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UGI for MBBS 3 guide to history, examination and acute management
- 1. APPROACH TO UPPER GI BLEED Dr. Tim Mutafya Gen Surg. resident MBBS III class
- 2. OVERVIEW Definition & Epidemiology Classification Pathophysiology Clinical presentation Screening & Diagnosis Initial management
- 3. Definition Upper GIB is that originating proximal to the ligament of Treitz; from the oesophagus, stomach and duodenum
- 4. EPIDEMIOLOGY UGIB is more common than bleeding from the lower GI tract, accounting for 70% of all gastrointestinal bleeding. 80% are self-limited. Most common source is stomach and proximal duodenum due to peptic ulcer Pts on anti platelet therapy has two fold increase in bleed as compared to normal ones. 20% of pts of moderate to high risk, who have recurrent bleeding (within 48-72 hrs) have poor prognosis. The mortality rate is 5% to 10% for severe UGI bleed.
- 5. RISK FACTORS Age > 50 years, Male Drugs: Use of NSAIDS, antiplatelet H-pylori infection Excessive alcohol intake Excess acid production
- 7. UPPER GI BLEEDING VARICEAL BLEEDING NON VARICEAL BLEEDING Esophageal varices Gastric varices Ulcer disease Esophagitis Gastritis/erosions Erosive duodenitis tumors Vascular ectasias Portal Hypertensive Gastropathy Mallory weiss tear Obscure UGIB Pathophysiologic
- 8. Anatomical
- 9. Major causes
- 10. Esophageal Varices Gastric Associated with high HPVG > 12mmHg About 40% of patients with cirrhosis and in 60% of patients with cirrhosis and ascites. Up to 25% of patients with newly diagnosed varices will bleed within two years. 80% will stop bleeding spontaneously. Can occur with HVPG less than 12 mm Hg High risk Not usually associated with cirrhosis o splenic vein thrombosis o Pancreatitis o pancreatic cancer.
- 11. Varices Prehepatic Portal venous thrombosis Infiltrative tumors Intrahepatic Schistosomiasis Liver cirrhosis Veno-occlusive disease Post hepatic Budd chiari syndrome
- 13. Most frequent cause of upper GI Bleeding Duodenal Ulcer-gastroduodenal A. PUD Gastric ulcer-left gastric A. PEPTIC ULCER DISEASE H.PYLORI: NSAIDS: * involves antrum * gastric ulcers > common *duodenal ulcers * 15-45% patients develop ulcers on regular use As the ulcer burrows deeper into the gastroduodenal mucosa,weakening and necrosis of the arterial wall,development of a pseudoaneurysm. weakened wall ruptures hemorrhage
- 14. MODIFIED JOHNSON CLASSIFICATION FOR GASTRIC ULCER
- 15. Mallory weiss syndrome / tears Mucosal or sub-mucosal lacerations that occur at the gastro-esophageal junction and usually extend distally into a hiatal hernia . Typically have a history of recent non-bloody vomiting with excessive retching followed by hematemesis.. Endoscopy usually reveals a single tear that begins at the gastro-esophageal junction and extends several millimeters distally into a hiatal hernia sac/within cardiac portion of stomach.
- 16. Haemorragic/Erosive gastritis Stress related mucosal injury Occur mostly in extremly sick patients Major Trauma Post Major Surgery 3rd Degree burns Major intracranial disease Severe medical illness (Ventilator dependence, coagulopathy) Significant bleeding probably does not develop unless ulceration occurs. Intravenous H2-receptor antagonist is the treatment of choice. Sucralfate also effective Aspirin and NSAIDS Half of the patient who chronically ingest NSAIDS have Erosions. (15 30% have Ulcers) Most Frequently and severely affected site is gastric antrum.
- 17. PORTAL GASTROPATHY On endoscopic examination mucosa is engorged and friable. Portal hypertensive gastropathy (PHG) is caused by increased portal venous pressure and severe mucosal hyperemia that results in ectatic blood vessels in the proximal gastric body and cardia and oozing of blood. Less severe grades of PHG appear as a mosaic or snake skin appearance and are not associated with bleeding. Usually, patients with severe PHG present with chronic blood loss, but they occasionally can present with acute bleeding.
- 18. DIEULAFOY'S LESION It is a large (1- to 3-mm) submucosal artery that protrudes through the mucosa. It is not associated with a peptic ulcer, and can cause massive bleeding. It usually is located in the gastric fundus, within 6 cm of the gastroesophageal junction. Dieulafoy's lesion can be difficult to identify at endoscopy because of the intermittent nature of the bleeding. the overlying mucosa may appear normal if the lesion is not bleeding.
