I. INTRODUCTION

UPPER GASTROINTESTINAL BLEEDING

Originates in the GI tract from the mouth to the ligament of Treitz where the duodenum, the

first part of the small intestine, ends. Bleeding from the esophagus may occur from esophageal

varices, dilation of the veins in the esophagus. One of the symptoms of upper GI bleeding is

vomiting of blood (hematemesis).If the blood travels

through the GI tract, the stool may appear tarry and black (melena) because of digested blood,

though the stool can still be stained with red blood (hematochezia). About 75% of patients

presenting to the emergency room with GI bleeding have an upper source. 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. Determining whether a

patient truly has an upper GI bleed versus lower gastrointestinal bleeding is difficult. Mortality

is about 11% in patients admitted with an UGIB.2 It is as high as 33% in patients who

develop bleeding whilst in hospital. A score of less than 3 using the Rockall system above is

associated with an excellent prognosis, whereas a score of 8 or above is associated with high

mortality.3 Most deaths occur in elderly patients with co-morbidity. Mortality is reported to be

lower in specialist units possibly because of adherence to protocols rather than because of

technical advances.2 The prognosis in liver disease relates significantly to the severity of the

liver disease rather than to the magnitude of the haemorrhage

Upper gastrointestinal bleeding is commonly caused by bleeding varices (varicose veins) in the

esophagus, peptic ulcers or a Mallory- Weiss tear at the esophageal gastric junction from

severe retching .Otherwise, bleeding over time results in anemia, characterized by lower than

normal blood hemoglobin and hematocrit with symptoms like weakness, fatigue, and fainting.

The most important step to evaluate upper GI bleeding is upper endoscopy. During this

procedure, performed by a gastroenterologist, a tube with a camera (endoscope) is passed

into the mouth and down the esophagus. The gastroenterologist can proceed to the stomach

and duodenum and localize the source of the bleeding, if possible. Other examination to

determine UGIB are 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.

Emergency 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. Pharmacotherapy 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.

II. OBJECTIVES

General objectives:

This case study focuses on the advancement of my skills in managing and administering the extensive range of my intervention to my client with Upper Gastrointestinal Bleeding (UGIB). This study will further help me to expand my knowledge about the said disease.

Specific objectives:

1. To established good rapport to the client and to get the physical assessment.

2. To define what is Upper Gastrointestinal Bleeding (UGIB).

3. To trace the pathophysiology of UGIB.

4. To enumerate the different signs and systems of UGIB.

5. To formulate and apply necessary nursing care plans utilizing the nursing process.

III. DEMOGRAPHIC DATA

Name: Patient X

Age: 14 y/o

Gender: Male

Status: Single

Nationality: Filipino Date admitted: September 20,2011

Religion: Catholic Time admitted: 04:30pm

Blood type: O+

Address:

Final Diagnosis: Upper Gastrointestinal Bleeding Anemia (UGIB Anemia)

CHIEF COMPLAINT

The patient was admitted at Gat Andres Bonifacio Memorial Medical Center on

September 20 2011 at 4:30pm in the afternoon due to tarry stool. He was attended at

the Emergency department and had taken a clinical history and physical

assessment. He was transferred at the Medical Ward part icularly in the Gastro

Intestinal Room of the hospital for further evaluation of the complaint. He was

attended by Dr. Feipe, a resident physician of the said hospital.

HISTORY OF PRESENT ILLNESS

2 Days- BM Black in color

PAST MEDICAL HISTORY

-None

FAMILY MEDICAL HISTORY

-None

IV. PHYSICAL ASSESSMENT

Actual Findings Normal Findings Interpretation

Head

Skull

Scalp

Hair

-Normocephalic

-No lumps

-

-no baldness

-Straight, Black hair, oily hair

-Normocephalic

-Smooth

-No lumps

-Absence of modules or masses

-No area of tenderness

-Symmetrical with protrusions

on the lateral part of parietal

forehead and occipital bone.

