TOPIC:MANAGEMENT OF UPPER GASTROINTESTINAL BLEEDINGPRESENTING UNIT:GASTROENTEROLOGYPRESENTER:UGWUNZE E.ODATE:10 MARCH 2014
OUTLINE • INTRODUCTION • EPIDEMIOLOGY • CLASSIFICATION • AETIOLOGY • CLINICAL FEATURES[HX AND PHYSICAL EXAMINATION] • INVESTIGATIONS • TREATMENT • PROGNOSIS • CONCLUSION
INTRODUCTION Upper gastrointestinal bleeding (UGIB) • is a potentially life-threatening abdominal emergency • results in high morbidity and mortality hence requires admission for urgent diagnosis and management. • approximately 4 times as common as bleeding from the lower GI tract • bleeding derived from a source proximal to the ligament of Treitz. • Can be categorized as variceal or non - variceal
EPIDEMIOLOGY • The incidence of UGIB is approximately 100 cases per 100,000 population per year. • England.Wales - 20,000 hospital admission per year. • USA - 100,000 admission per year. • The incidence of UGIB is 2 fold greater in males than in females. • Mortality increases with older age[>60yrs] in males and females.
In Nigeria, a retrospective endoscopic study done on aetiology of UGIB by Mustapha et al in University of Maiduguri TH and FMC Gombe[2003 to 2008] showed : • A preponderance of male affectation[69.8% vs 30.2%]- 2fold increase in M:F. • Oesophagealvarices were the commonest cause of UGIB ffg by erosive mucosal disease ,then PUD. • Mortality rate of 17.9%[all mortality in patients with variceal bleeding] compared with 10% in most western studies.
CLASSIFICATION Nonvariceal bleeding • high pressure arterial haemorrhage - ulcer mucosal, deep tears • low-pressure venous haemorrhage, telangiectasia, and angioectasias vascular malformation that represents an abnormal dilation of mucosal and submucosal vessels
Variceal haemorrhage • elevated portal pressure transmitted to esophageal and gastric varices and resulting in portal gastropathy. • A complication of end stage liver disease.
AETIOLOGY Common causes of UGIB • Duodenal (DU) and Gastric ulcers (GU) (50% of bleeds),DU>GU. • Varices – Gastric , Oesophageal. • Acute gastric/duodenal erosions. • Mallory weiss tears. • Erosive Oesophagitis.
LESS COMMON CAUSES : • Boerhaave syndrome • GAVE(gastric antral vascular ectasia)(chronic GIB). • Dieulafoy leison • Gastric carcinoma, • Gastrinoma • Stomal Ulcer • Oesophageal Ulcer • Oesophageal carcinoma
Rare causes of UGIB. • Benign gastric tumours • Duodenal tumours • Arterial aneurysms, aorto-enteric fistula • Pseudoxanthoma elasticum. • Hereditary haemorrhagic telangiectasia(Osler- Weber-Rendu syndrome).
Haemangiomas • Bleedingdisorders • Munchausen Syndrome(factitious uppr GIT bleed).
MANAGEMENT • Involves • history taking , • physical examination • investigations • treatment
HISTORY A good and careful history taking • Patient history includes • weakness, • dizziness, • syncope assoc with Haematemesis, (coffee ground vomitus) • melaena (black stools with a rotten odour), • haematochezia (red or maroon stools)- seen in brisk UGIB and suggests a large upper tract hemorrhage.
Previous history of dyspepsia (esp. nocturnal symptoms) • peptic ulcer disease, • early satiety, • nonsteroidal anti-inflammatory drug or aspirin use. • hematemesis or meleana w/out previushx of dyspepsia • Hx of chronic renal disease.
Vomiting may point to Mallory weiss tears. • Weight loss, dysphagia, anorexia may be associated with malignancy .
PHYSICAL EXAMINATION • Objectives of the physical exam. • Assess the Haemodynamic state of patient and Determine the degree of shock. • Pulse and Bp should be checked supine and Upright positions to note effect of blood loss. • A systolic Bp < 100mmHg and pulse > 100/min indicate a 20% depletion of blood volume or more. • Tachycardia and Hypotension, indicate hypovolaemia.
Other signs of shock include • cool extremities, • oliguria, • chest pain, • presyncope, • confusion, • delirium. • Haematemesis and malaena to be noted. • Anaemia – indicates chronic blood loss
Signs of chronic liver disease should be noted – • spider angiomata. • gynaecomastia. • splenomegaly. • ascites. • pedal oedema. • Asterixis.
Signs of malignancy should be noted and portend a poor progress – • nodular liver, • abdominal mass, • firm lymphadenopathy suggestive. • Subcutaneous emphysema with a history of vomiting suggestive of Boerhaave syndrome (Oesophageal perforation). • Telangiectasias – may indicate rare Osler Weber-Rendu Syndrome.
INVESTIGATIONS • FBC: Hb may be normal or low. • Grouping and crossmatching of blood based on the rate of active bleeding(e.g 2 – 6 units). • BUN-to-creatinine ratio: value > 36 in a pxt without renal insufficiency is suggestive of UGIB.
Coagulation profile: PT, APTT,INR(coagulopathy, advanced liver disease) • Platelet count. • LFT. • Serum calcium:hypercalcemia increases acid secretion. • Gastrin level.
ENDOSCOPY • Early endoscopy within 24hrs and after resuscitation. • Urgent in patients with shock, liver disease, continued bleeding. • Cause of bleeding detected in > 80% • Can detect more likely cases to rebleed. • Varices can be injected at first endoscopy • Bleeding ulcers may be injected or vessels coagulated. • Improve rebleed but do not significantly improve mortality rebleed . Other Investigations. • Chest radiographs, Abd-x-Ray < supine, upright. • Barium studies – can affect endoscopy
CT scan and ultrasonography – cirrhosis, cholecystitis, pancreatitis, with pseudocyst and haemorrh, aorto- enteric fisfula, etc. • Nuclear medicine scan - areas of active bleeding • Angiography – Important as salvage therapy, embolization of bleeding vessel in failed endoscopic therapy. • Nasogastric lavage ; • confirm recent bleeding, active bleeding etc • Can reduce patient’s need to vomit • Character of nasogastric lavage fluid > severity of bleeding
HISTOLOGICAL FINDINGS. • Bleeding vessel in ulcer. • Fibrinoid necrosis, pseudoaneurysmal dilation of vessel. • Take biopsy samples from edge of gastric ulcer to rule out cancer. • H pylori lesion – chronic active gastritis with organisms in stained sample
PRINCIPLES OF MANAGEMENT1.Assessment *Brief and essential history *Physical examination2.Resuscitation *I.V. fluids – crystalloids, colloids, blood *Urethral catheterisation *C.V.P. line3.Re-assessment4.Endoscopy – OGD (diagnostic/therapeutic)5.Other investigations6.Definitive treatment7.Follow - up
Endoscopy • Injection of epinephrine or sclerosants, • heater-probe coagulation, • bipolar electrode coagulation, • laser coagulation • endoscopic application of clips, • use of banding devices, • argon plasma coagulation.
surgery • The indications for surgery in patients with bleeding peptic ulcers are as follows: • Severe, life-threatening hemorrhage not responsive to resuscitative efforts • Failure of medical therapy and endoscopic hemostasis with persistent recurrent bleeding • A coexisting reason for surgery, such as perforation, obstruction, or malignancy • Prolonged bleeding, with loss of 50% or more of the patient's blood volume • A second hospitalization for peptic ulcer hemorrhage