Sindrome Mallory Weisss

UPPER GASTROINTESTINAL BLEEDING 406

THE PROFESSIONAL VOL:11, NO:04 OCT, NOV, DEC, 2004. 1

ORIGINAL PROF-808

UPPER GASTROINTESTINAL BLEEDING;ASSESSMENT OF CAUSES AND COMPARISON WITH OTHERRELEVANT STUDIES

MAJOR DR. JAVED IQBALMBBS, FCPS (Medicine)

Medical SpecialistCMH Pano Aqil Cantt (Sindh)

ABSTRACT ... [email protected] Objective: To determine incidence of different causes of upper

Gastrointestinal (UGI) bleeding in reference to UGI endoscopy in one hundred patients and to comparethe results with similar studies conducted globally. Design: Prospective, comparative study. Place andduration of Study: The department of medicine, Combined Military Hospital Peshawar during theperiod of one year from June 2002 to June 2003. Patients and Methods: First consecutive one hundredpatients were selected with symptoms and signs of UGI bleeding and endoscopy was performed within48 hours of start of symptoms. Results of the study were compared with similar studies conducted atother centers in Pakistan and abroad. Results: Major cause of UGI bleeding was found to be esophagealvarices (39%) followed by duodenal ulcer (19%), gastric ulcer (9%), superficial mucosal lesion (20%),neoplasia (4%). In 9% patients no cause of UGI bleeding was found on endoscopy. Conclusion: Majorcause of UGI bleeding in our set up is esophageal varices while peptic ulcer is less common comparedwith western world. This reflects high prevalence of chronic liver disease due to viral hepatitis.

Key words: Upper Gastrointestinal bleeding, esophagogastroduodenoscopy, esophageal varices.

INTRODUCTION

Upper gastrointestinal (UGI) bleeding is acommon medical condition that results in highmorbidity, mortality and medical care cost. AcuteUGI bleeding is a frequent cause ofhospitalization . In a study from a large1

maintenance organization, the annual incidence ofhospitalization for acute UGI bleeding was 102per 100,000 population; the incidence was twice ascommon in males as in females, and it increased

with age . UGI endoscopy is the diagnostic2

modality of choice for acute UGI bleeding . It is3

highly sensitive and specific for locating andidentifying bleeding lesions in UGI tract. Thisstudy was planned to find out the etiology of UGIbleeding in 100 patients who were admitted inmedical unit 1 Combined military hospital(CMH) Peshawar during the period from June2002 to June 2003.

mailto:[email protected].



PATIENTS & METHODS

Endoscopy was performed with Olympus GIFType E, on patients who were admitted with UGIbleeding or were referred from other units ofCMH or CMHs of NWFP fulfilling thefollowing criteria.

The inclusion Criteria as under:

< Patients of either sex, 15 years of age andabove.

< History of hematemesis on presentation.Hematemesis witnessed by medicalpersonnel.

< Patients with malenic tarry stoolswitnessed by naked eye examinationconsecutively for 2 days

The exclusion Criteria as followed.

< History of sore throat, cough, and onexamination pharyngitis tonsillitis andepistaxis

< History of chest pain, congestive cardiacfailure, bleeding diathesis, corrosiveingestion, chronic renal failure andterminally ill patients.

< Patients with history of accident ortrauma, post operative with stress ulcers.

A detailed history was obtained abouthematemesis and melena with particular emphasison onset, duration and progression of symptoms,recurrent episodic epigastric pain, nocturnalwakening with pain, pain relief with food andantacids, use of NSAIDS or corrosive ingestion.History about abdominal distension, anorexia,weight loss or recurrent jaundice was alsoenquired.

A complete and thorough physical examinationwas conducted including common signs of bloodloss like low blood pressure, tachycardia,

sweating, anemia, signs of chronic liver diseaselike spider naevi, gynaecomastia, testicularatrophy, ascities, prominent abdominal veins, lossof body hair, splenomegaly and shrunken liver.

Protocols for endoscopic examination wereestablished. Before doing endoscopy informedconsent was obtained and all the patients weresubjected to laboratory investigations like bloodComplete Picture, Urinalysis, Stool for occultblood, ova, cyst, Serum LFTs, HBsAg, HCVAntibody, bleeding profile including BT, CT,PT/INR, blood Urea Creatinine, Electrolytes.

Abdominal Ultrasound, ECG and chest X-raywere performed.

UGI endoscopy was performed within 48 hoursof onset of bleeding symptoms. Local throatanaesthesia with 4% xylocain spray followed byinjection atropine and injection valium 10 mg IVwere given. The site of lesion was documented byvisualizing active bleeding lesion.

Blood clot or a brown or black slough adherent tothe base or part of the base or a margin of an ulcerwas taken into account where no active UGIbleeding was visualized. Cases where endoscopydid not reveal any abnormality were classified asdue to undetermined cause.

RESULTS

Among the total of 100 patients the youngest was15 year old and eldest was 80 years with averageage of 40 years. Male to Female ratio was 3:2(Table I). UGI endoscopy was helpful inidentifying site of bleeding in 91% of patients.

