OBJECTIVES • History & Examination & portal system • Definition & Related terms • Clinical presentation • Differential Diagnosis • Hematemesis VS Hemoptysis • Management
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%
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
HPS • Portal Hypertension • Pressure difference between the portal vein and the hepatic veins=< 5 mm Hg • Portacaval Anastomosis portal circulation systemic circulation left gastric veinAzygos vein Esophageal Varices UGIB
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%
Peptic Ulcer • A break in the epithelial surface (i.e. ulceration) of the oesophagus, stomach or duodenum . • PU includes Duodenal ulcer. (commonest) Gastric ulcer.
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).
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?
The Forrest classification of PU Bleeding • F-IActive bleeding: F-I/a. Spurting arterial bleeding F-I/b. Oozing bleeding • F-IISignes 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
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 %
Gastric Ulcer Type I Type II Same as PU M>F 3:1 , 50+ yrs. Epigastric pain induced by eating. Weight loss. Nausea and vomiting. Anaemia from chronic blood loss.
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 .
Treatment 2- Endoscopic Topical treatment Injection treatment Mechanical treatment Thermal treatment
Topical treatment • Tissue adhesives (cyanoacrylat) • Blood clotting factors (thrombin,fibrinogen) • Vasoconstricting drugd (epinephrin) • collagen • Ferromagnetic tamponade
Injection therapy • Sclerotizing drugs (Aethoxysklerol) • Alcohol (96-99.5 %) • Epinephrin (Tonogen) • Thrombin
Mechanic treatment • Loops • Sutures • Balloon treatment • Haemostatic clips
Thermal treatment • Laser fotocoagulation • Heater probe • Electrocoagulation • Monopolar • Bipolar • Electrohydrothermo sond
3-Surgical treatment • Local operation? Suture Stiching of ulcer • Local operation + vagotomy • resection type operation
Local operation • The rebleeding rate is very high, • 70-80 %, • Insufficient solution • Today is not advised!!!
Local operation with vagotomy • Quicker than resection • Rebleeding rate 17 % • Suture insufficiency 3 %
Resection type operations • Rebleeding only in 3 % • Insufficency of duodenal stump 13 % • The duration of operation is the most longer
Oesophageal varicosity • dilated sub-mucosal veins in the esophagus • portal hypertension • left gastric vein + Azygos vein
Treatment • Balloon tamponade Sengstaken-Blakemore Linton • Sclerotherapy • Oesophageal transsection • Variceal ligation, or banding • TIPS ( transjugular intrahepatic portosystemic shunt)
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
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
Treatment • nasogastric intubation and irrigation with alkaline fluid • H2RA, PPI • Electrolyt and blood replacement • Sedation • Operative treatment is often avoidable
Where is it from? GI TRACTRESPIRATORY TRACTDark 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
Differentiation mild bleeding severe bleeding Normal Pulse Weak & Rapid Normal BP BP>10Hg Normal breathing Deep & Tach Mucosa slightly dry Parched Slightly Urine OP Anuris Conscious Fainting <15% >15%
Definition Hematemesis is vomiting of gross blood. Causes: • Esophagus • Stomach • Duodenum • hepatic
Hepatic Portal System • system of veins that comprises the hepatic portal veinand its tributaries • Hepatic portal vein • Splenic vein • celiac trunk • superior mesenteric vein • inferior mesenteric vein
Assessment • resuscitation • nasopharyngeal tube • lab assessment (CBC-Coagulation Factors) • Radiology. • endoscopy within 48hrs • medical therapy / surgery
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.