1. 1 UPPER GIT BLEEDING 4 th YEAR 4 th YEAR BY BY Dr. HAYDER M. ABDULNABI Dr. HAYDER M. ABDULNABI CABS CABS

2. 2 DEFINITION HEMATESIS HEMATESIS Vomiting of blood (fresh, unalterd or Vomiting of blood (fresh, unalterd or digested by gastric secretion --- digested by gastric secretion --- acid hematin) acid hematin) It is a manifestation of a bleeding site It is a manifestation of a bleeding site located between the oropharynx & located between the oropharynx & the ligament of Treitz the ligament of Treitz There may be a simultaneous melena There may be a simultaneous melena

3. CLACIFICATION OF CAUSES 1. OESOPHAGEAL a. VARICES a. VARICES b. PEPTIC ESOPHAGITIS b. PEPTIC ESOPHAGITIS c. CARCINOMA c. CARCINOMA d. FOREIGN BODY d. FOREIGN BODY 2. STOMACH a. PEPTIC ULCER (ACUTE-CHRONIC) a. PEPTIC ULCER (ACUTE-CHRONIC) b. EROSIONS b. EROSIONS 3

4. c. GASTRITIS c. GASTRITIS d. CARCINOMA d. CARCINOMA e. HIATUS HERNIA e. HIATUS HERNIA f. MALLORY-WEISS SYNDROME f. MALLORY-WEISS SYNDROME g. BENIGN TUMOURS g. BENIGN TUMOURS h. FOREIGN BODY h. FOREIGN BODY 3. DUODENUM a. PEPTIC ULCER a. PEPTIC ULCER b. DIVERTICULUM b. DIVERTICULUM c. DUODENITIS c. DUODENITIS 4

5. 4. MISCELLANEOUS a. HEPATIC TRAUMA(HEMTOBILIA) a. HEPATIC TRAUMA(HEMTOBILIA) b. BLOOD DYSCRASIAS b. BLOOD DYSCRASIAS c. HERIDITARY TELENGIECTASIA c. HERIDITARY TELENGIECTASIA 5

6. 6 MOST COMMON CAUSES MOST COMMON CAUSES 1. Peptic ulceration 1. Peptic ulceration 2. Gastritis & Erosions 2. Gastritis & Erosions 3. Esophagogastric varices 3. Esophagogastric varices 4. Reflux esophagitis(Hiatus hernia) 4. Reflux esophagitis(Hiatus hernia) 5. Neoplasims 5. Neoplasims Peptic ulceration --- (1/2-2/3 of cases) Peptic ulceration --- (1/2-2/3 of cases) (duodenal ulcer 4 times more (duodenal ulcer 4 times more frequent than gastric ulcer) frequent than gastric ulcer) Due to errosion of a regional artery. Due to errosion of a regional artery. (gastroduodenal, Lt. & Rt. Gastric) (gastroduodenal, Lt. & Rt. Gastric)

7. 7 Patients with atherosclerosis, persistant Patients with atherosclerosis, persistant bleeding is more likely (failure of bleeding is more likely (failure of retraction of vessels wall) retraction of vessels wall) Erosions --- (not true ulcers)(often Erosions --- (not true ulcers)(often multiple)(does not extend multiple)(does not extend through the muscularis through the muscularis mucosae)(body or fundus are mucosae)(body or fundus are involved) involved) Tube ulcer --- (suction drawing mucosa Tube ulcer --- (suction drawing mucosa into N.G. tube) into N.G. tube)

8. 8 Stress ulcer --- (secondary to shock & Stress ulcer --- (secondary to shock & sepsis following operations, sepsis following operations, trauma & burn)(decrease in the trauma & burn)(decrease in the splanchnic blood flow – ischemia splanchnic blood flow – ischemia of superficial gastric mucosa & of superficial gastric mucosa & microcoagulation) microcoagulation) Curling ulcer --- (after burn) Curling ulcer --- (after burn) Cushing ulcer --- (postcraniotomy) Cushing ulcer --- (postcraniotomy)

9. 9 0ther causes of upper GIT bleeding 0ther causes of upper GIT bleeding Hepatic trauma --- hematobilia Hepatic trauma --- hematobilia Mallory-weiss syndrome --- (linear tears Mallory-weiss syndrome --- (linear tears of esophagogastric junction) of esophagogastric junction) (severe vomiting in alcoholic & (severe vomiting in alcoholic & pregnant women) pregnant women) Heriditary telengiectasia Heriditary telengiectasia Leukemia Leukemia

10. 10 DIAGNOSIS History --- Active ulcer History --- Active ulcer Violent retching or vomiting Violent retching or vomiting Recent ingestion of drugs Recent ingestion of drugs Bleeding tendency Bleeding tendency Previous gastric surgery Previous gastric surgery Heart burn acentuated by Heart burn acentuated by recumbancy recumbancy Upper abdomen or chest trauma Upper abdomen or chest trauma

11. 11 Examination --- Skin & mucous membrane Examination --- Skin & mucous membrane (icterus, spider angioma, liver (icterus, spider angioma, liver palms, hair loss) – hepatic cause palms, hair loss) – hepatic cause ( melanin spots – Peutz-jeghers ( melanin spots – Peutz-jeghers syndrome ) syndrome ) Lips, tongue, ear Lips, tongue, ear (hereditary tlangiectasia) (hereditary tlangiectasia) Supraclavicular L.N. Supraclavicular L.N. (intraabbdominal maignancy) (intraabbdominal maignancy) Epigastric tenderness Epigastric tenderness (ulcer or gastritis) (ulcer or gastritis)

12. 12 Palpable liver,splenomegaly, Palpable liver,splenomegaly, abdominal veins abdominal veins (varices) (varices) N.G. tube aspiration N.G. tube aspiration (presence of blood at this (presence of blood at this level & extent of bleed- level & extent of bleed- ing) ing)

13. 13 TESTS Hb level decrease ( 4-6 hours) Hb level decrease ( 4-6 hours) Leukocytosis ( leukemia ) Leukocytosis ( leukemia ) Neutrophils & platelets decrease(hepatic) Neutrophils & platelets decrease(hepatic) Clotting factors(bleeding tendency) Clotting factors(bleeding tendency) Endoscopy Endoscopy Radiological studies Radiological studies 1. Radionuclide imaging(Tc 99m sulfur 1. Radionuclide imaging(Tc 99m sulfur colloid or Tc 99m labled eryth- colloid or Tc 99m labled eryth- rocytes) rocytes)

14. 14 2. Selective angiography (celiac & 2. Selective angiography (celiac & superior mesenteric) superior mesenteric) (bleeding rate must be in the rate of (bleeding rate must be in the rate of 3-5ml/min) 3-5ml/min) 3. Barium swallow,enema & follow 3. Barium swallow,enema & follow through through Explorative laparotomy Explorative laparotomy

15. 15 Barium swallow (esophageal varices)

16. 16 FILING DEFECT (Ca stomach)

17. 17 Erosive gastritis (covered with hematin)

18. 18 Erosive gastritis

19. 19 Reflux esophagitis

20. 20 Reflux esophagitis

21. 21 Big ulcer crater (stomach)

22. 22 Gstric ulcer

23. 23 Healed gastric ulcer

24. 24 Bleeding DU

25. 25 Clip management

26. 26 Healing

27. 27 Kissing DU