-Whitish

-No nits, lice and dandruff

-no baldness

-Black or brown in color

-Hair is evenly distributed

-No area of baldness

-Thick

-Normal

-Normal

-Normal

Face

Eyes

Eyebrows

Eyelashes

Eyelids

-Symmetrical with movement

-Expressions appropriate to

situations

-Symmetrical

-No cloudiness

-No Lacrimation

-Symmetrical

-Equally distributed

-Curved slightly outward

-Skin intact

-No discharge

-No discoloration

-Lids close symmetrically

-approximately 15-20

involuntary blinks per minute;

-Fine

-Curly/kinky/straight

-Dry/oily/shiny hair

-Symmetrical with movement

-Expressions appropriate to

situations

-Symmetrical

-No protrusions

-Dear or no Cloudiness

-No excessive Lacrimation

-Moves symmetrically

-Hair evenly distributed

-Skin Intact

-Equally distributed

-Curved slightly outward

-Skin intact

-No discharge

-No discoloration

-Normal

-Normal

-Normal

-Normal

-Normal

Lid margins

Lower

palpebral

conjunctiva

Sclera

Iris

bilateral blinking

-No secretions

-No erythema

-No redness

-Pink, shiny, with visible blood

vessels

-No discharges

-White in color

-Clear

- No redness

-Flat

-Brown

-Round

-Transparent/Shiny

-Lids close symmetrically

-approximately 15-20

involuntary blinks per minute;

bilateral blinking

-No scaling

-No secretions

-No erythema

-No redness

-Pink, shiny, with visible blood

vessels

-No discharges

-White/yellowish in black

Americans

-Clear, No cloudiness

-No redness

-Flat

-Brown

-Even coloration

-Symmetrical

-Round

-Normal

-Normal

-Normal

-Normal

Pupils

Eye Movement

Field of vision

*Visual acuity

Ear

-PERRLA

-Moves in unison

-coordinated

-Same as the color of the face

-No swelling

-Shell shape

- Waxy cerumen

-Presence of cilia

-Transparent/Shiny

-PERRLA(Pupils Equally Round,

Reactive to Light &

Accommodation

-Moves in unison

-coordinated

-Good peripheral vision

-20/20 in both eyes

-Parallel with outer canthus of

the eyes

-Same as the color of the face

-No swelling

-No tenderness

-Shell shape

-Firm cartilage

-Yellowish

-Normal

-Normal

-Normal

-Normal

Ear Canal

Hearing acuity

Nose

Lips

-With good hearing acuity in

both ears

-No lesions

-Presence of cilia

-Darker lips

-Ability to purse lips

-Pink, moist

-Dry/waxy cerumen

-Presence of cilia

-No foreign body

-With good hearing acuity in

both ears

-Symmetric and straight

-No discharge or flaring

-Uniform color

-No tenderness

-No lesions

-Presence of cilia

-Uniform pink color(darker,

e.g,Bluish hue, in Mediterranean

groups and dark-skinned clients)

-Soft, moist, smooth texture

-Symmetry of contour

-Ability to purse lips

-No tenderness

-Pink, moist

-Normal

-Normal

-Normal

-Decrease of

oxygen supply

Gums

Teeth

Tongue

Frenulum

Soft Palate

Hard Palate

Uvula

-No swelling

-No tenderness

-No discharges

-white

-Pink, even, rough dorsal surface

and moist

-Midline

-pinkish

-With visible veins

-Pink, moist, no swelling/No

tenderness

-Bony, Light pink in color, moist

-No swelling

-No tenderness

-No discharges

-No retraction(lower and upper)

-32 in number

-White

-Upper teeth over-rides lower

teeth

-Pink, even, rough dorsal surface

and moist

-Midline

-pinkish

-With visible veins

-Pink, moist, no swelling/No

tenderness

-Bony, Light pink in color, moist

-Normal

-Normal

-Normal

-Normal

-Normal

Tonsils

Neck

Upper

Extremities

Skin

-Midline moves when the client

says “Aah”

-Pinkish

-No discharge

-No inflammation

-Same as the skin color

-No lymphs, No mass

-Pink, moist

-Midline moves when the client

says “Aah”

-Pinkish

-No discharge

-No inflammation

-Erect & midline

-Same as the skin color

-No tenderness

-No lymphs, No mass

-Symmetrical

-Muscles equal in size; head

centered

-Coordinated, smooth

movements with no discomfort

-Varies from light to deep

-Normal

-Normal

-Normal

-Normal

Nails

Chest and back

Posterior

-No abrasions or other lesions

-When pinched, skin springs

back to previous state

- with edema

-Convex curvature

-white

brown; from ruddy pink to light

pink; from yellow overtones to

olive

-No edema

-No abrasions or other lesions

-Freckles, some birthmarks,

some flat and raised nevi

-When pinched, skin springs

back to previous state

-Convex curvature

-Smooth texture

-Highly vascular and pink in

light-skinned clients; dark-

skinned clients may have brown

or black pigmentation in

longitudinal streaks

-Intact epidermis

-Prompt return of pink or usual

color(generally less than 4

seconds)

