3 Introduction Bleeding of GIT proximal to ligament of treitz. Ligament of treitz- a fibromuscular band which extends from right crus of diaphragm to duodenojejunal flexure.
4 Presents as:Haematemesis,, malena, hematochezia or occult blood.Malena can present with loss of 50-60ml of blood.May be acute or chronic100 cases per 100,000 person per year.
5 Accounts for 3-5% of all hospitalizations The incidence is 2- fold greater in males but death rate is similar in both sexes.Overall mortality from acute bleeding is 20% .Mortality & morbidity increases as age advances (>60 yrs)
13 Aetiology (Common causes) Mallory- Weiss syndrome5% of casesCharacterized by longitudinal mucosal tear in the cardioesophageal region.Result from repeated vomitting or retching.Common in male alcoholic patients
20 Acute upper GI bleeding Presents as emergency with hemetemesis or malena.Hypovolaemia:Mild: no significant hypovolaemia.Moderate: hypovolaemia which responds to volume replacement.Severe: hypovolaemia with continued active major bleeding making resuscitation difficult even with blood transfusions.These patients are difficult to manage.Patients will show all signs of shock.
21 Note: all patients should be examined for stigmata of CLD. H/O drugs (NSAIDS).H/O ulcers.H/O alcohol abuse.
22 Resuscitation Initial management has 4 primary goals: Quick assessment with attention to hemodynamic statusAppropriate resuscitation (ABC) & monitoringIdentify major source of bleedingSpecific therapeutic intervention.
23 Resuscitation (General measures) Airway cleared of clot.Oxygen inhalation.Maintain IV line with at least 2 wide bore cannulaeSample to blood bank for cross matching.Class I + II hemorrhage replace with crystalloid.Class III + IV hemorrhage replace with crystalloid & blood.Pass NG tube for diagnostic & therapeutic purpose.Catheterize the patient.Sedation may be needed.
25 Specific measuresIf stable following resuscitation, proceed for upper GI endoscopy.Endoscopy ideally done within 4-24 hrs.If patient could not be stabilized, an emergency laparatomy may be necessary.
26 Diagnosis History of: Epigastric pain or retrosternal burning hematemesis, melena, or hematochezia.Vomiting, weight loss, alteration of bowel habits.Aortic graft surgeryUse of ASA, NSAID’S, steroids, alcohol addiction
27 Diagnosis Physical examination Vital signs may show hypotension & tachycardia.Cool, clammy skin.Petechiael hemorrhage & purpura seen in coagulopathy.Signs of chronic liver disease.Proper abdominal & rectal examination.
28 Investigations Upper GI endoscopy. Arteriography. Barium swallow UltrasoundLab investigations
29 Endoscopy Most important investigation For diagnosis & intervention Establishes diagnosis in 90% of patientsCan be repeated more than once.
30 ArteriographyIn pts who bleeds contineously & site can not be identified.Has accuracy of 50-90%.Accuracy is increased if there is active bleeding during investigation.Demonstrates bleeding of ml/minWith technetium-labelled RBC, ml/minEmbolisation may be done at same time
31 Barium swallow / meal Used when endoscopy is not available Double contrast study is idealMay show varices, esophagitis, peptic ulcers, gastric tumors etc
32 Abdominal Ultrasound scan To assess both liver architecture and portal circulationMore widely available than ArteriographyShould be performed before more invasive procedures
33 Lab Investigations CBC Electrolytes Glucose Coagulation studies Liver function studiesBlood grouping and cross-match
34 Lab investigations CBC, urea/creatinine, S/Electrolytes, ABGs. ed urea/ creatinine in upper GI bleeding.Normal Hb in pts with active bleeding.Iron deficiency anemia in chronic blood loss.
35 Treatment ( peptic ulcer disease) At endoscopy10ml epinephrine at ulcer baseThermal treatment with bipolar diathermyLaser photocoagulationRebleed is treated similarlyA second rebleed is treated by surgery
36 Post endoscopy treatment Continuous intravenous infusion of Octretide (somatostatin analogue)Proton pump inhibitorsH. pylori treatment may be required.
38 Surgery - PUD Indications for surgery are: Exsanguinating hemorrhage Visible spurting arterial bleedConcomitant perforationPts >60 yrs, who rebleed once or need 4 units at resuscitation or 8 units in 48 hrsYounger pts requiring 8 units at initial resuscitation or 12 units in 48 hrsRare blood group
39 Treatment Gastric erosions / stress ulcers Treatment of underlying causeIntraluminal antacidsIV proton pump inhibitorsBleeding usually subsides in hrs
40 Treatment Esophageal varices 1. Endoscopic sclerotherapyRepeated at 3 weeks interval then 3 monthly until varices disappearSome sclerosing agents are ethanolamine oleate, sodium morrhuate, 3% tetradecyl sulphate, absolute alcohal2. Rubber band ligation3. Vasoconstriction therapy (octreotide, vasopressin, propranolol)
43 4. Balloon tamponade: if above measures fail Modified Sengstaken- Blakemoore tubeMinnesota tube, Linton tube, Foley catheterBalloon tamponade applied for 12 hrsStop bleeding in 80% of casesMust be followed by surgery as bleeding is likely to recur after removal.
45 Surgery – esophageal varices TIPS: in refractory bleedShunt established between portal vein & Rt or middle hepatic veinStapling transection of esophagus at CEJDistal splenorenal shuntPortosystemic shuntsSpleenectomy in hypersplenismLiver transplantation
57 ConclusionUpper GI bleeding is not uncommon & may be life threatening.Prompt intervention could be life saving.It require multidisciplinary approach.Definitive treatment depends upon the final diagnosis.