Upper GIT bleeding

Upper GIT bleeding

•         Haematemesis: Vomiting of blood, usually coffee ground materials due to partially digested blood in stomach.

•         Melena: Passage of tarry black stool per rectum. It also can be due to diseases of right side of colon.

•         It is an emergency condition and patient needs hospital admission. 

•         Upper GIT: areas proximal to ligament of Treitz ( usually oesophagus, stomach and duodenum).

Management

1. Intravenous access using at least one large bore cannula.

2. Initial clinical assessment:

•         Define circulatory status: severe bleeding causes tachycardia, hypotension, oliguria and shock. The patient is cold and sweating and may be agitated.

•         Seek evidence of chronic liver disease: Spider naevi, hepatosplenomegaly, jaundice and  ascites

•         Define comorbidity: like heart, cerevascular diseases, renal diseases are important because the risks of endoscopy and surgery are increased and also these conditions become more worse after bleeding.

3. Blood tests:

•         Full blood count: chronic or subacute bleeding leads to anaemia, but the haemoglobin concentration may be normal after sudden major bleeding until haemodilution occurs.

•         Urea and electrolytes: may show evidence of renal failure. Urea increases as absorbed blood product from intestine metabolised by the liver.

•         Liver function tests

•         Prothrombin time: If there is evidence of liver disease or anticoagulant therapy.

•         Cross-matching of at least 2 units of blood.

4. Resuscitation: Intravenous crystalloid fluids or colloid are given to restore the blood pressure. Blood is transfused when the patient is shocked or when the haemoglobin concentration is less than 100g/l.

Normal saline should be avoided in patient with chronic liver disease.

CVP (central venous pressure) monitoring is useful in severe bleeding especially if cardiac disease is present to avoid fluid overload.

5. Oxygen:  Given by face mask to all patients with shock.

6. endoscopy: This should be done after adequate resuscitation. A diagnosis will be achieved in 80% of cases. Patients who are found to have major endoscopic stigmata of recent haemorrhage can be treated endoscoply using heater probe, I njection of adrenaline (diluted) into bleeding point and using of metalic clips. It can stop active bleeding and if IV proton pump inhibitor is given in addition, it can prevent rebleeding and avoid need for surgery.

7. Monitoring: patient should be closely observed, with hourly pulse, BP and urine output measurement.

8. Surgical operation: If bleeding not stopped or rebleeding occur in one occasion in elderly or two occasions in young fit patient.

Prognosis

The mortality is about 10% after acute bleeding.

Risk factors:

1. Increasing age 2. Comorbidity 3. Shock 4. Diagnosis e. g. bleeding varices have worse prognosis 5. Endoscopic finding of active bleeding and non-bleeding visible vessel associated with high risk.5.Rebleeding: Associated with 10 fold rise in mortality.

Improved mortality can be achieved by specialised center and team work of physicians and surgeons