Upper GIT bleeding

By
PROF/ GOUDA ELLABBAN
 Definition:
 It is an acute bleeding occurring from
a lesion proximal to the level of Teritz
ligament.
 Teritz ligament is a well defined
peritoneal fold that ascend to the Rt.
Crus of the diaphragm & it demarcate
the dudeno-jejunal junction.
 pathophysiology
It can be acute or chronic.
chronic may lead to anemia (Fe
deficiency)
If acute (hematemisis or melena) may
lead if sufficiently sever to
hypovolemic shock if bld loss is more
than 25% of bld volume.
 Etiology
Divided into:
General: bleeding diathesis,
hemophilia, leukemia,
thrombocytopenia, anticoagulant
therapy & hemorrhagic hereditary
telangactasia.
Local: in GI problem.
 classification
 Severity
 Anatomical location
 frequency
 To severity
 Massive as in:
1. Peptic ulcer
2. Gastritis
3. Portal HPN
4. Rupture of splenic
artery by erosion of
stomach.
5. Rupture of aortic
aneurysm by erosion
of the jejunum
6. Esophageal varices
 Con:
 Non massive:
1. Ca of stomach
2. Hiatus hernia
3. Peptic esophegitis
 anatomically
 Esophagus:
 Varieces, peptic esophegitis, foreign
body & rarely Ca.
 Stomach:
 Peptic ulcer, gastric erosion, gastritis,
Ca, hiatus hernia, Mallory Weiss
syndrome, & FB.
 Duodenum (commonest):
 Peptic ulcer, diverticulim.
 Cont:
 Miscellaneous:
 Aneurysm of splenic artery, uremia,
AVM & disorder of GI blood vessels.
 Frequency:
Chronic peptic ulcer 65%

Acute peptic ulcer

Multiple erosions 30%
Esophageal varieces
Ca of stomach
Mallory-Weiss synd
PU in meckles 5%
Hemophilia
Purpura
Anemia
 Clinical features
 General apearance:pale, anxious w/
moderate to sever Hg, sweating or
shock.
 Vital signs: hypotension, tachycardia,
fever if associated with infection,
shallow & rapid breathing.
 skin: jaundice, palmer erythema,
spider navei & other signs of portal
HTN including gynecomastia.
 Cont:
 Head & neck: pale or dry mucous
memb.
 Abdomen: distention, boule sound
increase, tenderness, ascites,
hepatosplenomegaly.
 Diagnosis
 CORRECT the hypovolemia & the
shock then take a good HX of peptic
ulcer, liver dis, any NSAID ingestion
or any predisposition cause.
 Physical EX
 Investigation:
1. NG tube to differ upper from lower
bleeding.
 Cont:
1. Fibroptic endoscopy which will detect
80-90%.
2. Fibroptic
esophgeogastroduodenoscopy.
3. Barium meal.
4. arteriography(only if bleeding is
more than 1-2ml/min.
 Cont:
The aim of investigation is to:
1. Pin point the exact cause of
bleeding.
2. To asses the effect of bleeding on
the pt.
3. To plan for treatment.
 Management:
Shock management:
1. ICU admission.
2. IV line (1L ringer lactate)
3. Draw blood for grouping & cross
matching.
4. NG tube (to prevent aspiration)
5. Monitor vital sign.
6. Urethral catheter.
 Cont:
 Blood transfusion.
 Gastric lavage.
 Valium or morphine to decrease
anxity(15mg IV)
 H2 blockers & antacids.
 Treatment
Upper GI bleeding stops spontaneously
in about 80-90% of pt.
1. Endoscopic coagulation(eg:injection
sclerosis, heater probes, laser)
2. Infusion of vasopressin or embolic
therapy by angiography.
3. Specific surgical treatment.
 Cont;
Surgical treatment should be done within
48hrs of bleeding based on indication for
surgery & failure of conservative
management.
Absolute indication for surgery:
1. Deterioration of vital signs in spite of IV
resuscitation.
2. Inability to correct hypovolemia with 2L of
bld.
3. Bld loss/requirement estimated at > 4
units of bld/24hrs.
 Cont;
1. Visible bleeding vessel visualized by
endoscopy.
2. Presence of co-existing lesion.
Relative indication:
3. Massive Hrg in pt > 60y
4. Previous major bleeding episode.
5. Past Hx of recurrent bleeds, ch ulcer,
arteriosclerosis.
 Cont;
Factors affecting prognosis:
1. Old age >60y
2. Shock on admission
3. Gastric ulcer
4. Ch liver dis
5. Arterial spurting from ulcer, visible
vessel in ulcer base, adherent fresh
clot.
 Cont;
 Prognosis:
 Overall mortality 10%
 >80y 20%
 Peptic ulcer dis
Despite the decrease in the frequency
of peptic ulcer dis in the last 3
decades it remains the most common
cause of upper GI bleeding.
Most duodenal ulcers are located in the
post wall pf duodenal bulb just
beyond the pylorice.
Majority of gastric ulcers are located in
the lesser curvature.
 Cont;
 Bleeding from a gastric ulcer is more
severe than a duodenal ulcer.
 Approximately ¾ of these bleeding
will stop spontaneously.
 Treatment
 Medical treatment
 Surgical treatment(
duodenal ulcer)
1. Selective vagotomy
A-highly selective cell
vagotomy
B-vagotomy &
antrectomy
 Cont;
C-vagotomy & pyloroplasty.
Gastric ulcer:
Distal gastrectomy to include the ulcer.
 Esophageal varices
 It take place anywhere from the lesser
curvature upward into the esophagus.
 Treatment
 Medical treatment:
1. Somatostatin administration.
2. Balloon tamponad.
 Surgical treatment:
1. Esophageal devascularisation by:
Transection & reanastomosis
 Con;
The standered procedures are
portosystemic shunt:
A-end to end side portacaval shunt.
B-side to side portacaval shunt.
C-interposition portacaval shunt using a
prosthetic grafts.
D-proximal splenorenal shunt.
E-Warren shunt.
 Cont;
F-the newest intervention is
transjugelar intrahepatic shunt (TIPS)
Thank you