UGIB is defined as bleeding derived from a source proximal to the ligament of Treitz.
Acute gastrointestinal (GI) bleeding is a potentially life-threatening abdominal emergency
-The incidence of upper gastrointestinal bleeding (UGIB) is approximately 0.1 % of the general population.
-Bleeding from the upper GI tract is approximately 4 times as common as bleeding from the lower GI tract and is a major cause of morbidity and mortality.
-The use of various endoscopic techniques, medical therapies, and visceral angiography has progressively diminished the role of surgery in the emergent management of UGIB
-Nevertheless, operative intervention still represents the most definitive intervention and remains the final therapeutic option for many bleeding lesions of the upper GI tract.
-Of patients who develop UGIB, 3-15% require a surgical procedure.
Hematemesis and melena are the most common presentations of acute UGIB, and patients may present with both symptoms. Occasionally, a brisk UGIB manifests as hematochezia.
In order of frequency:
1. Hematemesis in 40-50% patients.
2. Melena in 70-80% of patients.
Symptoms 30 days prior to admission
1.Dyspepsia ,Epigastric pain ,Heartburn
2.Diffuse abdominal pain
The history findings can be extremely helpful in determining the location of the GI hemorrhage.
-Alcohol abuse or a history of cirrhosis should elicit consideration of portal gastropathy or esophageal varices -A history of recent nonsteroidal anti-inflammatory drug (NSAID) abuse -a gastric ulcer or chronic back –pain –need for NSAIDs
-History of treatment for Peptic ulcers-bleeding could be PUD or gastric ulcers.
Differential diagnoses for UGIB
- Gastric ulcer and Duodenal ulcer
- Esophageal varices /Gastric varices
- Mallory-Weiss tear, Boerhave tear
- Esophagitis , Hemorrhagic gastritis
- Neoplasm-Esophageal ca, stomach ca, Kaposi sarcoma.
- Dieulafoy lesion
- Arterio-venous malformations.
- Pancreatic pseudocyst and Pancreatic pseudoaneurysm
- Foreign body 14.Merkels diverticulum
- Coagulopathy 13.Aortoenteric fistula
b) Injecting a volume of sterile isotonic sodium chloride solution and providing a tamponade effect also leads to hemostasis, although not as effectively as epinephrine
The sclerosant solutions used today include
- Absolute ethanol
- Sodium tetradecyl sulfate.
-These achieve hemostasis by inducing thrombosis, tissue necrosis, and inflammation at the site of injection.
-When large volumes are injected, the area of tissue necrosis can produce an increased risk of local complications such as perforation.
-Uses direct pressure and thermal therapy to achieve hemostasis.
-Thermal therapy includes monopolar and bipolar electrocoagulation and heater-probe application.
-The bleeding vessel is isolated, compressed, and tamponaded prior to coagulation therapy. By using both maneuvers, the depth of tissue injury is minimized.
-Coaptive coagulation is as effective as injection therapy in achieving hemostasis
–Combining injection therapy with heater-probe coagulation can be used in an attempt to reduce the rebleeding rate in high-risk patients who have spurting arterial bleeding observed during endoscopy
Other aspects of treatment
Proton pump inhibitors decrease rebleeding rates in patients with bleeding ulcers associated with an overlying clot or visible nonbleeding vessel in the base of the ulcer.
It is administered at the same time as endoscopy.
The indications for surgery in patients with bleeding peptic ulcers are as follows:
- Severe life-threatening hemorrhage not responsive to resuscitative efforts
- Failure of medical therapy and endoscopic hemostasis with persistent recurrent bleeding
- A coexisting reason for surgery such as perforation, obstruction, or malignancy
- Prolonged bleeding with loss of 50% or more of the patient’s blood volume
- A second hospitalization for peptic ulcer hemorrhage
The 3 most common operations performed for a bleeding duodenal ulcer are as follows
a)Truncal vagotomy and pyloroplasty with suture ligation of the bleeding ulcer
c)Truncal vagotomy and antrectomy with resection or suture ligation of the bleeding ulcer
d)Proximal (highly selective) gastric vagotomy with duodenostomy and suture ligation of the bleeding ulcer
The patient with acute variceal bleeding may initially be treated with
- intravenous vasopressin and nitroglycerine
- somatostatin, or one of its analogs (eg, octreotide).
Vasopressin is a potent splanchnic and systemic vasoconstrictor, including coronary vasoconstriction. Nitroglycerin should be concomitantly administered to titrate and maintain the SBP in the range of 90-100 mm Hg. Nitroglycerin should be initiated at 40 mcg/min to protect the coronary arteries from the profound adverse cardiovascular effects of the vasopressin. The intravenous infusion of vasopressin is started at 0.2-0.4 U/min.
The 2 main endoscopic techniques available to control variceal bleeding are endoscopic sclerotherapy and endoscopic variceal band ligation.
Endoscopic sclerotherapy involves injecting a sclerosing agent, such as ethanolamine or polidocanol, into the varix lumen (intravariceal) or immediately adjacent to the vessel (paravariceal) to create fibrosis in the mucosa overlying the varix, which leads to hemostasis. Endoscopic variceal banding ligation consists of the placement of a rubber band around the varix. This technique is performed by first sucking the varix into a sheath attached to the distal end of the endoscope. Once the varix is suctioned into the sheath, a trigger device allows the deployment of a rubber band around the varix, a procedure that strangulates the varix.
Variceal banding associated with significantly lower mortality rates, lower variceal rebleeding, less esophageal perforation, and stricture formation compared to sclerosants
Can be a life-saving maneuver when medical and endoscopic efforts fail to control the bleeding. Achieve temporary control of the bleeding but recurrent bleeding with release of the tamponade occurs in most patients
They are also cause complications as
- Airway obstruction
- esophageal necrosis with rupture
Because of the severe life-threatening complications and limited use, the tubes are used only as a temporary measure while the patient is resuscitated.
The tubes act as a bridge to help stabilize the patient until a time when the patient is prepared for either a repeat endoscopy procedure or a portal pressure decompression through a radiological or surgical method
Resuscitation of a hemodynamically unstable patient begins with assessing and addressing the ABCs (ie, airway, breathing, circulation) of initial management.
Earliest opportunity is taken to intubate the patient and avoid risk of aspiration.
Using two large bore venous access in the antecubital fossa. Replace blood loss with crystalloid in the ration of 1 ml of blood loss replaced by 3ml of crystalloid.
Urethral catheter for monitoring the urine production.
Continuously monitor the resuscitation measures especially the circulatory aspect:
- Urine output should be 30-50ml/hr
- BP monitoring systolic BP not <90mmHg
- Decrease in BP and urine output suggest need for colloids but a decrease in urine output but normal BP suggest need for crystalloids
- Pulse. Pulse should be less than 120/minute
- Pulse oximetry
- CVP monitoring the best to avoid over-infusion
- State of patient should be calm
-Once the maneuvers to resuscitate are underway, insert a nasogastric tube (NGT) and perform an aspirate and lavage procedure.
-This should be the first procedure performed to determine whether the GI bleeding is emanating from above or below the ligament of Treitz.
– If the stomach contains bile but no blood, UGIB is less likely. If the aspirate reveals clear gastric fluid, a duodenal site of bleeding may still be possible