Dr RAJESH SISODIYA

HISTORYprior episodes of upper gastrointestinal

bleeding (ulcers or varices), liver disease, intestinal polyps or cancer, and blood transfusions.

Alcohol abuse and illicit drug use should also be investigated.

medication use including aspirin, nonsteroidal anti-inflammatory drugs (NSAIDs), and anticoagulation drugs (warfarin, heparin).

Clinical presentationhematemesis,hematochezia, hypotension-related symptoms as dizziness,

light-headedness, weakness, pallor, palpitations, tachycardia, orthostatic hypotension, shock, and

melena or with a positive screening fecal occult blood test (FOBT) or

chronic iron-deficient anemia with no obvious source of blood loss

Symptoms such as abdominal pain, nausea, vomiting, early satiety, anorexia, and weight loss should be sought.

GPEsigns of chronic liver disease, such as

jaundice, caput medusae, spider telangiectasia, and/or ascites.

digital rectal examination and an NG tube aspiration.

Video capsule endoscopya small capsule (11 mm with camera, lens,

and transmitter) is ingested orally can diagnose a site of bleeding in over 50% of

patientsbe considered, especially in patients with

obscure bleeding in whom an exploratory operation is the next step.

should not be used in patients with suspected strictures or known extensive adhesions.

Radionucleotide scanswith either Technetium pertechnate-labeled

autologous red blood cells or Technetium sulfur colloid can detect bleeding at a rate of 0.1–0.4 ml/min.

Angiography Angiography can detect a bleeding rate of

greater than 0.5 ml/min show abnormal vessels or vascular blushes

even in the absence of active bleeding. embolization with gelfoam, polyvinyl alcohol,

or a solid blocking material

Operative exploration/intraoperative enteroscopy

EMERGENT MANAGEMENTa large-bore intravenous (IV) catheterResuscitation the hematocrit should be kept above 30%,

while in young, healthy patients, the target hematocrit should be above 20%.

GASTRIC LAVAGEESOPHAGOGASTRODUODENOSCOPY Red blood cell-tagged radionucleotide scanVideo capsule endoscopy

Peptic UlcersEndoscopy is the first line therapyif the patient requires more than 4–6 units of blood

and the bleeding is not controlled endoscopically, the patient should be managed operatively.

hemodynamically unstable and have ongoing hemorrhage should also be treated operatively.

Other criteria for operative intervention include a rebleeding ulcer that is not controlled by endoscopy and medical therapy and possibly those patients with giant ulcers and a ‘‘visible vessel.’’

For duodenal ulcers, vessel ligation through a longitudinal duodenotomy over the site of the ulcer is performed.

high-dose, intravenous PPI therapy. H. pylori, antibiotic eradication should be

initiated and later confirmed.

Variceal BleedingEndoscopic hemostasis with band-ligation,

injection sclerotherapy, or clip placement Concomitant drug therapy with octreotide,

somatostatin, or glypressinSengstaken Blakemore tube a transjugular intrahepatic portosystemic shunt

(TIPS) to decompress the portal system. not candidates for liver transplantation and who

are stable should undergo a distal splenorenal shunt, amesocaval graft, a porto-caval shunt, or a gastric devascularization with esophageal transection

Hemorrhagic GastritisPPIs, H2 receptor blockers, antacids, and/or

sucralfate. If medical treatment fails, administration of

vasopressin via the left or right gastric arteries.

If severe bleeding persists, a total or sub-total gastrectomy

Mallory-Weiss Tearsresult from repeated vomiting most patients, the bleeding stops without

therapy.If bleeding persists, endoscopic coagulation high anterior gastrotomy

Dieulafoy lesionsintermittent, recurrent, acute upper GI bleeding. abnormally large-caliber submucosal artery

becomes exposed at the surface of the mucosa and then ruptures, usually in the stomach.

Diagnosis may be quite difficult as lesion is focal and bleeds only intermittently.

endoscopic visualization or demonstration by angiography.

banding, clipping, electrocautery, cyanoacrylate glue injection, sclerosant injection, epinephrine injection, heat probe, banding, and laser therapy.

HemobiliaLoss of blood through biliary tree directly

into the duodenal lumen secondary to operative trauma, prior

percutaneous biliary intubation. Melena, jaundice and abdominal pain angiography and treated by arterial

embolization

ThanksThanks