UPPER GI BLEEDING

Definition: Bleeding proximal to the ligament of Treitz Symptoms: 1) 2) 3) 4) Causes: 1) Gastritis/Erosion a. Causes i. Alcohol ii. NSAIDS iii. Stress iv. Zollinger-Ellison syndrome v. Spicy foods vi. Post-endoscopy 2) Peptic ulcer disease a. Types i. Duodenal ulcer ii. Gastric ulcer b. H. Pylori i. A Gram-negative rod ii. In 1987, in a publication in the prestigious Lancet journal, a TCD team led by current Dean of Health Sciences, Professor Colm OMorin proved that ulcers of the duodenum (small intestine) could be cured by eradicating H.pylori. iii. Causes damage by 1. Invading and hiding in the epithelial lining, evading normal macrophages 2. Secretion that lowers the pH to a level favourable to its survival iv. Linked to PUD 1. Duodenal ulcer 98% 2. Gastric ulcer 90% 3. Gastric CA hasnt been properly proven v. Complication Haemetemesis Melena Pain in the epigastrium Fresh PR bleeding in a case of profuse upper GI bleeding

1. Perforation causing gastric juices of pH 6.9 to 7.1 to spill out into the abdomen, causing systemic inflammatory response, which culminates in multiple organ failure. The solution to pollution is dilution vi. H. Pylori test 1. CLO test Urease 2. 2 sample biopsy 3. Carbon 13-labeled urea breath test 4. Stool test Urease 5. ELISA vii. Treatment 1. Triple therapy regimen (usually) a. Amoxicillin 1g TDS b. Clarithromycin 500g QDS c. Losec 40 mg B.D. 2. 4 antibiotics regimen Triple therapy + Metronidazole 3. Adjuncts a. Bismuth sticks to exposed mucosa 4. Proton pump inhibitor inhibits the proton pump, has safer profile a. Losec (Omeprazole) 20mg / 40mg cheapest b. Nexium isomer of Losec more expensive c. Lansoprazole 15mg / 30 mg d. Pantoprazole 20mg / 40 mg *!!! Plavix and Losec interfere, making the patient more prone to bleeding. Avoid giving Plavix with Losec or Nexium!!! 3) 4) 5) 6) Oesophageal trauma/rupture Varices as a result of portal hypertension Mallory-Weiss tear Angiodysplasia a. Dieulafoy b. Aortic-enteric fistula i. An abnormal connection between the epithelial lining of the aorta and the small bowel (usually)

Management of Upper GI Bleeding: 1) Stable a. Screening OGD i. Rockall Scoring system gives a predictor of mortality ii. Treatment procedure 1. Clipping of vessel 2. Injection of adrenaline 3. Argon ablation therapy 4. Heat probe 5. Yag laser b. Tissue biopsy c. Repeat endoscopy (if needed) d. Chest X-ray free air under diaphragm i. Erect chest X-ray after at least 20 minutes of sitting upright or ii. Lateral decubitus X-ray e. CT free fluid or free air f. Operating theatre (if needed) i. Laparoscopy or ii. Midline laparotomy 2) Unstable - Shock a. Immediate resuscitation - ABC i. Airway ii. Breathing iii. Circulation b. IV access i. Green, orange or grey = 14G,12G or 10G c. IV fluids rapid fluids i. Hartmans 1. More isotonic 2. Has the extra electrolytes, good for post-op d. Stat dose of PPI ( Losec 80mg) e. PPI infusion of 8mls/hr f. Urinary catheter to measure output i. Minimal urine output in a normal patient is 0.5 to 1.0 ml per kg per hour ii. Minimal urine output in a shock patient is 1.0 ml per kg per hour g. Once stabilized, follow the steps for the stable patient