Upper GI Bleeding

Clinic:

  • There’s plenty of time to take history and physical from the pt
  • History:
    • More likely to come to the clinic w\ coffee ground than fresh blood
    • Ask about medications: NSAIDS and anticoagulants
  • Physical exam:
    • Vital signs (tachycardic), general inspection of the pt, abdominal exam

CASE: 65 yo lady, repeated episodes of vomiting in the morning with coffee ground blood, taking NSAIDS, some tachycardia, and mild epigastric tenderness, no other relevant physical findings. Ddx?

  • PUD, stomach Ca, esophageal varices
  • Side note: aspirin is taken as prophylaxis against ischemic hear disease, colon ca, prostate ca

What to do next?

  • Labs: CBC and coagulation profile
  • Definitive dx: endoscopy (shows reflux, esophagitis, varices, duodenal or gastric ulcer, malignancy)

How to manage?

  • Most of UGIB are treated medically/conservative -> PPI + eradication (after confirming H. pylori)
  • If gastric ulcer -> take biopsy, why? High risk of malignancy (not if duodenal, though)

Emergency:

  • Start w\ resuscitation (before h&p)
  • If it’s severe enough -> consider urgent endoscopy as emergency to identify the source of bleeding
  • During resuscitation we give blood, but has its own limitations
    • Massive blood transfusion -> coagulopathy (↓), hypothermia, acidosis
  • Ddx:
    • Duodenal\gastric ulcers, esophageal varices (in cirrhosis pts, it’s more common to bleed from an ulcer than varices), Mallory weiss, cancer

How to manage?

  • If esophageal varices -> endoscopic banding -> if persists; esophageal transection
  • If duodenal ulcer -> clips, andrenaline injection, diathermy -> if bleeds again and you can see a big pulsating blood vessel -> over saw ulcer + ligate gastroduodenal artery
  • If gastric ulcer -> potentially malignant -> excision
  • If cancer -> temporary clip + adrenaline

If massive massive bleeding or in trauma pts; best place to resucitate is in the OR -> do endoscopy there and try to stop the bleeding there; It might be an aorto-enteric fistula (prev aortic surgery -> graft -> infection -> erosion into GIT)

 


Download the PDF version: here


References:

  • Dr Boghdadly’s lecture

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