- 19. GASTRIC ANTRAL VASCULAR ECTASIA Gastric antral vascular ectasia (GAVE), also described as watermelon stomach. Characterized by rows or stripes of ectatic mucosal blood vessels that emanate from the pylorus and extend proximally into the antrum . Unknown etiology Common in older women and patients with ESRD
- 20. Aortoenteric fistula The A-E fistula is a communication between the native abdominal aorta and, most commonly, the third portion of the duodenum. Bleeding is usually acute and massive, with a high mortality rate(30-100%). Often, a self-limited herald bleed occurs hours to months before a more severe, exsanguinating bleed. The fistula usually forms between three and five years after graft placement.
- 21. Presentation
- 22. 1. Hematemesis Vomiting of red blood or coffee- grounds material when gastric acid converts hemoglobin into methemoglobin . Differentiate from :- Hemoptysis. Bleeding from Pharynx , nasal passage USUALLY hematemesis requires a bucket; BUT haemoptysis a small bowl.
- 23. 2. Melena Passage of black tarry stools. EBL > 50-100 ml /day will produce melena. The black color is caused by Hematin, the product of oxidation of Heme by intestinal and bacterial enzymes. 10% LGI bleed Can be swallowed blood from epistaxis Blood for 14 hrs in the GI tract Drugs like Oral iron and bismuth mimics melena. 3. Hematochezia It is defined as passage of bright-red or maroon blood from the rectum. Common in bleeding from colon, rectum and anus. In case of brisk bleeding in the UGI, bright red blood may come out unchanged in the stool. 10% of UGI bleed Symptoms of blood loss or anemia Light headedness, syncope, angina, or dyspnea, palpitations
- 24. Aetiology Leading history MalloryWeiss tear Multiple Emesis before hematemesis, alcoholism, retching Esophageal ulcer Dysphagia, Odynophagia, GERD Peptic ulcer Epigastric pain, NSAID or aspirin use Stress gastritis Patient in an ICU, gastrointestinal bleeding occurring after admission,respiratory failure,multiorgan failure,coagulopathy Varices, portal gastropathy Alcoholism, Cirrhosis of liver Gastric antral vascular ectasia Renal failure, cirrhosis Malignancy Recent involuntary weight loss, dysphagia, cachexia, early satiety Angiodysplasia Chronic renal failure, hereditary hemorrhagic telangiectasia Aortoenteric fistula Known aortic aneurysm, prior abdominal aortic aneurysm repair Clues regarding the cause of acute UGI bleeding
- 25. Pallor , signs of dehydration , Shock Icterus Clubbing Oedema }Liver disease Physical Examination
- 26. Lymphadenopathy Virchows Node (Troisiers sign) Vital signs Tachycardia Hypotension Tachypnea
- 27. Ascites Spider naevi Palmar erythema Dupuytrens contracture
- 28. Leuconychia Gynecomastia Bleeding manifestations Scars of previous surgery
- 29. Splenomegaly Caput medusae Parotid Swelling Fetor hepaticus Asterixis Testicular atrophy Acanthosis nigricans Alopecia Glossitis Loss of Axillary hair Loss of Pubic Hair
- 30. Inspection Distention , Dilated Veins Swelling Visible peristalsis Palpation Tenderness HSM, secondary metastasis Sister Mary Joseph nodules Mass Percussion Shifting dullness HSM Auscultation Absent Bowel sound Bruit Cruveilhier-Baumgarten venous hum ABDOMEN EXAMINATION
- 31. APPROACH TO A PATIENT WITH UGIB Immediate Initial Assessment Stabilization of haemodynamic status Identify bleed source Stop active bleed Treat underlying cause Prevent recurrence of bleeding
- 32. Risk assessment & triage Risk for mortality and rebleeding. Categorised as low, intermediate high risk Record the GCS Poo prognostic factors 1. Age over 60 2. Shock(SBP<100mmhg), pulse >100 3. Malignancy or varices as bleeding source. 4. Severe coagulopathy 5. Comorbid medical illness 6. Continued or recurrent bleeding 7. Multi-organ failure
- 33. Workup Bloods Hematology - FBC, G+ crossmatch Biochemistry- U&Es, LFT+ albumin Serology - H-pylori, Hep B/C,HIV, schistosomiasis Coagulation profile Stool: occult blood Imaging Esophagogastroduodenoscopy o Therapeutic and diagnostic CXR ECG Abdominal USS CT Angiography
- 34. MANAGEMENT OF UGIB GENERAL MEDICAL MANAGEMENT TYPE OF BLEEDING VARICEAL BLEEDING NON VARICEAL BLEEDING MEDICAL ENDOTHERAPY SURGICAL INERVENTION PRESSURE TECHNIQUES
- 35. AUGIB Rapid Assessment Monitor Hemodynamic Status Fluid Resuscitation Ryle;s tube for Gastric Lavage Self Limited Hemorrhage (80%) Continued bleeding (10-25%) Urgent endoscopy Recurrent Hemorrhage Elective Endoscopy (With in 24 48 hours) Definitive Therapy (If Necessary) Site not localized Localized Further Assessment (Extended EGD, Radio-isotope scan, Arteriography, Exploratory Definitive