Upper gastrointestinal bleeding.doc

Upper gastrointestinal bleedingFrom Wikipedia, the free encyclopediaJump to: navigation, search Upper gastrointestinal bleedingClassification and external resourcesEndoscopic image of a posterior wall duodenal ulcer with a clean base, which is a common cause of upper GI hemorrhage.ICD-10K92.2ICD-9578.9eMedicinemed/3565Upper gastrointestinal (GI) bleeding refers to hemorrhage in the upper gastrointestinal tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of the colon.Upper GI bleeds are considered medical emergencies, and require admission to hospital for urgent diagnosis and management. Due to advances in medications and endoscopy, upper GI hemorrhage is now usually treated without surgery.Contentshide 1 Presentation 2 Causes 3 Diagnosis o 3.1 Diagnostic testing o 3.2 Bayesian calculations 4 Treatment o 4.1 Refractory bleeding 5 Epidemiology 6 See also 7 References 8 External links edit PresentationPatients with upper GI hemorrhage often present with hematemesis, coffee ground vomiting, melena, or hematochezia (maroon coloured stool) if the hemorrhage is severe. The presentation of bleeding depends on the amount and location of hemorrhage.Patients may also present with complications of anemia, including chest pain, syncope, fatigue and shortness of breath.The physical examination performed by the physician concentrates on the following things: Vital signs, in order to determine the severity of bleeding and the timing of intervention Abdominal and rectal examination, in order to determine possible causes of hemorrhage Assessment for portal hypertension and stigmata of chronic liver disease in order to determine if the bleeding is from a variceal source. Laboratory findings include anemia, coagulopathy, and an elevated BUN-to-creatinine ratio.edit CausesGastric ulcer in antrum of stomach with overlying clot. Pathology was consistent with gastric lymphoma.A number of medications increase the risk of bleeding including NSAIDs and SSRIs. SSRIs double the rate of upper gastrointestinal bleeding.1There are many causes for upper GI hemorrhage. Causes are usually anatomically divided into their location in the upper gastrointestinal tract.People are usually stratified into having either variceal or non-variceal sources of upper GI hemorrhage, as the two have different treatment algorithms and prognosis.The causes for upper GI hemorrhage include the following: Esophageal causes: o Esophageal varices o Esophagitis o Esophageal cancer o Esophageal ulcers o Mallory-Weiss tear Gastric causes: o Gastric ulcer o Gastric cancer o Gastritis o Gastric varices o Gastric antral vascular ectasia o Dieulafoys lesions Duodenal causes: o Duodenal ulcer o Vascular malformation, including aorto-enteric fistulae. Fistulae are usually secondary to prior vascular surgery and usually occur at the proximal anastomosis at the third or fourth portion of the duodenum where it is retroperitoneal and near the aorta.234 o Hematobilia, or bleeding from the biliary tree o Hemosuccus pancreaticus, or bleeding from the pancreatic duct o Severe superior mesenteric artery syndrome edit DiagnosisThe diagnosis of upper GI bleeding is assumed when hematemesis is documented. In the absence of hematemesis, an upper source for GI bleeding is likely in the presence of at least two factors among: black stool, age 50 years, and blood urea nitrogen/creatinine ratio 30 or more. In the absence of these findings, consider a nasogastric aspirate to determine the source of bleeding. If the aspirate is positive, an upper GI bleed is greater than 50%, but not high enough to be certain. If the aspirate is negative, the source of a GI bleed is likely lower. The accuracy of the aspirate is improved by using the Gastroccult test.edit Diagnostic testingWhiting studied a cohort of 325 patients and found the odds ratios for the strongest predictors were: black stool, 16.6 (95% confidence interval CI, 7.7-35.7); age 12.9 g/dL (men) or 11.9 g/dL (women) 2. Systolic blood pressure 109mm Hg 3. Pulse 100/minute 4. Blood urea nitrogen level 18.2mg/dL 5. No melena or syncope 6. No past or present liver disease or heart failure edit Bayesian calculationsThe predictive values cited are based on the prevalences of upper GI bleeding in the corresponding studies. A clinical calculator can be used to generate predictive values for other prevalences.edit TreatmentEndoscopic image of small gastric ulcer with visible vesselEmergency treatment for upper GI bleeds includes aggressive replacement of volume with intravenous