-Chest symmetric

-Skin Intact; uniform

temperature

-Chest wall intact

-No tenderness

-accumulation

of excess fluid

-Decrease O2

supply

Thorax

Anterior

Thorax

Abdomen

-No tenderness

-No masses

-Full expansion

-Tachypnea

-No masses

-Full and symmetric chest

expansion

-Vesicular and bronchovesicular

sounds

-Quiet, rhythmic, and effortless

respirations

-Full symmetric excursion

-Bronchial and tubular breath

sounds in the trachea

-Vesicular and bronchovesicular

breath sounds

-Unblemished skin

-Uniform color

-Silver-white striae or surgical

scars

-Flat, rounded(convex),or

scaphoid (concave)

- Symmetric movements caused

by respiration

- Audible bowel sounds

- No tenderness

-Normal

-Difficulty of

breathing

Lower

extremities

Skin

Nails

-Unblemished skin

-Uniform color

-Brown in color

- with edema

- No abrasions or other lesions

- with edema

- Relaxed abdomen with

smooth, consistent tension

- Varies from light to deep

brown; from ruddy pink to light

pink; from yellow overtones to

olive

- No edema

- No abrasions or other lesions

- Freckles, some birthmarks,

some flat and raised nevi

- when pinched, skin springs

back to previous state

- Concave curvature

- Smooth texture

- highly vascular and pink in

light-skinned clients; dark-

skinned clients may have brown

or black pigmentation in

longitudinal streaks

- Intact epidermis

- Prompt return of pink or usual

color (generally less than 4

secs.)

-Normal

- accumulation

of excess fluid

Motor

functions:

- Concave curvature

-Brown pigmentation in

longitudinal streaks

- Repeatedly and rhythmically

touches the nose

- Rapidly touches each finger to

thumb with each hand

- Can readily determine the

position of fingers and toes

- Has upright posture and steady

gait with opposing arm swing;

walks unaided, maintaining

balance

- May sway slightly but is able to

maintain upright posture and

foot stance.

- Maintain stance for at least 5

secs

- maintains heel-toe walking

along straight line

- Repeatedly and rhythmically

touches the nose

- Rapidly touches each finger to

thumb with each hand

- Can readily determine the

position of fingers and toes

-Normal

-Normal

GORDONDS

Before

hospitalization

During

hospitalization

Interpretation Analysis

a. activity-

exercise pattern

- hobbies

Elimination

pattern

According to her

she does the

household

choirs and at the

same time it is

her way of

exercising and

she can perform

different

activities.

Prior to

hospitalization

she defecates

every day. She

urinates normal

amount and

normal color.

urinates

During her

hospitalization

she is in

complete bed

rest.

For the period of

hospitalization

her defecation

does not vary

but her urine

output

decreases.

She was not able

to perform the

activities

because of the

disease process.

The patient’s

elimination

pattern changed

during

hospitalization

because she is

under

medication.

Exercise is very

important to our

body because it

promotes good

health and helps

us build and

maintain healthy

muscles, bones,

and joints and it

reduces

depression and

anxiety.

Good

elimination

pattern reduces

the risk of

having cancer. It

helps us to

detoxify waste

in our body to

free ourselves

from

complications

Sleep and rest

pattern

Cognitive-

perceptual

pattern

Self –perception

Before she

sleeps 6 hours

every day

The patient is a

2nd year college

undergraduate.

She is literate.

Prior to

hospitalization

she is a happy

person and

positive thinker.

Throughout her

hospitalization

sleeps 12 hours

and can take

naps.

Same

During her

hospitalization

she is still a

positive thinker.

Due to

confinement the

patient has no

problem with

her sleep.

Due to

confinement the

patient has no

problem with

understanding

Even she is in

the hospital

herself

perception does

not change. She

stayed the same

as she was

before.

Enough and

good sleep and

rest pattern can

reduce stress,

helps us to think

better.

Good education

is important to

overcome

poverty.

Good self-

perception and

self-concept

pattern helps us

to overcome

problems and

trials.

Good

relationship to

each member of

the family

creates unity

and self-concept

pattern

Role-

relationship

pattern

The patient’s

family is nuclear

type. They are 8

in the family.

