Upper GI Bleeding

(F) 42 yr. old Bah K/C/O HTN diagnosed in 2015Presented to A/E H/O black stool, vomiting, abdominal pain for 2 days. - Stool: notice black stool but no streaks of blood. - Vomit: twice food content and fresh blood. - Abdominal pain: epigastric, localized, colic in nature, aggravated by eating food and retrieved by laying flat.Pt. recently had ERCP for stone reveled in CBD and discharged on 26-4-15H/O cholecystectomy Pt. on Norvasc OD for HTNHe is teacher and ex-smoker.ERCP : Endoscopic retrograde cholangiopancreatographyCBD: common bile duct1ExaminationsVitally stable, afebrile.On visual examination: pale, conscious, alert, not in RD.Chest: N .CVS: N.Abdomen: N.PR: not examined ECG done was normal.X-ray done was normal.

Previous was 14.3

DDxPeptic ulcer diseaseGastroesophageal varicesErosive esophagitis/gastritis/duodenitisMallory Weiss tearVascular ectasiaNeoplasmDieulafoys lesionAortoenteric fistulaHemobilia, hemosuccus pancreaticusRare, but cannot afford to missMost commonPt. had diagnostic gastroscopy:* Mild gastritis * No bleedingPt. given Omeprazole 40mg BD for tow daysanddischarged on it

Upper GI BleedingEsophageal varicesDr. Ali M.J 2015What is it ?UGIB is a common medical emergency Defined as bleeding arising from the esophagus, stomach, or duodenum.

Upper gastrointestinal bleeding (or hemorrhage) is that originating proximal to the ligamentof Treitz; in practice from the esophagus, stomach and duodenum.7How it present ?UGIB may present in five ways: Hematemesis is vomitus of red blood or coffee-grounds material.Melena is black, tarry, foul smelling stool.Hematochezia is the passage of bright red or maroon blood from the rectum.Maybe identified in the absence of overt bleeding by a fecal occult blood test or the presence of iron deficiency.Patients may present only with symptoms of blood loss or anemia such as lightheadedness, syncope, angina, or dyspnea.1- if red blood appear is a sign of active bleeding

Coffee-ground vomitus refers to the vomiting of black material which is assumed to be blood.3- Occasionally profuse upper gastrointestinal or small bowel bleeding can be responsible.

8Types of UGIB :Two types:Variceal: Chronic liver disease usually cirrhosis Prolonged INRLow plateletsNon-variceal:Peptic UlcerErosionsEsophagitisMalignancyMiscellaneous*

MiscellaneousOesophagusMallory-Weiss tear, Reflux oesophagitis, Oesophageal ulcer, Barrets ulcer, Cameron ulcer within hiatus hernia*, Oesophageal neoplasmStomachGastric ulcer, Gastric erosions, Haemorrhagic gastritis,Gastric carcinoma, Gastric lymphoma, Leiomyoma, Gastric polyp, Hereditary haemorrhagic telangiectasia, Dieulafoy lesion*,Gastric Antral Vascular Ectasia (GAVE)*,Angiodysplasia*DuodenumDuodenal ulcer, Duodenal erosions, Vascular malformation, Aorta-duodenal fistula,Polyps (including Peutz-Jeghers syndrome and other polyposis syndromes), Carcinoma of ampulla, Carcinoma of pancrease, Haemobilia*Small bowelStomal ulcer, Diverticulum, Vascular malformation, TumorIdentify patients at high risk for adverse outcomesHelps determine disposition (ICU vs. ward vs. outpatient)May help guide appropriate timing of endoscopyRisk StratificationInitial AssessmentAlways remember to assess A,B,CsAssess degree of hypovolemic shockClass IClass IIClass IIIClass IVBlood loss (mL)750 750-15001500-2000>2000Blood volume loss (%)< 15%15-30%30-40%>40%Heart rate100>120>140SBPNo changeOrthostatic changeReducedVery low, supine Urine output (mL/hr)>3020-3010-20