Upper gi tract bleed

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  • 1. Upper GI tract bleed

2. Upper GI bleed presents with hematemesis Hematemesis means vomiting of blood The appearance of hematemesis resembles coffee grounds It indicates bleeding from upper GI usually from esophagus, stomach and duodenum above ligament of treitz Conditions which cause hematemesis can also cause melena 3. Causes of Upper GI bleed Peptic ulcer Esophageal varices Erosive gastritis Esophagitis Mallory weiss syndrome Carcinoma stomach Hereditary hemorrhagic telengeictasia Bleeding disorders 4. Peptic ulcer It means ulcers in those parts of the gut which are exposed to acid. Common sites are duodenum , stomach and can also occur in lower esophagus. Causes: Increase acid secretion(duodenal ulcer) Decrease mucosal resistance(gastric ulcer) NSAIDs ingestion H.Pylori infection Zollinger Ellison syndrome (uncommon) 5. Peptic ulcer pain is felt in the epigastrium and is well localized. Patient points with one finger to the site of pain- the pointing sign- Duodenal ulcer Occurs in the 1st part of duodenum. Symptoms include Pain epigastrium aggravated by empty stomach(hunger pain), relieved by food and antacids Nocturnal pains occur Pain in the morning is not due to peptic ulcer History of periodicity may be present. Signs Localized tenderness in the epigastrium 6. Investigation Barium meal shows duodenal deformity/ulcer crater. Endoscopy confirms ulcer presence. 7. Gastric ulcer Symptoms Relation of pain to meals and timings is variable May be relieved or aggravated by food Nocturnal pain is uncommon Signs Epigastric tenderness Investigation Barium meal shows ulcer crater Endoscopy confirms Every gastric ulcer must be biopsied to exclude malignancy 8. Treatment 1st line therapy includes PPI ,Antibiotics( clarithromycin and amoxicillin) 2nd line therapy includes quadruple therapy PPI ,Antibiotics(clarithromycin and amoxicillin) bismuth For long term ulcer use only PPI Complications of peptic ulcer Bleeding Perforation Chronicity Gastric outlet obstruction 9. Esophageal varices These are dilated tortuous veins in the esophagus These are communication channels between the portal and systemic venous systems and become dilated in portal hypertension Most common cause of portal hypertension is hepatic cirrhosis 10. Symptoms Hematemesis is massive and recurrent Distention of abdomen due to ascites History of jaundice Hematemesis may be the first manifestation of cirrhosis Signs Jaundice Dependent edema Gynecomastia and testicular atrophy Palmar erythema, dupuytren contracture, Spider angiomas, parotid swelling (common in alcoholic cirrhosis) 11. Veins of abdominal wall may be prominent Liver may be enlarged/shrunken Palpable spleen Ascites in advanced disease Investigation Endoscopy 12. treatment I.V fluid replacement with 0.9% saline Vasopressor Prophylactic antibiotics (cephalosporin) Variceal band ligation PPI Lactulose 13. Erosive gastritis In addition to inflammation of stomach, there are multiple mucosal erosions and petechiae. Causes A. drugs Aspirin and NSAIDS Theophylline Potassium chloride B. stress Head injury Shock Trauma Burns Sepsis Hepatic encephalopathy 14. Symptoms Hematemesis with or without epigastric pain h/o drug intake Signs Tenderness in the epigastrium Investigation Endoscopy 15. Esophagitis Abnormal reflux of gastric contents into lower esophagus is the most common cause of esophagitis Smokers and obese are more prone Symptoms Retrosternal burning and pain(heart burn), increases on bending forward or lying flat Relieved by antacids 16. History of regurgitation Water brash Bitter taste in the morning Persistent dysphagia indicates peptic stricture Aspiration of regurgitant material cause laryngitis and aspiration pneumonia Signs Pallor may occur Investigation Barium swallow demonstrates reflux Esophageal ulcers may be seen 17. Endoscopy shows Hyperemic mucosa with or without ulcers If mucosa looks normal , biopsy will demonstrate microscopic inflammation PH monitoring 4% of time is suggestive of acid reflux Treatment Lifestyle modification PPI H2 antagonists Prokinetic drugs 18. Mallory weiss syndrome Repeated retching and vomiting can cause vertical mucosal tear at gastroesophageal junction Symptoms H/o repeated vomiting and retching before hematemesis 19. Sign Epigastric tenderness Investigation Endoscopy 20. Carcinoma stomach Occurs after age of 40 years Risks include Pernicious anemia Partial gastrectomy Gastroenterostomy Symptoms Loss of appetite, nausea and discomfort after meal Vague epigastric pain and feeling of distention after meals Early satiety is common Persistent vomiting if gastric outlet obstruction Marked loss of weight 21. Signs Pallor Epigastric mass may be palpable In later stages, patient may have enlarged scalene lymph nodes, nodular liver and ascites due to metastases Investigation Iron deficiency anemia Barium meal shows filling defect Endoscopy shows mass/ulcer Biopsy confirms diagnosis. In case of ulcer, six biopsies should be taken Treatment Gastrectomy (partial and complete) Palliative treatment 22. Hereditary hemorrhagic telengeiectasis It is an autosomal dominant disease. Bleeding occurs from multiple telangiectasias which consists of localized collection of non-contractile capillaries. Symptoms Recurrent hematemesis/epistaxsis/hemoptysis 23. Sites of telangiectasias Face Hands Mucous membranes of nose, oral cavity and GIT Investigation Telengiectasia may be seen in gastric mucosa on Gastroscopy 24. Bleeeding disorders Causes A. Defects of blood vessels: Vascular purpura Hereditary hemorrhagic telengiectasia B. Platelet disorders Thrombocytopenia Thrombocythemia Thromboasthenia 25. C. Clotting disorders Hereditary Hemophilia Christmas disease Von willebrand disease Acquired Vitamin K deficiency Oral anticoagulant therapy Advanced liver disease D. Consumption coagulopathy DIC 26. Basic investigations Full blood count show anemia Urea and electrolytes :elevated urea with normal creatinine concentration implies severe bleeding Liver function tests may show evidence of chronic liver disease Prothrombin time shows bleeding disorders and liver synthetic dysfunctions 27. Management of upper GI bleeding Intravenous access using one large bore cannula Initial clinical assessment Define circulatory status Seek evidence of liver disease Identify other comorbidity Resuscitation with crystalloids or transfusion in severe bleeding Ventilation with oxygen mask Monitoring of B.P and urinary output Endoscopy should be performed within 24 hours. It is used in treatment of bleeding from peptic ulcer using injection of epinephrine and thermal clips.in varicial bleeding band ligation is also done endoscopically. Surgery 28. History taking related to GI bleeding Duration Episodes of hematemesis Quantity Color(coffee ground appearance) Blood in stools (maroon colored stools can be present in acute severe upper GI bleeding) History of jaundice(cirrhosis) History of epigastric pain (peptic ulcer, esophagitis, erosive gastritis) Weight loss (carcinoma stomach) 29. Signs in upper GI bleeding Anemia Epigastric tenderness Ascites Hepatomegaly and spleenomegaly Jaundice Palmar erythema ,dupuytren contracture, Spider angiomas ,parotid swelling in alcoholic cirrhosis Gynecomastia and testicular atrophy Prominent abdominal veins Dependent edema Abdominal mass Palpable scalene, paraumblical , virchow lymph nodes 30. Thanks