They have 6

children and she

allotted time for

her family to

bond. She is

sociable to

everyone.

Ever time she

encounters

difficulties she

asks guidance

and help from

God.

Throughout her

hospitalization

her family is

with her side at

all times to

support her.

During her

hospitalization

she just prays

Due to her

hospitalization

the family

becomes closer

to one another

and become

stronger.

Her coping

stress is the

same as what

she is doing

before.

and compact

relationship with

each other.

Good

relationship with

other people can

gain trust,

acceptance,

support, and

someone to Call

On When You

Need a Hand.

Having a good

coping to stress

can overcome

stressors and

depressions.

Good health

perception can

maintain health,

the body can

function

properly and it

acts as personal

strength.

Coping-stress

tolerance

pattern

Health

perception

Sexuality-

reproductive

According to her

health is very

important

because it is

wealth.

Before

hospitalization

she menstruates

regularly.

She is an INC.

They go to

church every

Thursday and

every time she’s

in pain.

During her

hospitalization

she still believes

that health is

wealth.

Same

Her health

perception is the

same as what

she believes

before.

Her reproductive

system works

properly.

Good sexuality-

reproductive can

easily determine

the fertilization

and can prevent

cancers in

reproductive

system.

Strong values-

beliefs help us to

overcome

difficulties and

trials.

pattern

Values- belief

pattern

Sunday.

During her

hospitalization

her husband and

her always prays

for her health.

Her values-

belief pattern

does not change

and her faith to

God become

stronger.

V. ANATOMY AND PHYSIOLOGY

UPPER GI

The upper GI tract consists of the mouth, pharynx, esophagus, and stomach. This is where ingestion

and the first phase of digestion occur.

MOUTH

The mouth includes the tongue, teeth, and buccal mucosa or mucous membranes containing the ends

of the salivary glands, continuous with the soft palate, floor of the mouth and under side of the

tongue. Chewing (mastication) is the mechanical process by which food, constantly repositioned by

muscular action of the tongue and cheeks, is crushed and ground by the teeth through the muscular

action of the lower jaw (mandible) against the fixed resistance of the upper jaw (maxilla).

Saliva excreted in the oral cavity by three pairs of exocrine glands (parotid, submandibular, and

sublingual) is mixed with chewed food to form a bolus, or ball-shaped mass. There are two types of

saliva: a thin watery secretion that wets the food and a thick mucous secretion that lubricates and

causes the food particles to stick together to form the bolus.

Digestive enzymes in saliva begin the chemical breakdown of food, primarily starches at this

point, almost immediately.

PHARYNX

The pharynx is contained in the neck and throat and functions as part of both the digestive

system and the respiratory system. The human pharynx is divided into three sections: the

nasopharynx behind the nasal cavity and above the soft palate;

The oropharynx behind the oral cavity and including the base of the tongue, the tonsils, and the

uvula; the hypopharynx or laryngopharynx includes the junction with the esophagus and the

larynx, where respiratory and digestive pathways diverge. The swallowing reflex is initiated by touch

receptors in the pharynx as the bolus of chewed food is pushed to the back of the mouth.

Swallowing automatically closes down the respiratory or breathing pathway as an anti-choking reflex.

Failure or confusion of reflexes at this point can result in aspiration of solid or liquid food into the

trachea and lungs.

ESOPHAGUS

The esophagus is the hollow muscular tube through which food passes from the pharynx to the

stomach. It is also lined with mucous membrane continuous with the mucosa of the mouth and into

which open the esophageal glands.

The esophagus is surrounded by relatively deep muscles that move the swallowed bolus of masticated

food through peristaltic action, piercing the thoracic diaphragm to reach the stomach.

STOMACH

The stomach is a hollow muscular organ, located below the diaphragm and above the small intestine

that receives and holds masticated food to begin the next phase of digestion. Two smooth muscle

valves, the esophageal sphincter above and the pyloric sphincter below, keep stomach contents

contained.

The stomach is surrounded by stimulant (parasympathetic) and inhibitor (orthosympathetic) nerve

plexuses which regulate both secretory and muscular activity during digestion. With a volume of as

little as 50 mL when empty, the adult human stomach may comfortably contain about a liter of food

after a meal, or uncomfortably as much as 4 liters of liquid.

DUODENUM

The duodenum precedes the jejunum and ileum and is the shortest part of the small intestine, where most chemical digestion takes place. The nameduodenum is from the Latin duodenum digitorum, or twelve fingers' breadths.

