Upper Gastro-Intestinal Bleed

Oliver McLaren

GI Tract

Upper GI Tract• Anatomically consists of:

» Mouth» Pharynx» Oesophagus» Stomach

• Upper GI bleeding can include bleeding from the duodenum up to the ligament of Treitz, just before the junction between the duodenum and the jejunum

Ligament of Treitz

Epidemiology• Upper GI bleeding is a potentially life-

threatening and remains a common cause of hospitalisation

• Incidence is 100 cases per 100,000 people per year

• Upper GI bleeds are 4 times more common than Lower

• Overall mortality rate is 6-10 % overall

Upper GI Bleed Presentation• Upper GI bleeding presents in 2 main

ways:•Melaena = Black motions/stool•Haematemesis = Vomiting blood

• Other symptoms:• Anaemia• Syncope• Fatigue

Clinical Indicator Probability of Upper GI Source

Haematemesis Almost certain

Melena Probable

Haematochezia Possible

Blood-streaked stool

Rare

Melaena• Melaena comes from the Greek melas meaning black

• Has a characteristic smell of “altered blood”

• Tar-like in presentation• Colour is a result of iron oxidation as

blood moves through ileum and colon

Haematemesis• Bloody vomitus• Bright red/frank blood• “Coffee-ground” vomitus

–Haem exposed to stomach acid for some time–Oxidises– Takes on dark colour

Causes of Upper GI bleeds• Common causes:

• Mallory Weiss tear• Oesophagitis• Oesophageal varices• Peptic Ulcers – gastric and duodenal ulcers• Gastritis/gastric erosions• Duodenitis• Malignancy• Drugs – NSAIDS, aspirin, steroids,

thrombolytics, anticoagulants• Ideopathic

•Mallory-Weiss tear = Tear in mucosal layer at junction between oesophagus and stomach•Often as a result of prolonged + forceful vomiting

Oesophagitis

Oesophageal varices

Duodenal ulcer seen via endoscopy

Gastric ulcer

PEPTIC ULCERS

•Severe Gastrits•Erosive gastritis on contrast radiograph

•Duodenitis

Causes of Upper GI Bleeds• Rare causes:

• Bleeding disorders (eg Haemophilia)• Portal hypertensive gastropathy• Aortoenteric fistula• Angiodysplasia• Haemobilia• Dieulafoy lesion• Meckel’s diverticulum• Peutz-Jegher syndrome• Osler-Weber-Rendu syndrome

Portal hypertensive gastropathy

Aortoenteric fistula

Angiodysplasia

Dieulafoy lesion

Meckel’s diverticulum

Osler-Weber-Rendu syndrome

Management• In medical emergency:

» Protect airway» IV line for fluids + cross match blood» Monitor urine output» Correct clotting abnormalities» Monitor pulse, BP, CVP» Inform surgeons of all severe bleeds

• Post-emergency:» Locate + diagnose source of bleed , eg

endoscopy» Stop bleed, eg surgery, electrocautery, laser

therapy, adrenaline, banding, clipping