No mortality or morbidity was reported inrelation to endoscopic examination. In descendingorder of frequency, the study revealed esophagealvarices as the cause in 39 cases (39%), duodenal



ulcer in 19 cases (19%), gastric ulcer in 9 cases(9%), superficial mucosal lesion (SML) in 20 cases(20%) (SML includes esophagitis, gastritis,duodenitis, Mallory Weis syndrome) andneoplasm in 4 cases (4%).

Table-I. Age & sex distribution (n=100)

Age in years Male Female Total

15-30 22 12 34

30-80 38 28 66

Total 60 40 100

Table-II summarizes the frequency of lesionsdetected. Table III shows comparison ofpercentage of accuracy of clinical diagnosis withlesions identified by endoscopy.

Table-II. Age distribution and frequency of lesions

Age in years Esophageal Varices Duodenal

Ulcer

Gastric Ulcer SML Growth Undetermined

15-20 6 1 1 4 - -

21-40 18 11 2 11 1 6

41-60 13 5 5 4 1 3

61-80 2 2 1 2 2 -

Total 39% 19% 9% 21% 4% 9%

Table-III. Comparison between clinical and endoscopic diagnosis

Lesion Total No. % age Clinical Diagnosis Endoscopic Diagnosis

Esophageal Varices 39 39% 33 39%

Duodenal Ulcer 19 19% 8 19%

Gastric Ulcer 9 9% 2 9%

SML 20 20% 6 20%

Growth 4 4% 1 4%

Undetermined 9 9% 0 9%

Table-IV. Comparison of results with other studies

Lesions Kartz1976

%

SilverStein

et al 1981%

Person1981

%

Qureshi1987

%

Harries1989

%

Lule GN KeneyateNH 1991

%

IrshadUH1993

%

Wascuki -A1997

%

PresentStudy2003

%

Duodenalulcer

15 22.8 22 29.37 16 17 14 30 19



GastricUlcer

5 21.9 18 10.45 7 - 6 20 9

SML 37 29.6 6 14.05 9 17 30 18 20

Growth - 8 2 - - - 1 2 4

Un-determ

12 - 12 7.18 - - 10 6 9

DISCUSSION

This study revealed that our results weresomewhat different from various studiesconducted in western countries but comparablewith studies conducted in Pakistan. Most ofendoscopic examinations were well tolerated andwere performed with only slight sedation.Sedation and information should be offered to allpatients undergoing endoscopy . At present days4

endoscopy offer a direct picture of the wholestomach and enable close observation of details.Any change found can be photographed innaturals colors. A early endoscopy in cases ofUGI bleeding has considerably altered the olderconcept of the causes of bleeding but theconsequences of the event have remained thesame. In this study, in 91% of cases cause ofbleeding was correctly determined.

Age and sex ratio in the study under discussionwas similar to those of other reported studies . In5

the National American Society forGastrointestinal Endoscopic Bleeding Survey(ASGE) on UGI tract involving 2,225 patients, 6pathological entities were responsible for mostbleeding episodes These include duodenal and6,7 .

gastric ulcer, acute gastritis, esophageal varices,esophagitis and Mallory Weis syndrome. Oncomparison with ASGE bleeding surveyesophageal varices were present in much higherproportion among our patients i.e. 39% versus15.4%.

In this study esophageal varices were the most

common cause followed by superficial mucosallesion and then peptic ulcer. These results weredifferent from studies conducted in Westerncountries. In the National American Society forGastrointestinal Endoscopic Bleeding Survey(ASGE) on UGI tract involving 2,225 patients,peptic ulcer was the most common cause, variceswere present in 15.4% case compared with 39% inour study . 6,7

But our results are comparable with the results ofstudies from other developing countries e.g., in astudy conducted in Kenya at National Hospitalesophageal varices was major cause of UGIbleeding. These results are also comparable withstudies conducted in Pakistan. The higherincidence of oesophageal varices was due to thehigh rate of chronic infection with Hepatitis Bvirus (HBV)and Hepatits C virus (HCV) leadingto end stage liver disease (cirrhosis).

Lower incidence of peptic ulcer as a cause ofbleeding could be due to frequent use of acidsuppressing drugs by medical practitioners inpatients with symptoms of dyspepsia.

Mortality from UGI bleeding was 10-12% in astudy conducted at Royal hospital London9

esophageal varices accounted for 62% of cases ofupper gastro intestinal bleeding . Mortality10

remains high with esophageal variceal bleeding at40% .11,12,13

In most of patients the cause of esophageal variceswas portal hypertension due to cirrhosis of liver.



Only in 2 patients, the cause of portalhypertension was portal vein thrombosis. Alcoholconsumption appeared to play little role as a causeof UGI bleeding in this population, most likelydue to religious prohibition of alcohol use in thecountry . Superficial mucosal lesion was14

recognized as the second commonest cause ofUGI bleeding in this study where the incidencewas 20%. Lower incidence of mortality found inpatients with duodenal ulcer confirms previouslyobserved trends .15

CONCLUSION

Esophagogastroduodenoscopy is the only reliabletool for correctly determining the etiology ofUGI bleeding. Major cause of UGI bleeding inour set up is esophageal varices while peptic ulceris less common compared with Western World.

This reflects high prevalence of chronic liverdisease due to viral hepatitis. Prevention oftransmission of hepatitis B and C and vaccinationagainst hepatitis B can significantly reduce burdenof chronic liver disease as well as upper GIbleeding.

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