In humans, the duodenum is a hollow jointed tube about 10–12 in long connecting the stomach to the jejunum. It begins with the duodenal bulb and ends at the ligament of Treitz.

The duodenum is largely responsible for the breakdown of food in the small intestine, using enzymes. Brunner's glands, which secrete mucus, are found in the duodenum. The duodenum wall is composed of a very thin layer of cells that form the muscularis mucosae. The duodenum is almost entirely retroperitoneal.

The duodenum also regulates the rate of emptying of the stomach via hormonal pathways. Secretin and cholecystokinin are released from cells in the duodenal epithelium in response to acidic and fatty stimuli present there when the pylorus opens and releases gastric chyme into the duodenum for further digestion. These cause the liver and gall bladder to release bile, and the pancreas to release bicarbonate and digestive enzymes such as trypsin,lipase and amylase into the duodenum as they are needed.

VI. PATHOPHYSIOLOGY

Precipitating factors Contributing factors Predisposing factors

old NSAIDs use Stress

Diet: spicy foods and coffee

addict

diet

Elicit their effects on

cyclooxegenase

Disruption of mucous

barrier

Inflammatory effect on

gastric mucusa Neutrophils – 86%

-Generalized body weakness BP: 180/90 RR:25 PR:90

-Dizziness

VII. LABORATORY

URINALYSIS

Definition:

Is an array of tests performed on urine and one of the most common methods of medical

diagnosis.

Indication:

It is used to detect the presence of UTI, Proteinuria,Glucosuria, Ketonuria, presence of urinary

sediments which indicates renal pathology.

Nursing Responsibility:

Instruct the patient perform perineal care prior to the procedure

Collect urine from the first voiding in the morning and examine within 30 mins.

Label specimen properly

Instruct patient to keep labia majora separated while urinating

Ulcers burrows deep

Weakening and necrosis of

arterial

Development of pseudo

anuerysms

Weakened wall raptures leading

Peripheral vasoconstriction

Pale nail beds and

conjuctivitis

UGIB

Instruct the patient to collect specimen by a midstream catch

Parameters Results

Color Light yellow

Transparency Slightly cloudy

Reaction 5.0

Sp gravity 1,020

Albumin + 2

Glucose (-)

RBC count 1-2

WBC count 25-30

Epithelial cells Few

Mucus threads 0 cc’l

Bacteria Moderate

Amorphous

Urates

Casts none

Analysis and interpretation

Laboratory results revealed that there is presence of Albumin in the blood, this indicates that

the glomerular cannot filter large molecules such as that of Albumin. It also revealed that

there is infection as evidence by presence of bacteria and red cells in the urine.

Hematology

Definition

Is the branch of internal medicine, physiology, pathology, clinical laboratory work,

and pediatrics that is concerned with the study of blood, the blood-forming organs, and blood

diseases. Hematology includes the study of etiology, diagnosis, treatment, prognosis,

and prevention of blood diseases. The laboratory work that goes into the study of blood is

frequently performed by a medical technologist. Hematologists physicians also very frequently do

further study in oncology - the medical treatment of cancer.

Indication

This test determines the concentration of hemoglobin in whole blood.

Nursing responsibility:

Explain the procedure to the patient

Collect blood sample by extraction from the vein in arm using needle or finger prick

Label the specimen properly .

Parameters Normal Values Results

Hemoglobin M- 130- 180 g/l

F – 120-160 g/l

60

Hematocrit M- 0.42-0.52

F- 0.37- 0.48

0.181

WBC count 4.3-10.8x 10/l

Segments 0.45-.0.74 0.83

Lymphocytes 0.16-0.45 0.15

Eosinophils 0-0.07

Monocyte 0.04-0.10 0.02

Basophils 0-0.02

Bands 0.02-0.04

Platelets 130-400x 10 /l 239

ESR M- 0.15 mm/hr

F- 0.20 mm/hr

RDW= 14.7 Normal MCV= 85.2 Normal MCH-= 28.3 Normal

MCHC= 332 Normal

Interpretation:

This test showed that the hemoglobin is less than the normal value therefore it indicates a

decrease of oxygen in the blood.

Blood chemistry

Definition

A blood test is a laboratory analysis performed on a blood sample that is usually extracted from a vein in the arm using a needle, or via finger prick.

