Upper GI Bleeding

Lecture 1 Upper GI bleeding • Definition: Any bleeding above ligament of Treitz. Signs and symptoms * Hematemesis (vomiting blood) and coffee ground vomiting * Melena (black and loose stool) * Fresh rectal bleeding * Hemodynamically unstable (posture hypotension -Orthostasis- and posture tachycardia and frank hypotension) * Dizziness and Palpitations * Pallor (due to anemia) * Abdominal pain and symptoms of Peptic ulcer disease * History of NSAID’s use -which is related to peptic ulcers* Jaundice and other stigmatas of chronic liver disease. • Peptic ulcer disease 1. Most common cause of GI bleeding. 2. Defect in GI mucosa extend from muscularis mucosa 3. Caused by *Helicobacter Pylori (common) *NSAID’s that cause imbalance between protective and damage factors. 4. There is an acid hypersecretion and G cell hyperplasia. 5. Two types: a. Duodenal ulcer b. Gastric ulcer (clean-base ulcer) • Stress ulcers 1. Happens in critically ill patients like ICU, burns, head trauma patients. 2. Types: a. Curling ulcer → in extensive burn patients Causes * Peptic ulcer disease →The most common cause. * Esophageal varices * Mallory Weiss tear * Neoplasms * Arteriovenous malformation (AVM) * Dieulafoy lesion * Stoma and Esophageal ulcers * Duodenitis * Hemobilia *Aorto- enteric fistulas • Mallory-Weiss tear 1. Pathogenesis: Multiple forceful vomiting → Laceration around the GE junction → bleeding 2. Laceration around the GE junction (because they vomit a lot): Chemotherapy patients/ pregnant women in first trimester who have hyperemesis gravidarum/ alcoholics • Hemobilia: Bleeding through ampulla of vater and biliary tree (Etiology: having previous procedures) • Esophageal Varices 1. *Dilated tortuous veins of the lower and mid esophagus. 2. Due to thrombocytopenia and portal hypertension and liver cirrhosis. 3. 60% Rebleeding rate. b. Cushing ulcer →head injury patients 4. Two types: 3. Causes: Vagal hyperstimulation and vascular hypoperfusion. a. Non-variceal bleeding patients→Treatment: 4. Multiple/ Body and fundus more affected proton pump inhibitors infusion. 5. Prophylaxis by proton pump inhibitor b. Variceal bleeding patients → Treatment: Octreotides = Somatostatin analog 5. rectal exam and endoscopy. 6. The target hemoglobin in varices patient is 7-8 mg\dL Adverse prognostic factors *Diagnosis (Varices + Malignancy)/ *Older age /*Severe initial bleeding (drop in hemoglobin)/ *Recurrence during hospitalization/ *Coincidental diseases (like: DM, ischemic heart disease, hypertension)/ *Endoscopic stigmata of recent bleeding/ *Need for emergency surgery/ *Need for emergency surgery. Management Secure Airway/ Maintain Breathing/ Circulation (IV fluids+ RBC) Cirrhosis and Portal hypertension Stigmata (identifying marks) of cirrhosis Jaundice Accumulation of bilirubin in the blood stream causing yellowish discoloration of plasma and heavily perfused tissues Spider Angiomas Small, centrally raised bumps (papules) caused by a dilated arteriole (small artery). A network of dilated capillaries (tiny blood vessels) radiate from the arteriole. Pressing on the lesion causes the redness to disappear briefly, and there is a rapid return of redness once the pressure is lifted. a condition where there is enlargement of the terminal end of the digit over the distal phalanx. It is usually symmetrical and affects the fingers Finger Clubbing Gynecomastia Breast development in men and breast atrophy in women Dupuytren’s Contractures Joint contractures Cirrhosis lead to→ portal hypertension varices Caput Medusae (complication of portal hypertension) Distended and engorged umbilical veins which are seen radiating from the umbilicus across the abdomen to join systemic veins. confusion→Drowsiness→ Somnolence→ coma Astraxia Flapping tremors, quick arrhythmic movement in background tonic muscle contraction spontaneous bacterial peritonitis (SBP)→ E.Coli + Klebsiella.