UPPER GIT BLEEDING HEMATEMESIS

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UPPER GIT BLEEDINGHEMATEMESIS
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OBJECTIVES

• History Examination portal system
• Definition Related terms
• Clinical presentation
• Differential Diagnosis
• Hematemesis VS Hemoptysis
• Management

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Anatomy of the Portal System
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History
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Definition

• Bleeding derived from any source proximal to the
  Ligament of Treitz

1 in 1000 in us who experienced upper GI
bleeding Men women 2
1 Mortality rate 10
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Related Terms

• Hematemesis?
• Vomiting of blood
• Red or Brown Dark ??? Coffee ground
• Hematochezia Upper OR Lower?
• Blood in the stool
• Melena Upper Or
  Lower?
• Black, tarry, smelly stool

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HPS

• Portal Hypertension
• Pressure difference between the portal vein and
  the hepatic veins
• Portacaval Anastomosis
• portal circulation
  systemic circulation
• left gastric vein
  Azygos vein
• Esophageal
  Varices UGIB

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Esophageal varices
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Clinical Presentation

• Hematemesis - 40-50
• Melena - 70-80
• Hematochezia - 15-20
• Syncope - 14.4
• Presyncope - 43.2
• Dyspepsia - 18
• Epigastric pain - 41
• Heartburn - 21
• Diffuse abdominal pain - 10
• Dysphagia - 5
• Weight loss - 12
• Jaundice - 5.2

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Peptic Ulcer

• A break in the epithelial surface (i.e.
  ulceration) of the oesophagus, stomach or
  duodenum .
• PU includes
• Duodenal ulcer.
  (commonest)
• Gastric ulcer.

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Common causes of PU

• Infection with H.pylori.
• NSAID and the usual suspects
• (Alcohol ,smoking, stress)
• Imbalance between the aggressive and protective
  mechanisms.
• Acid hypersecretion due to increase number of
  parital cells or as seen in (Zollinger-Ellison
  syndrome).

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Clinical Features (PU)

• M F ,20-50 yrs.
• Epigastric pain during fasting (hunger pain),
  relieved by food and Antacids.
• Back pain if ulcer is penetrating posteriorly.
• Hematemesis from ulcer penetrating GD artery
  posteriorly.
• Can lead to peritonitis if ulcer occurs
  anteriorly.
• Can lead to pyloric stenosis.how?

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The Forrest classification of PU Bleeding

• F-I Active bleeding
• F-I/a. Spurting arterial bleeding
• F-I/b. Oozing bleeding
• F-II Signes of recent haemorrhage
• F-II/a. Visible vessel on the base
  of ulcer
• F-II/b. Coagulum in the ulcer
• F-II/c. Coffee ground ulcer base
• F-III No signe of bleeeding

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F 1A
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Beheviour of PU Bleeding

• Spontaneous stoping 70-80
• Probability of rebleeding 30-50
• Rebleeding within 24-48 hours 70-80
• Mortality among patients operated
• because of rebleeding 20-30

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Gastric Ulcer
Type I
Type II
Same as PU
MF 31 , 50 yrs. Epigastric pain induced by
eating. Weight loss. Nausea and vomiting. Anaemia
from chronic blood loss.
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Treatment

• 1-Medical
• In chronic PU eradication of H.pylori.
• General management
• Avoid smoking and food that cause pain.
• Antacids for symptomatic relief.
• H2 blockers .

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Treatment

2- Endoscopic Topical treatment Injection
treatment Mechanical treatment Thermal
treatment
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Topical treatment

• Tissue adhesives (cyanoacrylat)
• Blood clotting factors (thrombin,fibrinogen)
• Vasoconstricting drugd (epinephrin)
• collagen
• Ferromagnetic tamponade

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Injection therapy

• Sclerotizing drugs (Aethoxysklerol)
• Alcohol (96-99.5 )
• Epinephrin (Tonogen)
• Thrombin

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Mechanic treatment

• Loops
• Sutures
• Balloon treatment
• Haemostatic clips

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Thermal treatment

• Laser fotocoagulation
• Heater probe
• Electrocoagulation
• Monopolar
• Bipolar
• Electrohydrothermo sond

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3-Surgical treatment

• Local operation?
• Suture
• Stiching of ulcer
• Local operation vagotomy
• resection type operation

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Local operation

• The rebleeding rate is very high,
• 70-80 ,
• Insufficient solution
• Today is not advised!!!