Indication

Blood tests are used to determine physiological and biochemical states, such

as disease, mineral content, drug effectiveness, and organ function. They are also used in drug tests. Although the term blood test is used, most routine tests (except for most haematology ) are done on plasma or serum, instead of blood cells.

Nursing responsibility

Explain the procedure to the patient

Collect blood sample by extraction from the vein in arm using needle or finger prick.

Label specimen properly

Parameters Normal values Results

Glucose 3.9-8 + mmol/l

Uric acid .16-.43

Urea nitrogen 2.5-6.1 1.2

Creatinine 53-115 umol 61

Cholesterol 0-5.2 mmol/l

Triglycerides .23-1.71 mmol/l

HDL .91 mmol/l

Total bilirubin 0.17-1 umol/l

Direct bilirubin .5 umol/l

Indirect bilirubin 0-12.1umol/l

Total protein 61-82 g/l

Albumin 34-50 g/l

Globulin 25-35 g/l

A/G ratio 1.5-2.5

SGOT 15-37 u/l

SGPT 30-65 u/l

Alkyl phosphate 50-136 u/l

Na 140-148 mmol/l 126

K 3.6-5.2 mmol/l 3.9

CHON Value control secs

APPT Value control secs

24 hr urine ECC M- .78-1.155 ml/sec

F- 1.03-1.81 ml/sec

24 hr urine CHON 28-41 mg/24hr

Glycosylated Hgb Up to 66%

Total Hgb

B/C 4.87

ECC 111

Interpretation

Sodium and potassium are normal which means there is still fluid and electrolyte balance.

IX. Discharge plan

Clients with Upper Gastrointestinal Bleeding are instructed to take the following

plan for discharge.

M- Medications should be taken regularly as prescribed, on exact dosage, time,

& frequency, making sure that the purpose of medications is fully disclosed by

the health care provider.

Losartan 50 mg/tab 1tab OD

Hydrocortisol 50 mg/tab 1tab

FeSo4 + folic acid 1tab TID

CaCo3 1tab

NaHCo3 1tab TID

Kalium durule 1tab x 2 days

Nefidipine 30 mg/tab BID

E- Exercise should be promoted in a way by stretching hand and feet every

morning. Encourage the patient to keep active to adhere to exercise program and

to remain as self –sufficient as possible

- bed rest

T- Treatment after discharge is expected for patients and watcher with UGIB to

fully participate in continuous treatment.

H- Health teachings regarding the importance of proper hygiene and hand

washing, intake of adequate water and vitamins especially vitamin C-rich foods to

strengthen the immune response and increasing of oral fluid intake should be

conveyed. Avoid spicy foods, carbonated beverages and coffee.

O- OPD such as regular follow-up check-ups should be greatly encouraged to

clients with UGIB as ordered by physician to ensure the continuing management

and treatment.

D- Diet which is prescribed should be followed.

S- Pray for faster healing and don’t losses hope.

Endoscopy: Risk assessment in upper gastrointestinal bleeding

Ernst J. Kuipers About the author

Abstract

Endoscopy is the mainstay for diagnosis and therapy of upper gastrointestinal bleeding. Early

risk assessment is crucial for effective timing of endoscopy and determination of the need for

other measures to be taken—scoring systems should be used for this purpose. A new prospective study suggests that the Blatchford score can identify patients who do not need endos copic

intervention.

Acute upper gastrointestinal bleeding (UGIB) is the gastrointestinal tract condition most likely to result in a medical emergency. The estimated incidence of acute UGIB is 50–150 per 100,000 population per year: 40–60% of these bleeds are caused by a peptic ulcer, 10% are related to varices, 10% are attributable to erosive esophagitis and the remainder are caused by a variety of conditions. Endoscopic treatment is the main therapy for patients with UGIB. However, risk assessment is necessary to determine whether endoscopic treatment is required; a study by Pang et al. has now assessed the

predictive value of two risk assessment scoring systems.

Endoscopic treatment, either with clips or thermocoagulation with or without epinephrine injection, can stop the initial bleed and reduce the risk of rebleeding considerably. This treatment improves outcome, as it can shorten the hospital stay, decrease the need for a blood transfusion, further endoscopic or surgical intervention, and reduce mortality. After adequate

endoscopic therapy, the outcome for high-risk patients (such as those with a visible vessel) can be further improved by profound acid suppressive therapy by means of a PPI given intravenously.

