Upper GIT bleeding

ByPROF/ GOUDA ELLABBAN

Definition:

It is an acute bleeding occurring from a lesion proximal to the level of Teritz ligament.

Teritz ligament is a well defined peritoneal fold that ascend to the Rt. Crus of the diaphragm & it demarcate the dudeno-jejunal junction.

pathophysiology

It can be acute or chronic. chronic may lead to anemia (Fe

deficiency) If acute (hematemisis or melena) may

lead if sufficiently sever to hypovolemic shock if bld loss is more

than 25% of bld volume.

Etiology

Divided into:General: bleeding diathesis, hemophilia,

leukemia, thrombocytopenia, anticoagulant therapy & hemorrhagic hereditary telangactasia.

Local: in GI problem.

classification

Severity Anatomical location frequency

To severity Massive as in:1. Peptic ulcer2. Gastritis 3. Portal HPN4. Rupture of splenic

artery by erosion of stomach.

5. Rupture of aortic aneurysm by erosion of the jejunum

6. Esophageal varices

Con:

Non massive:1. Ca of stomach2. Hiatus hernia 3. Peptic esophegitis

anatomically Esophagus: Varieces, peptic esophegitis, foreign

body & rarely Ca. Stomach: Peptic ulcer, gastric erosion, gastritis,

Ca, hiatus hernia, Mallory Weiss syndrome, & FB.

Duodenum (commonest): Peptic ulcer, diverticulim.

Cont:

Miscellaneous: Aneurysm of splenic artery, uremia,

AVM & disorder of GI blood vessels.

Frequency:

Chronic peptic ulcer 65%

Acute peptic ulcer Multiple erosions

Esophageal varieces30%

Ca of stomach Mallory-Weiss synd PU in meckles Hemophilia Purpura Anemia

5%

Clinical features

General apearance:pale, anxious w/ moderate to sever Hg, sweating or shock.

Vital signs: hypotension, tachycardia, fever if associated with infection, shallow & rapid breathing.

skin: jaundice, palmer erythema, spider navei & other signs of portal HTN including gynecomastia.

Cont:

Head & neck: pale or dry mucous memb.

Abdomen: distention, boule sound increase, tenderness, ascites, hepatosplenomegaly.

Diagnosis

CORRECT the hypovolemia & the shock then take a good HX of peptic ulcer, liver dis, any NSAID ingestion or any predisposition cause.

Physical EX Investigation:1. NG tube to differ upper from lower

bleeding.

Cont:

1. Fibroptic endoscopy which will detect 80-90%.

2. Fibroptic esophgeogastroduodenoscopy.

3. Barium meal.4. arteriography(only if bleeding is

more than 1-2ml/min.

Cont:

The aim of investigation is to:1. Pin point the exact cause of

bleeding.2. To asses the effect of bleeding on

the pt.3. To plan for treatment.

Management:

Shock management:1. ICU admission.2. IV line (1L ringer lactate)3. Draw blood for grouping & cross

matching.4. NG tube (to prevent aspiration)5. Monitor vital sign.6. Urethral catheter.

Cont:

Blood transfusion. Gastric lavage. Valium or morphine to decrease

anxity(15mg IV) H2 blockers & antacids.

Treatment

Upper GI bleeding stops spontaneously in about 80-90% of pt.

1. Endoscopic coagulation(eg:injection sclerosis, heater probes, laser)

2. Infusion of vasopressin or embolic therapy by angiography.

3. Specific surgical treatment.

Cont;

Surgical treatment should be done within 48hrs of bleeding based on indication for surgery & failure of conservative management.

Absolute indication for surgery:1. Deterioration of vital signs in spite of IV

resuscitation.2. Inability to correct hypovolemia with 2L of

bld.3. Bld loss/requirement estimated at > 4

units of bld/24hrs.

Cont;

1. Visible bleeding vessel visualized by endoscopy.

2. Presence of co-existing lesion.Relative indication:3. Massive Hrg in pt > 60y4. Previous major bleeding episode.5. Past Hx of recurrent bleeds, ch ulcer,

arteriosclerosis.

Cont;

Factors affecting prognosis:1. Old age >60y2. Shock on admission3. Gastric ulcer4. Ch liver dis5. Arterial spurting from ulcer, visible

vessel in ulcer base, adherent fresh clot.

Cont;

Prognosis: Overall mortality 10% >80y 20%

Peptic ulcer dis

Despite the decrease in the frequency of peptic ulcer dis in the last 3 decades it remains the most common cause of upper GI bleeding.

Most duodenal ulcers are located in the post wall pf duodenal bulb just beyond the pylorice.

Majority of gastric ulcers are located in the lesser curvature.

Cont;

Bleeding from a gastric ulcer is more severe than a duodenal ulcer.

Approximately ¾ of these bleeding will stop spontaneously.

Treatment Medical treatment Surgical treatment(

duodenal ulcer)1. Selective

vagotomyA-highly selective cell

vagotomyB-vagotomy &

antrectomy

Cont;

C-vagotomy & pyloroplasty.Gastric ulcer:Distal gastrectomy to include the ulcer.

Esophageal varices

It take place anywhere from the lesser curvature upward into the esophagus.

Treatment

Medical treatment:1. Somatostatin administration.2. Balloon tamponad. Surgical treatment:1. Esophageal devascularisation by:Transection & reanastomosis

Con;

The standered procedures are portosystemic shunt:

A-end to end side portacaval shunt.B-side to side portacaval shunt.C-interposition portacaval shunt using a

prosthetic grafts.D-proximal splenorenal shunt.E-Warren shunt.

Cont;

F-the newest intervention is transjugelar intrahepatic shunt (TIPS)

Thank you