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Local operation with vagotomy

• Quicker than resection
• Rebleeding rate 17
• Suture insufficiency 3

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Resection type operations

• Rebleeding only in 3
• Insufficency of duodenal stump 13
• The duration of operation is the most longer

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Oesophageal varicosity

• dilated sub-mucosal veins in the esophagus
• portal hypertension
• left gastric vein Azygos
  vein

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Treatment

• Balloon tamponade
• Sengstaken-Blakemore
• Linton
• Sclerotherapy
• Oesophageal transsection
• Variceal ligation, or banding
• TIPS ( transjugular intrahepatic portosystemic
  shunt)

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Mallory-Weiss syndrome (tear)

• The cause the sudden increase of intragastric
  pressure
• Alcohol intoxication
• Pathology Rupture of the mucosa in the cardia
• Treatment Conservative treatment usually
  sufficient, no need of operation

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MWS
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Erosive inflammation in the upper GIT

• Regular or incidental alcohol intake
• Side effect of a medicine
• NSAID
• Salycil containing drugs
• Steroids
• Other illnesses
• cardio-respiratory, cardio-vascular, trauma,
  burning postoperative conditions

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Treatment

• nasogastric intubation and irrigation with
  alkaline fluid
• H2RA, PPI
• Electrolyt and blood replacement
• Sedation
• Operative treatment is often avoidable

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Where is it from?

• GI TRACT
  RESPIRATORY TRACT
  
  Dark red or brown
  
  Bright red
• In clumps
  Foamy, runny bubbly
• Mixed with food
  mixed with mucous
• Acidic pH
  alkaline pH
• Stomachache, abdominal discomfort
  chest pain, warmth
• Nausea, retching before and after episode
  persistent cough

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Differentiation

• mild bleeding
  severe bleeding
• Normal Pulse
  Weak Rapid
• Normal BP
  BP10Hg
• Normal breathing Deep
  Tach
• Mucosa slightly dry
  Parched
• Slightly Urine OP
  Anuris
• Conscious
  Fainting
• 15

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Summary
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• Definition
• Hematemesis is vomiting of gross blood.
• Causes
• Esophagus
• Stomach
• Duodenum
• hepatic

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Hepatic Portal System

• system of veins that comprises the hepatic portal
  vein and its tributaries
• Hepatic portal vein
• Splenic vein
• celiac trunk
• superior mesenteric vein
• inferior mesenteric vein

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Assessment

• resuscitation
• nasopharyngeal tube
• lab assessment (CBC-Coagulation Factors)
• Radiology.
• endoscopy within 48hrs
• medical therapy / surgery

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MANAGMENT

• Minimal blood loss
• If this is not the case, the patient is
  generally administered a proton pump inhibitor
  (e.g. omeprazole), given blood transfusions (if
  the level of hemoglobin is extremely low, that is
  less than 8.0 g/dL or 4.5-5.0 mmol/L), and kept
  nil per os(nil by mouth) until endoscopy can be
  arranged. Adequate venous access (large-bore
  cannulas or a central venous catheter) is
  generally obtained in case the patient suffers a
  further bleed and becomes unstable.
• Significant blood loss
• In a "hemodynamic ally significant" case
  of Hematemesis, that is hypovolemic shock,
  resuscitation is an immediate priority to prevent
  cardiac arrest. Fluids and/or blood is
  administered, preferably by central venous
  catheter, and the patient is prepared for
  emergency endoscopy, which is typically done in
  theatres. Surgical opinion is usually sought in
  case the source of bleeding cannot be identified
  endoscopically, and laparotomy is necessary.