Upper Gastro intestinal Bleeding by yurtgc548


									    Massive Upper GI Bleeding
         John Meisel MD
   28 year old man presented with hematemesis
    of 1 liter of blood one hour ago
   He was weak and sweaty
   Physical examination was otherwise normal:
    no jaudice, ascites, abdominal mass,
    cachexia, telangectasia,
   Lecture will discuss how to deal with him and
    patients with similar problems
   Copy of lecture at: www.drmeisel.com
Massive Upper Gastro-
intestinal Bleeding
   A medical emergency; mortality 8-9%

   Upper GI bleeding 5X more common

                than lower
    Good treatment improves outcome
Chronic Upper GI Bleeding
 (will not discuss)
   Presents often with Microcytic anemia in
    the absence of pain
   Usually some symptom to suggest
    diagnosis: weight loss, dysphagia,
    abdominal pain, vomiting
   Most common cause in the world of GI
    bleeding and Microcytosis is Hookworm!
Massive Upper GI Bleeding
Clinical Presentation
   Sudden Weakness, sweating, nausea,
   Postural Hypotension before tachycardia
   Blood Loss: Hematemesis or melena
       Iron and Bismuth cause black stools
       Stools may not be seen for 4-6 hours
        because of slow GI transit in some patients
       It takes 100 cc blood to produce melena,
        which can come from nose to right colon.
Upper GI Bleeding
Common Causes
   Peptic Ulcers: 1/3 have no preceding pain before
   Esophageal Varices from cirrhosis
   Mallory Weiss Tear: gastroesophageal junction
    injury from vomiting or wretching
   Gastritis: usually from anti inflammatories, alcohol,
   Cancer of esophagus, stomach
   Many rare causes, including Dieulafoy’s(superficial
    pseudoanurysem of mucosa without ulcer:
    intermittent arterial bleeding)
The medical History
   Exact description of events, including number and
    volume of stools or vomitus
   Medicines, including anything taken except food.
    (Baby Aspirin often forgotten)
   Other illnesses: clues to severity, possible cause
   Prior GI complaints: pain, trouble swallowing,
    weight loss,
   During history, IVs are being started, blood is being
    drawn(rapid treatment improves outcome
Physical Examination
   Vital Signs: BP initially low, then tachycardia, check
   Pallor(only if anemic), lymph nodes, abdominal mass,
    liver or spleen, rectal to test stool for blood
   Rarer findings: bruising with coagulopathy, arthritis
    as clue for anti inflammatories, telangectasia,
    abdominal scars of trauma or surgery, bruits of
    vascular disease, ascites from liver disease
Immediate Treatment
   IV fluids: or sips of liquids in
   Bed rest with legs up
   Check Blood counts: remember with
    acute bleeding counts unchanged till
    diluted with IV fluids or time
   Type and Cross match Blood: do not
    give unless under 24% unless
    heart/lung disease
Immediate Treatment
   Naso-gastric tube ?: can tell if active bleeding or not, reliable
    if bile obtained. Only used 50%; Unless vomiting persistent
   If bright red blood, urgent endoscopy
   Benefits of Endoscopy: Not just because we want to know,
    but does it really help the patient?
   The characteristics of the ulcer will define prognosis, need
    for hospitalization (Visible vessel or active bleeding 90% vs.
    clean ulcer 5% chance of re-bleeding:( Lee,JG, Gastro Endo
       Decrease the need for transfusion

       Decrease the need for surgery

       (Injection of Erythromycin will help clear stomach

         before endo(Gastro 202;123:17)
       If endoscopy delayed 12-24 hours, use only if dysphagia,

         continued bleeding, weight loss or other alarm symptoms
Endoscopic Therapy
Stopping Ulcer Bleeding

   Electrocautery: monopolar or bipolar(Bicap)
        Bipolar safer because injury more superficial
   Clips
   Injection: 1;10,000 epinephrine or other solution (works by
    vasospasm and tamponade
   Banding. May cause bowel necrosis if applied to deeper
   Combination Treatment: most common Epinephrine and Bicap
   Argon Plasm Coagulation: Deeper, controlled burn: Expensive
   Fibrin Sealant: Experimental, but seals fistulae
Endoscopic Therapy
   About 1/25 bleeders can not be stopped and
    require surgery
   Some require second endoscopy, and 75% are
    successfully treated
   IV Omeperazole by Infusion: may be helpful but very
   Surgery is usually over sew ulcer in USA(where
    availability and cost of medicines better than long
    term side effects of ulcer surgery(diarrhea, weight
    loss); Definitive ulcer operation sensible
    elsewhere to avoid lifetime medications.
Common Causes of Bleeding
   Gastric or Duodenal Ulcers: In USA 50%
    Helicobacter, 50% Anti inflammatories
       A very good medication history
       Blood test for antibodies, Stool for Antigen, Biopsy
        or assume everyone positive (Cambodia)
   Esophagitis from reflux plus anti
    inflammatories: can be focal ulcer
   Tear at GE junction from Vomiting: Mallory
    Weiss tear: sometimes needs clips, injection
Common Causes of Bleeding
   Gastritis: from drugs, alcohol, stress,
    cannot be focally treated
    endoscopically,usually not massive
   Cancer: Temporarily stopped
   Esophageal Varices from Cirrhosis:
    Banding better than sclerotherapy
   Multiple Rare causes
Other Issues GI Bleeding
   No need to treat Helicobacter acutely
   Transfusion: Hct <22%, elderly <26%
   Endoscopy also allows us to triage
       Clean based ulcer: watch 24 Hr, or
        discharge, the chance of rebleeding ,5%
       Clot, visible vessel: rebleeding 12-20%
       Actively Bleeding: higher, surgery possible
Prevention of Bleeding
   Identified Cause will allow for Prevention
   If anti inflammatories the cause, treat with
    alternative medicine for headaches/arthritis, etc or
    the patient will start taking them again
   Adequate treatment duration: Duodenal ulcers
    treat for 6 weeks; Gastric ulcers for 3 months;
   Treat Helicobacter; Test for cure Stool or Breath
    test (Blood antibodies will persist)
   Some Patients will re-bleed without
    antiinflammatories and Helicobacter treated: about
    20% of ulcers: Other causes yet to be discovered.

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