| ID | 39 |
|---|---|
| Name | Acute Upper Gastrointestinal Bleeding |
| Cause | |
| Signs Symptoms | |
| Diagnosis | Laboratory findings: 1. Hb% may fall as a result of bleeding or expansion of the intravascular volume with i.v fluids. 2. BUN may rise as a result of absorption of blood nitrogen from the small intestine and prerenal azotemia. Endoscopic diagnosis: Endoscopic examination is the most diagnostic procedure in almost all cases of upper gastrointestinal bleeding. Endoscopy should be carried out after adequate resuscitation. In patients with severe bleeding, endoscopy is usually performed within 6-8 hours of admission, after resuscitation and restoration of haemodynamic stability. |
| Investigations | |
| Management | Management: The patient must be immediately hospitalized. About 80% of patients stop bleeding spontaneously within a few hours of admission & generally have an uneventful recovery. 20% of patients have more severe bleeding. The assessment and initial management of bleeding should be started immediately: 1. Rest: both physical and mental, which may promote ulcer healing. 2. Sedation: Inj. diazepam 10mg i.v may be given. 3. The patient should be kept in a calm and quiet room with foot end raised. 4. Quick examination is to be carried out to find out the causes. 5. O2 inhalation in severely ill patient or all shocked patients. 6. Pulse, B.P should be hourly recorded. Blood grouping & cross matching; repeated Hb% estimation; urea & electrolytes to be done (to show evidence of renal failure). Blood transfusion should be given if B.P is below 100/60 mmHg, pulse rate over 100/min and there is faintness, cold, clammy skin & Hb% < l0gm/dl. 7. If blood is not available soon- 5% dextrose in normal saline 2000-3000ml i.v. stat and continued untill B.P is satisfactory. Dextran or plasma may also be given to combat immediate shock. 8. Within 2 hours feeding by mouth can be started with 200ml ice cold milk every 2 hourly. After 2 days milky porridge is allowed. 9. In case of chronic peptic ulcer: a. Liquid Antacid 15-20ml every 2 hourly. b. Inj. Cimetidine 200mg i.m 4-6 hourly, max. 2.4gm daily, or Ranitidine 150mg or Famotidine 20mg by continuous i.v infusion over 24 hours can be given to maintain intragastric pH greater than 4.0. After 4 hours pH to be checked, if pH < 4, then dose should be doubled. c. Inj. Morphine 10mg i.m (15mg for heavier patient) stat or by slow i.v injection, quarter to half corresponding i.m dose. Or, Inj. Diazepam 10mg i.m. or slow i.v. stat may be given. NB: Vasopressin & i.v Octreotide should not be used in ulcer bleeding. 10. In case of Oesophageal varices: a. Inj. Vasopressin 20 units in 100 ml of 5% Dextrose in aqua i.v. slowly in 10 minutes & may be repeated. Or, Inj. Octreotide (synthethic somatostatin) can be given in a dose 50mgm i.v followed by an infusion of 50mgm hourly. b. Sclerotherapy or variceal banding- in acute variceal bleeding, sclerotherapy or alternatively variceal banding are the treatment of choice. This is usually done during urgent diagnostic endoscopy (see below). By this method about 80-90% cases of active bleeding are arrested, and also reduces early rebleeding to a considerable extent from 70% to 30-40%. c. Balloon temponade- it is a pressure method used mainly to control bleeding where vasoconstrictor or sclerotherapy has failed or unavailable or contraindicated. In this method, a tube is used (commonly Sangstaken-Blackmore), which is introduced into the stomach & inflated as balloon and pulledback in close apposition to the gastro-oesophageal junction to prevent variceal blood flow to the bleeding point. If the gastric balloon is not enough to control bleeding, an’oesophageal balloon can be used then. Although this is an effective procedure in controlling bleeding, but is very unpleasant to the patient and may cause some serious complications such as Oesophageal rupture, mucosal ulceration or aspiration pneumonia. d. Antibiotic prophylaxis- administration of a course of quinolone preparation (e.g ciprofloxacin or norfloxacin or ofloxacin i.v or orally) for 3-10 days with a broad-spectrum antibiotic (e.g amoxycillin with clavulanate or a third generation cephalosporin) i.v before the endoscopy is advisable to reduce the incidence of infection complications (such as spontaneous bacterial peritonitis). e. Injection Vitamin-K 10mg (1 amp) daily or b.d may be given. N.B: Never give injection Morphine or Pethidine- which may precipitate hepatic coma. 11. Endoscopy: Endoscopy is performed in patients with continued active bleeding sometimes on emergency basis. In patients with severe bleeding, endoscopy is usually performed within 6-8 hours of admission, after resuscitation and restoration of haemodynamic stability. Patients having major endoscopic stigmata of recent haemorrhage are treated endoscopically with contact cautery probes applied directly to the ulcer vessels, by injection of dilute adrenaline (epinephrine) into the bleeding point or by application of metallic clips.2 In case of oesophageal varices, sclerotherapy with a sclerosing agent (e.g ethanolamine, tetradecyl sulphate etc) or variceal banding is the choice of haemostatic therapy. In case of bleeding from ulcer vessels injection is performed into and around the ulcer vessel with epinephrine (1:10,000), ethanol, or saline. Coagulation may also be achieved with contact cautery probes. Using any of these methods injection or cautery modalities, successful haemostasis is achieved in 90% of actively bleeding lesions. Less than 10% of patients treated with haemostatic therapy will require surgery. 12. If endoscopy fails, introduce Ryles tube- a. for gastric washing for urgent endoscopy. b. to assess bleeding, c. for feeding purpose. 13. If above measures fail to control bleeding within 48 hours, surgery is indicated. Indications for Surgery: 1. Age- above 60 years. 2. Persistant shock. 3. Persistant bleeding nore than 2-3 days. 4. Recurrence of massive bleeding in spite of medical treatment. 5. When bleeding is recurrent. |
| Introduction | Acute upper gastrointestinal bleeding is the most common gastrointestinal emergency, usually presents with haematemesis & melaena and other features of circulatory failure. |
| History | |
| Etiology | |
| Clinical Features | Clinical features: 1. Patients usually present with haematemesis & or melaena. 2. History of peptic ulcer or other causes of haematemesis and melaena. 3. Weakness, faintness sometimes leading to syncope; nausea and vomiting, sweating. 4. Blurring of vision, dry mouth & throat. 5. Coldness of the limbs. 6. The patient is pale, anxious, anaemic. 7. Pulse is weak and rapid. B.P low. 8. Oliguria. |
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