in the morningPersistent dysphagia indicates peptic strictureAspiration of regurgitant material cause laryngitis

and aspiration pneumonia SignsPallor may occur InvestigationBarium swallow demonstrates refluxEsophageal ulcers may be seen

Endoscopy shows Hyperemic mucosa with or without ulcersIf mucosa looks normal , biopsy will demonstrate

microscopic inflammation PH monitoring <4 for >4% of time is suggestive of

acid reflux TreatmentLifestyle modificationPPIH2 antagonistsProkinetic drugs

Mallory weiss syndromeRepeated retching and vomiting can

cause vertical mucosal tear at gastroesophageal junction

SymptomsH/o repeated vomiting and retching before

hematemesis

SignEpigastric tenderness

InvestigationEndoscopy

Carcinoma stomach Occurs after age of 40 years Risks include Pernicious anemia Partial gastrectomy Gastroenterostomy Symptoms Loss of appetite, nausea and discomfort after meal Vague epigastric pain and feeling of distention after

meals Early satiety is common Persistent vomiting if gastric outlet obstruction Marked loss of weight

Signs Pallor Epigastric mass may be palpable In later stages, patient may have enlarged scalene lymph nodes,

nodular liver and ascites due to metastases Investigation Iron deficiency anemia Barium meal shows filling defect Endoscopy shows mass/ulcer Biopsy confirms diagnosis. In case of ulcer, six biopsies should

be taken Treatment Gastrectomy (partial and complete) Palliative treatment

Hereditary hemorrhagic telengeiectasisIt is an autosomal dominant disease.Bleeding occurs from multiple

telangiectasias which consists of localized collection of non-contractile capillaries.

SymptomsRecurrent

hematemesis/epistaxsis/hemoptysis

Sites of telangiectasiasFaceHandsMucous membranes of nose, oral cavity

and GITInvestigationTelengiectasia may be seen in gastric

mucosa on Gastroscopy

Bleeeding disordersCausesA. Defects of blood vessels:Vascular purpuraHereditary hemorrhagic telengiectasiaB. Platelet disordersThrombocytopeniaThrombocythemiaThromboasthenia

C. Clotting disordersHereditaryHemophiliaChristmas diseaseVon willebrand diseaseAcquiredVitamin K deficiencyOral anticoagulant therapyAdvanced liver diseaseD. Consumption coagulopathyDIC

Basic investigations

Full blood count show anemiaUrea and electrolytes :elevated urea with

normal creatinine concentration implies severe bleeding

Liver function tests may show evidence of chronic liver disease

Prothrombin time shows bleeding disorders and liver synthetic dysfunctions

Management of upper GI bleeding Intravenous access using one large bore cannula Initial clinical assessment Define circulatory status Seek evidence of liver disease Identify other comorbidity Resuscitation with crystalloids or transfusion in severe bleeding Ventilation with oxygen mask Monitoring of B.P and urinary output Endoscopy should be performed within 24 hours. It is used in

treatment of bleeding from peptic ulcer using injection of epinephrine and thermal clips.in varicial bleeding band ligation is also done endoscopically.

Surgery

History taking related to GI bleedingDurationEpisodes of hematemesisQuantity Color(coffee ground appearance)Blood in stools (maroon colored stools can be

present in acute severe upper GI bleeding)History of jaundice(cirrhosis)History of epigastric pain (peptic ulcer,

esophagitis, erosive gastritis)Weight loss (carcinoma stomach)

Signs in upper GI bleeding Anemia Epigastric tenderness Ascites Hepatomegaly and spleenomegaly Jaundice Palmar erythema ,dupuytren contracture, Spider angiomas ,parotid swelling in alcoholic cirrhosis Gynecomastia and testicular atrophy Prominent abdominal veins Dependent edema Abdominal mass Palpable scalene, paraumblical , virchow’ lymph nodes

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