Early risk assessment is crucial in patients presenting with UGIB to ensure optimal timing of endoscopy, and to determine

whether other measures (such as hospital admission, blood transfusion and treatment in an intensive care unit) are required. Several risk assessment scales have been developed over the past 15 years that are based on retrospective analyses of cohorts of patients presenting with UGIB. Prospective cohort studies are required to assess the validity and

usefulness of these scoring systems. For that purpose, Pang and colleagues compared two frequently used risk assessment scales—the Blatchford and pre-endoscopic Rockall scoring systems—for their ability to predict the need for endoscopic

therapy.3

Early risk assessment is crucial in patients presenting with UGIB...

Both the Blatchford and pre-endoscopic Rockall scoring systems are based on parameters that can be assessed during first

presentation. The pre-endoscopy Rockall scoring system is based on the patient's age, comorbidities, and signs of shock on presentation. By contrast, the Blatchford scale does not consider age, but does assess urea and hemoglobin levels. The Blatchford scale is also more focused on symptoms than the Rockall scoring system.

Pang and colleagues assessed the two scoring systems prospectively in 1,087 patients presenting with UGIB. Endoscopic

therapy was given to 297 (27.3%) of the patients. The decision to apply endoscopic treatment was made by the individual

endoscopist, who was guided by an in-hospital protocol that required such treatment for all actively bleeding lesions, as well

as for visible vessels and adherent clots.

Patients requiring endoscopic treatment were divided fairly equally over all the Rockall score categories. The pre-endoscopic Rockall score was thus unable to predict the need for endoscopic treatment. By contrast, the Blatchford score was able to

make this prediction, as none of the patients with a score of 0 needed endoscopic intervention. The investigators conclude

that the Blatchford score, but not the pre-endoscopic Rockall score, is a useful predictor of the need for endoscopic intervention. The Blatchford score can, therefore, be used to immediately discharge the subgroup of patients that present

with UGIB who are at low risk and so can return to the hospital at a later date for outpatient endoscopic treatment. 3

The results of this study provide valuable confirmation of the usefulness of the Blatchford score for the identification of low-risk patients, enabling the targeted use of resources. Pang et al.'s findings support the recommendation of the latest international guidelines that strongly advise the use of pre-endoscopic risk assessment scores in patients with nonvariceal UGIB. Several other reports also confirmed that patients with a Blatchford score of 0 rarely require endoscopic intervention.

The clinical impact of these important observations is, however, limited by two closely related factors. First, a minority of

cases have a Blatchford score of 0. In Pang et al.'s study, 4.6% (n = 50) of patients were given this score.3 In other studies the proportion of patients given a Blatchford score of 0 varied between 1% and 15%.Second, the positive predictive value of a Blatchford score >1 for the need for intervention is low. For these reasons, the next question that needs to be addressed is

whether the clinical impact of the Blatchford score can be augmented. In contrast to the pre-endoscopic Rockall score, the probability of the need for intervention increases with increasing Blatchford scores.

In a UK study to validate the Blatchford scoring system, approximately 20% of the participants had a score of 1 or 2, and 5% of these patients required intervention.5Similarly, Pang and colleagues found that one-fifth of patients had a score of 1 or 2, but 16% required endoscopic treatment.3 This difference in the need for endoscopic treatment is remarkable because Pang and colleagues' study only used endoscopic intervention as the outcome parameter, whereas the UK study also included other interventions, such as blood transfusion, in their outcome parameter. None of the available studies provided more detailed information regarding the endoscopic appearance of the bleeding lesion and the type of intervention provided. Such

information is needed from future studies to enable the selection of a more sizable proportion of patients with UGIB for endoscopy on an outpatient basis. This strategy would better reflect the fact that only a minority of patients with UGIB

require endoscopic treatment.3,5

Together, these data support the use of prognostic scores for rapid assessment of patients with UGIB, as recommended by

international guidelines. Unfortunately, this strong recommendation is not routinely followed. In a nationwide survey of 6,750 patients with UGIB in more than 200 UK hospitals, pre-endoscopic risk assessment did not influence timing of endoscopy in hospitalized patients and 42% of high-risk patients did not undergo endoscopy within 24 h, as recommended by the international guidelines.9The results of this audit probably reflect the situation in many other countries around the

world. These results also show that studies, such as the one by Pang et al., are urgently required to assess the performance of prognostic scales and stress the need for their use in the treatment of patients with UGIB —a condition associated with serious comorbidity and mortality.

