Upper Gastrointestinal Bleeding

Upper gastrointestinal bleeding (UGIB) is a significant and potentially life threatening worldwide problem. Despite advances in diagnosis and treatment, mortality and morbidity have remained constant.1 Bleeding from the upper gastrointestinal tract is about 4 times as common as lower gastrointestinal tract bleeding. Typically patients present with bleeding from a peptic ulcer and about 80% of such ulcers stop bleeding. Increasing age and comorbidity increase mortality. It is important to identify patients with a low probability of rebleeding from patients with a high probability of rebleeding

[ندعوك للتسجيل في المنتدى أو التعريف بنفسك لمعاينة هذا الرابط]

Causes of upper gastrointestinal bleeding

A cause is found in 80% of cases. Approximate percentages given.
Note the predominance of peptic ulcer disease

Peptic ulcer disease 35 to 50%
◦Duodenal ulcer 25%
◦Gastric ulcer 20%
Gastroduodenal erosions 8 to 15%
Oesophagitis 5 to 15%
Oesophageal varices 5 to 10%
'Mallory-Weiss' tears 15%
Upper gastrointestinal malignancy 1%
Vascular malformations 5%
Rare causes - less than 5%:
◦Dieulafoy lesion (a vascular malformation of the proximal stomach)
◦Angiodysplasia
◦Haemobilia (bleeding from the gallbladder or biliary tree)
◦Pancreatic pseudocyst and pseudoaneurysm
◦Aortoenteric fistula
◦Bleeding diathesis
◦Ehlers-Danlos syndrome
◦Pseudoxanthoma elasticum
◦Gastric antral vascular ectasia
◦Osler-Weber-Rendu syndrome

.Risk factors for upper gastrointestinal bleeding

An aging population with associated conditions and a worse prognosis has helped maintain constant mortality figures despite advances in treatment. Mortality is about 11% in patients admitted because of bleeding but some three times higher amongst those developing UGIB whilst in hospital.2 Peptic ulcer disease is the most common cause of UGIB. Risk factors for peptic ulcer disease are

Alcohol abuse
Chronic renal failureNon-steroidal inflammatory use
Age
Low socioeconomic class
Although duodenal ulcers are more common than gastric ulcers both contribute nearly equally to the incidence of UGIB. After an initial bleed the risk factors for rebleeding, with associated higher mortality, are

Age over 60
Presence of signs of shock at admission
Coagulopathy
Pulsatile haemorrhage
Cardiovascular disease

Assessment

History

Is there abdominal pain?

History of other gastrointestinal symptoms should be sought. The symptoms in order of frequency are
◦Haematemesis including coffee-ground emesis: 40 to 50%
◦Melaena: 70 to 80%
◦Haematochezia (red or maroon stool): 15 to 20%
◦Syncope: 14%
◦Presyncope: 43%
◦Dyspepsia:18%
◦Epigastric pain: 41%
◦Diffuse abdominal pain:10%
◦Weight loss: 12%
◦Jaundice:5%
Alcohol intake
Past history of bleeding (haematemesis or melaena) or of anaemia
Drug history is important. Drugs such as non-steroidal anti-inflammatories and corticosteroids are an important cause of bleeding. Iron and bismuth may mimic melaena
Retching may precede bleeding with a 'Mallory-Weiss' tear

Examination

The main aim of examination is to assess blood loss and look for signs of shock. A secondary aim is to look for signs of underlying disease and significant co-morbid conditions. For example

Pallor and signs of anaemia should be sought
Pulse and blood pressure
Postural hypotension may be detected and usually indicates a blood loss of 20% or more
Other signs of shock:
◦Cool extremities
◦Chest pain
◦Confusion
◦Delirium
Evidence of dehydration (dry mucosa, sunken eyes, skin turgor reduced)
Stigmata of liver disease may be present (Jaundice, gynaecomastia, ascites, spider naevi, flap etc)
Signs of a tumour may be present (nodular liver, abdominal mass, lymphadenopathy)
Subcutaneous emphysema and vomiting suggests Boerhaave syndrome (oesophageal perforation)
Urine output should be monitored (oliguria is a sign of shock)

Differential Diagnosis

Other conditions which may form part of the differential diagnosis include

Abdominal aortic aneurysm
Boerhaave syndrome
Cholecystitis
Coeliac sprue
Dengue fever
Disseminated intravascular coagulation
Zollinger-Ellison syndrome
Von Willebrand disease