solutions, and blood products if required. As patients with esophageal varices typically have coagulopathy, plasma products may have to be administered. Vital signs are continuously monitored.Early endoscopy is recommended, both as a diagnostic and therapeutic approach, as endoscopic treatment can be performed through the endoscope. Therapy depends on the type of lesion identified, and can include: injection of adrenaline or other sclerotherapy electrocautery endoscopic clipping or banding of varices Stigmata of high risk include active bleeding, oozing, visible vessels and red spots. Clots that are present on the bleeding lesion are usually removed in order to determine the underlying pathology, and to determine the risk for rebleeding.Same ulcer seen after endoscopic clippingPharmacotherapy includes the following: Proton pump inhibitors (PPIs), which reduce gastric acid production and accelerate healing of certain gastric, duodenal and esophageal sources of hemorrhage. These can be administered orally or intravenously as an infusion depending on the risk of rebleeding. Octreotide is a somatostatin analog believed to shunt blood away from the splanchnic circulation. It has found to be a useful adjunct in management of both variceal and non-variceal upper GI hemorrhage. It is the somatostatin analog most commonly used in North America. Terlipressin is a vasopressin analog most commonly used in Europe for variceal upper GI hemorrhage. Antibiotics are prescribed in upper GI bleeds associated with portal hypertension If Helicobacter pylori is identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI is suggested.edit Refractory bleedingRefractory cases of upper GI hemorrhage may require: Repeat esophagogastroduodenoscopy Anti-fibrinolytics, such as tranexamic acid Angiography to identify and possibly occlude the feeder vessel Recombinant Factor VII is sometimes used as an adjunct in refractory bleeding, but its utility has only been tested for variceal hemorrhage Balloon tamponade Surgery, to oversew or remove the area of hemorrhage Certain causes of upper GI hemorrhage (including gastric ulcers require repeat endoscopy after the episode of bleeding to ascertain healing of the causative lesion.edit EpidemiologyAbout 75% of patients presenting to the emergency room with GI bleeding have an upper source .6 The diagnosis is easier when the patient has hematemesis. In the absence of hematemesis, 40% to 50% of patients in the emergency room with GI bleeding have an upper source 5 8 13edit See also Lower gastrointestinal bleeding Forrest classification Rockall score edit References1. Are SSRIs associated with upper gastrointestinal bleeding in adults?. Global Family Doctor. /search/GFDSearch.asp?itemNum=12057&ContType=HDA. 2. Graber CJ et al. (2007). A Stitch in Time A 64-year-old man with a history of coronary artery disease and peripheral vascular disease was admitted to the hospital with a several-month history of fevers, chills, and fatigue. New Engl J Med 357 (10): 102934. doi:10.1056/NEJMcps062601. PMID17804848. /cgi/content/full/357/10/1029. 3. Sierra J, Kalangos A, Faidutti B, Christenson JT (2003). Aorto-enteric fistula is a serious complication to aortic surgery. Modern trends in diagnosis and therapy. Cardiovascular surgery (London, England) 11 (3): 1858. doi:10.1016/S0967-2109(03)00004-8. PMID12704326. 4. Cendan JC, Thomas JB, Seeger JM (2004). Twenty-one cases of aortoenteric fistula: lessons for the general surgeon. the American surgeon 70 (7): 5837; discussion 587. PMID15279179. 5. a b Witting MD, Magder L, Heins AE, Mattu A, Granja CA, Baumgarten M (2006). ED predictors of upper gastrointestinal tract bleeding in patients without hematemesis. Am J Emerg Med 24 (3): 2805. doi:10.1016/j.ajem.2005.11.005. PMID16635697. /retrieve/pii/S0735-6757(05)00427-4. 6. a b Ernst AA, Haynes ML, Nick TG, Weiss SJ (1999). Usefulness of the blood urea nitrogen/creatinine ratio in gastrointestinal bleeding. Am J Emerg Med 17 (1): 702. doi:10.1016/S0735-6757(99)90021-9. PMID9928705. /retrieve/pii/S0735-6757(99)90021-9. 7. Rosenthal P, Thompson J, Singh M (1984). Detection of occult blood in gastric juice. J. Clin. Gastroenterol. 6 (2): 11921. doi:10.1097/00004836-198404000-00004. PMID6715849. 8. a b Cuellar RE, Gavaler JS, Alexander JA, et al. (1990). Gastrointestinal tract hemorrhage. The value of a nasogastric aspirate. Arch. Intern. Med. 150 (7): 13814. doi:10.1001/archinte.150.7.1381. PMID2196022. 9. Holman JS, Shwed JA (1992). Influence of sucralfate on the detection of occult blood in simulated ga