In conclusion, international guidelines strongly recommend the use of pre-endoscopic risk assessment scores to stratify

patients as either low-risk or high-risk, and thus determine the use of resources and timing of endoscopy. Pang and colleagues' findings suggest that the Blatchford score is more useful for this purpose than the pre-endoscopic Rockall score.

A low Blatchford score is adequate for the selection of patients who are unlikely to require endoscopic intervention. In some series, these patients are identified by a score of 0, in others by a score of <2. Further studies are now required to improve the predictive value of the Blatchford scoring system.

Competing interests statement

The author declares no competing interests.

References

van Leerdam, M. E. et al. Acute upper GI bleeding: did anything change? Time trend analysis of incidence and outcome of

acute upper GI bleeding between 1993/1994 and 2000. Am. J. Gastroenterol. 98, 1494–1499 (2003)

Article

PubMed

ChemPort

Barkun, A. N. et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann. Intern. Med. 152, 101–113 (2010).

Pub Med

Pang, S. H. et al. Comparing the Blatchford and pre-endoscopic Rockall score

SUMMARY

Originates in the GI tract from the mouth to the ligament of Treitz where the duodenum, the first part of the small

intestine, ends. Bleeding from the esophagus may occur from esophageal varices, dilation of the veins in the esophagus. One of

the symptoms of upper GI bleeding is vomiting of blood (hematemesis).If the blood travels

through the GI tract, the s tool may appear tarry and black (melena) because of digested blood, though the stool can s till be

s ta ined with red blood (hematochezia). About 75% of patients presenting to the emergency room with GI bleeding have an

upper source. 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. Determining whether a patient truly has an upper GI

bleed versus lower gastrointestinal bleeding is difficult. Morta lity i s about 11% in patients admitted with an UGIB.2 It is as high

as 33% in patients who develop bleeding whilst in hospital. A score of less than 3 us ing the Rockall system above is associated

with an excellent prognosis, whereas a score of 8 or above is associated with high mortality.3 Most deaths occur in elderly

patients with co-morbidity. Morta lity is reported to be lower in specialist units possibly be cause of adherence to protocols

rather than because of technical advances.2 The prognosis in l iver disease relates significantly to the severity of the liver

disease rather than to the magnitude of the haemorrhage

Upper gastrointestinal bleeding is commonly caused by bleeding varices (varicose veins) in the esophagus, peptic ulcers or a

Mal lory- Weiss tear at the esophageal gastric junction from severe retching .Otherwise, bleeding over time results in

anemia, characterized by lower than normal blood hemoglobin and hematocrit with symptoms like weakness, fatigue, and

fa inting.

The most important s tep to evaluate upper GI bleeding is upper endoscopy. During this procedure, performed by a

gastroenterologist, a tube with a camera (endoscope) is passed into the mouth and down the esophagus. The

gastroenterologist can proceed to the s tomach and duodenum and localize the source of the bleeding, if possible. Other

examination to determine UGIB are 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 i f the bleeding is from a variceal source.

Laboratory findings include anemia, coagulopathy, and an elevated BUN-to-creatinine ratio.

Emergency treatment for upper GI bleeds includes aggressive replacement of volume with intravenous solutions,

and blood products i f required. As patients with esophageal varices typically have coagulopathy, plasma products may have to

be administered. Vital s igns 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.

Pharmacotherapy 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 ci rculation. 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 i s identified as a contributant to the source of hemorrhage, then therapy with antibiotics and a PPI i s suggested.

Reaction:

Nowadays there are many technologies discovered to treat diseases like the Upper Gastrointestinal Bleeding. Before UGIB is

difficult to treat because of lack of equipments and high technology equipments and because of that the mortality of UGIB is very high. Until they discovered endoscopy (means looking inside and typically refers to looking inside the body for medical reasons using an endoscope an instrument used to examine the interior of a hollow organ or cavity of the body. Unlike most other medical imaging devices,

endoscopes are inserted directly into the organ) to treat UGIB. It is easier now to treat UGIB with the new way while maintaining the

medications prescribed, but still there is disadvantage with endoscopy like risk for infection due to sepsis. The mortality of

UGIB now is low unlike before.

University of Perpetual Help College of Manila

214 V Concepcion Street Sampaloc Manila

Case Study of

Upper Gastrointestinal Bleeding

Submitted to: Submitted by: Racca, Freegie B.

Ms. Ma. Evelyn Lumio