Investigations

Laboratory testsFull blood count

Crossmatch blood (usually between 2 and 6 units according to rate of active bleeding)
Coagulation profile
◦Platelet count
◦Prothrombin time with activated partial thromboplastin time and an international normalised ratio (INR)
◦Fibrinogen level
Liver function tests to detect underlying liver disease
Plasma fibrinogen level
Urea and electrolytes
BUN-to-creatinine ratio (greater than 36 in renal insufficiency suggests UGIB)
Calcium level should be assessed to detect hyperparathyroid patients and to monitor the effect of citrated blood transfusions
Gastrin levels can identify the rare gastrinomas causing UGIB

Note

Haemoglobin is measured serially (4-6 hourly in the first day) to help assess trend. The requirement for transfusion is based on initial haemoglobin and a clinical assessment of shock. Co-morbid conditions such as advanced cardiovascular disease require transfusion to help prevent myocardial ischaemia
A consumptive coagulopathy may occur with UGIB. This may be associated with thrombocytopenia. A platelet count of less than 50 with active bleeding requires platelet transfusion and fresh frozen plasma to try and make up for depleted clotting factors
Coagulopathy may be a marker also for advanced liver disease. Low fibrinogen and abnormal liver function tests may also indicate liver disease

Imaging

CXR

[ندعوك للتسجيل في المنتدى أو التعريف بنفسك لمعاينة هذا الرابط]

◦May identify aspiration pneumonia
◦Pleural effusion
◦Perforated oesophagus
Erect and supine abdominal X ray to exclude perforated viscus and ileus
CT scan and ultrasound can identify:
◦Liver disease
◦Cholecystitis with haemorrhage
◦Pancreatitis with haemorrhage and pseudocyst
◦Aortoenteric fistulae
Nuclear medicine scans have been used to identify areas of active haemorrhage
Angiography may be useful if endoscopy fails to identify site of bleeding

.Endoscopy

[ندعوك للتسجيل في المنتدى أو التعريف بنفسك لمعاينة هذا الرابط]

This is useful for

Diagnosing the cause of bleeding
Estimating prognosis
Therapeutic haemostasis (see under management below)
Patients with minor bleeding can be managed with observation on the general ward followed by elective endoscopy and probably an early hospital discharge.2 Major bleeding requires active resuscitation in an HDU or ITU setting followed by endoscopy urgently. Recently it has become apparent with therapeutic endoscopy that prognosis can be improved in severe bleeding. This is most appropriately performed in dedicated endoscopy suites or operating theatres with full facilities for resuscitation

.Contraindications to upper endoscopyThese include:.

Uncooperative patient
Acute myocardial infarction (unless haemorrhage life-threatening)
Perforated viscus

Assessment of bleeding severity

This can be assessed by

The extent of blood loss
The degree of shock
However there are other factors which affect risk of death

Age. Deaths under age 40 years are rare. 30% of patients over 90 years old with UGIB die as a result of the bleed.
Co-morbidity. Complications are more likely with co-morbid disease
Shock. The presence of signs of shock confers a worse prognosis
Endoscopic findings. Much work has been done on classifying and identifying endoscopic findings which correlate with high risk. For example
◦'Mallory-Weiss' tears or clean ulcers have a low risk of rebleeding and death
◦Active bleeding in a shocked patient carries an 80% risk of rebleeding or death
◦Non bleeding but visible vessel has a 50% risk of rebleeding
Various method have been designed to assess the risk of rebleeding. These include Rockall
score (see below) and Baylor score. Use of these remains controversial

Management

Patients with an UGIB (other than minor bleeding2) should be admitted to a high dependency unit or intensive care unit. Some hospitals have beds specifically for patients with an UGIB. Emergency endoscopy should be available 24 hours a day in such units. Note that patients with liver disease are a special case and have separate guidelines for management. It is important as when dealing with all critically ill patients that a list of tasks is completed although in practice some of these may be performed simultaneously rather than sequentially

Assess the patient taking history and examining the patient as above
Identify and treat any co-morbid conditions
Take blood for routine bloods as above
Establish venous access for intravenous fluids
Estimate the severity of bleeding. This can be difficult to assess without the additional information from endoscopy (see table for Rockall scoring system). Clinical judgement is needed to establish
◦Mild to moderate bleeding
Normal pulse and blood pressure
Haemoglobin concentration greater than 100 g/l
No or insignificant co-morbidity
Usually less than 60 years of age
◦Severe bleeding
Pulse over 100 beats/minute and systolic blood pressure less than 100 mm Hg
Haemoglobin concentration less than 100 g/l
Most will have significant co-morbidity
Patients are usually over 60 years of age

Resuscitation

It has been demonstrated that early and aggressive resuscitation reduces mortality in UGIB.4 Resuscitation is a priority to

