Upper GI bleed Approach and Management

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  • 1.UGI bleed Dr Manoj K Ghoda M.D., M.R.C.P. Consultant Gastroenterologist Visiting faculty, GCS hospital mkghoda@yahoo.com Gujarat gastro group

2. 45 years old male Referred for UGI endoscopy for hematemesis Vomited blood previous night Since then he has blood collecting in his mouth No h/o drug ingestion No alcohol, no tobacco Previously diagnosed to have hypertension and on medication but otherwise fit and well When confronted with such a case scenario what should you check? 3. When confronted a patient with hematemesis you should have following check list Is it really hematemesis? If it is, is patient stable? How bad is hematemesis? What is the estimated amount of blood loss? What could be the lesion? Where could be the lesion? What could be its blood supply? 4. Is it really hematemesis? Vomiting of blood from GI tract is called hematemesis. Apart from UGI tract, blood could be from respiratory tract, from mouth, and from nose. Unless a careful history is taken, wrong assumption could be made leading to diversion to a system actually not responsible in the first place, causing delay in diagnosis and even death, not to speak of unnecessary expense and hardship to patient. 5. Is it Hematemesis?......... Some clinical considerations.. Bright red blood is less likely to be from upper GI. Consider epistaxis, hemoptysis or bleeding gums and of course, fictitious bleeding. Frothy blood or blood in lumps is more likely to be from lungs. Epistaxis is never a part of hemetemesis. More likely that blood from epistaxis is swallowed and brought out as hematemesis. Blood pressure in such cases is very high. A small amount of blood, mostly red, after several bouts of violent retching and non-bloody vomiting, is almost certainly a Mallory-Weiss tear, and if this is followed by severe chest pain, a transmural esophageal tear, the Boerhaave syndrome. 6. Blood accumulating in mouth requiring patient to spit it out is either dental bleed or epistaxis. Dental or gum disorders may be present in the past. Coffee colored or black vomiting is hematemesis, due to bleeding from upper GI, unless otherwise proved. History and physical findings of portal hypertension or acid peptic disease may be present. This preliminary inquiry will always lead you to the correct line of investigation and treatment. 7. It always help to check visually... 8. Patient with hematemesis usually requires a bucket; whereas patient with hemoptysis usually requires a small bowl Is it hematemesis? 9. How bad is the bleeding? . Assessing the blood loss. Resting pulse and B.P. normal = < 500 ml. blood loss. Resting tachycardia and postural drop of B.P. = up to 2.0 L loss. Shock = > 2.0 l blood loss. 10. What could be the cause of bleeding? Common causes of UGI bleed in Indian context. Remember!! Ca esophagus or Ca stomach rarely, if ever, present with GI bleed. They always have other features of presentation. Esophageal Gastric varices are now one of the commonest cause of upper GI bleed in pediatric population Peptic ulcer, duodenal or gastric. Related or unrelated to H. Pylori. NSAID induced mucosal injury, erosions, and ulcers. Esophageal varices are now one of the commonest cause of upper GI bleed in India. Mallory-Weiss tear. Gastric varices. Portal hypertensive gastropathy. Dieulafoy lesion. 11. Dieulafoy lesion Varices Gastric erosions 12. Where could be the lesion? 13. What is the blood supply of the lesion? 14. Could you name these blood vessels ? 15. Blood supply of the lesion Esophagus: Upper esophagus is supplied from superior and inferior thyroid arteries. Mid-esophagus by the bronchial, right intercostal arteries and descending aorta. Distal esophagus by left gastric left inferior phrenic and splenic arteries. 16. The venous drainage of upper esophagus is through the superior vena cava. Mid esophagus through azygous veins. Distal esophagus through portal vein by means of left and short gastric veins. Through these veins there is a porta-systemic communication. There is an extensive submucosal venous anastomotic network which is very important because in portal hypertension blood is diverted from high pressure portal venous systems to low pressure systemic circulation via this network resulting in esophageal varices. 17. X X X X X X Vascular supply of stomach Could you name these blood vessels ? 18. Stomach: Arterial supply is from celiac artery; through common hepatic, left gastric and splenic arteries, which form two arterial arcades along lesser curvature and lower two thirds of greater curvature. Gastric fundus and left upper aspect of greater curvature are supplied via short gastric arteries, which arise from the splenic artery. Greater curvature below fundus is supplied from above by left gastroepiploic artery, a branch of splenic artery and from below by right gastroepiploic artery, a branch of gastroduodenal artery and these two usually anastomose. Lesser curvature is supplied from above by left gastric artery and from below by right gastric artery or gastroduodenal artery, branches of common hepatic artery. 19. X X Duodenum: Celiac trunk supplies proximal duodenum via hepatic artery, from which arises gastroduodenal artery, which in turn branches into superior pancreaticoduodenal artery, which gives off anterior and posterior branches to duodenum. Distal duodenum is supplied by branches the superior mesenteric artery. Could you name these blood vessels ? 20. Branches of Common Hepatic Artery? 21. Remember, the celiac trunk has three main branches 1--Left gastric artery (supplies L greater curvature of stomach) 2--Splenic artery (spleen, pancreas, left greater curve of stomach) 3--Common hepatic artery (liver, gall bladder, right greater curvature, head of the pancreas) 22. Clinical presentation of UGI bleed: Presentation may be as coffee-brown vomiting known as hematemesis, or there may be frank red blood. Mallory-Weiss tear usually presents with one or more clear vomits followed by reddish, rather than coffee brown blood. Some patients present with dark black, like coal tar, stool known as melena. Some people with massive bleed will have both Hemetemesis and bleeding PR which is not dark black but red. There may be nausea, dizziness, and perspiration related to hypovolemia and hypotension Patients with acid-peptic disease give a history of epigastric pain for sometime before the illness and there may be history of analgesic ingestion. There may be past history of jaundice, ascites or other features of chronic liver disease. 23. How will you decide if the patient needs admission or could be discharged home? 24. Identifying high risk patients. When the patient is in shock. Patients above the age of 65 years. Patients with co-morbid conditions like IHD, hypertension, diabetes, coagulopathy or chronic liver disease. Where there is simultaneous upper and lower GI bleeding. Previous ulcers/bleed Patient having rebleed during the same admission On steroids or NSAIDs Alcoholic or tobacco smoker Can you Identifying high risk Doctors ? 25. The Rockall Score for stratifying risk Variable 0 Score 1 2 3 Age (yrs) < 60 60-79 80 Comorbidity No or mild coexisting Moderate coexisting (e.g., hypertension) Severe coexisting (e.g., CHF) Life threatening (e.g., RF) Hemodynamic status No shock P < 100 Syst BP 100 P 100 plus Sys BP 100 Hypotension Diagnosis MW tear, normal endoscopy with no blood seen All other diagnosis Malignancy of UGI tract Major stigmata of recent hemorrhage None or dark spot Blood in UGI tract Adherent clot, visible or spurting vessel Rockall, Lancet 1996 26. ROCKALL System - Rebleeding According to Risk Score Category Rockall et al. Gut 1996;38:316 Rockall score Cumulativepatientswithrebleeding Enns RA, W J Gastroenterol, 2006 27. The Glasgow-Blatchford Bleeding Score GBS superior to total/clinical Rockall scores (ROC curves, P