Correct fluid losses
Restore blood pressure

Therapeutic endoscopy

Meta-analysis of trials5 has shown that endoscopic haemostatic techniques

Reduce rebleeding
Reduce the need for surgery
Reduce mortality
Choice of technique is influenced by the size of the bleeding vessel. Above 2 mm diameter vessels are likely to require clips, banding or surgery. Angiographic techniques may be required when surgery is high risk. Interventional radiology using stents is being developed as a therapeutic option.
Techniques include

Banding and injection sclerotherapy for varices
Injection of adrenaline solution achieves haemostasis in 95% of cases but 15-20% will rebleed.
Injection of sclerosants reduces rebleeding but introduces the risk of necrosis at the injection site.
Injection of agents to stimulate clot formation such as fibrin glue or thrombin have been shown to be effective but are not widely available
Application of heat
◦Laser therapy is no longer used. It was used in combination with adrenaline but could increase bleeding by drilling into the bleeding vessel.
◦Heater probe (teflon coated). This heats to about 250 degrees centigrade and achieves haemostasis with heat and pressure. It is as effective as adrenaline
◦Multipolar coagulation (BICAP) is as effective as the heater probe
◦The argon plasma coagulator requires further study. It seems less effective if vessels are larger than 1 mm diameter
◦Combinations of heat with adrenaline have been tried but are no better than adrenaline alone except in active arterial bleeding
Application of clips. These perform well in trials but may be difficult to apply

Drug therapy

Three classes of drugs have been tested for non variceal bleeding
Acid suppressing drugs
◦H2- receptor antagonists have not been shown to be effective in UGIB
◦Proton pump inhibitors (PPIs). In general small studies have shown benefit. Consensus suggests use after endoscopic therapy at high dose for all patients with bleeding ulcers (for example 80mg of omeprazole followed by 8mg per hour for 72 hours).
Somatostatin. There is insufficient data to recommend use.
Anti-fibrinolytic drugs. Tranexamic acid has been used but more work is needed

Management after endoscopy

Careful monitoring is needed after endoscopy for UGIB (pulse, blood pressure, urine output). It is imperative to identify rebleeding or continuing bleeding
If patients are stable 4-6 hours after endoscopy they should be put on a light diet as there is no benefit in continued fasting
Repeat endoscopy is required if there is evidence of rebleeding (for example with melaena or unstable observations)
Occasionally major rebleeding may be an indication for surgical intervention without further endoscopy

Surgical intervention

Surgical intervention is required when endoscopic techniques fail or are contraindicated. Clinical judgement is required and consideration given to local expertise

In general it is recommended
◦To inform surgeons early of the possibility of surgery
◦To use the most experienced personnel available
◦To avoid operations in the middle of the night
The particular procedure required depends on a number of factors not least the site of bleeding. Gastric ulcers are probably best excised. There are few studies comparing the different techniques

Complications

The complications of UGIB are self evident. Other complications can arise from treatments administered. For example

Endoscopy
◦Aspiration pneumonia
◦Perforation
◦Complications from coagulation, laser treatments
Surgery
◦Ileus
◦Sepsis
◦Wound problems
Salvage surgery for patients who continue to bleed is associated with a high mortality

.Prognosis

Mortality is about 11% in patients admitted with an UGIB.2 It is as high as 33% in patients who develop bleeding whilst in hospital. A score of less than 3 using the Rockall system above is associated with an excellent prognosis, whereas a score of 8 or above is associated with high mortality.3 Most deaths occur in elderly patients with co-morbidity. Mortality is reported to be lower in specialist units possibly because of adherence to protocols rather than because of technical advances.2 The prognosis in liver disease relates significantly to the severity of the liver disease rather than to the magnitude of the haemorrhage

Prevention

The most important factor to consider is treatment for Helicobacter pylori infection. This should be completed as an outpatient

جميل اوى

هو انت فى تانيه تمريض

لان الحاجات دى احنا وخدنها السنه دى

اه انا ثانية تمريض قمر بحب برضو حاجات ما اخذتها اعرفها قبل ما اخذها شكرا ع مرورك قمر

ميرسي ليك جدا
انت بتفيدنا كتير
والله
وفعلا زى ماقمر
قالت ان الحاجات دى
عندنا السنة دى بس طريقة شرحك اجمل من
الطريقةالي مشروح لنا بيها
ممكن تجيب موضوع عن heamatemsis

معناها ترجيع مع دم
vomiting with blood
لو عندكو ماشي هاتها
لو مش عنكو متتعبشي نفسك

ميرسي جدا ليك

حياااااااااااااااااااااك الله سماااااااااااح وشكرا ع مرورك وراح احاول انزل موضوعك

ميرسي ليك جدا
تسلم

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