UGIB

UGIB : Upper Gastrointestinal Bleeding

Intro:

1. Types of UGIB 

2. pathogenesis 

3. Signs and symptoms to look out for

4. Investigations

5. Management

6. Follow up plans

* scores used: Rockfall score, Child pugh score

Types: varieal and non variceal

1. variceal: 

• ulcer in esophagus wall caused by increase pressure in vein
• closely related to portal hypertension - in pt with cirrhosis/ hepB
• rupture will cause death and massive bleeding

2. non variceal 

• are ulcers not in esophagus, can be in stomach or any other places
• non variceal bleeding ties closely related to the portal tension. 

* portal tension(normal : 5-10, high>12mmHg)

    - if portal tension is > IJC tension. it will cause back flow of blood into the vessel lining on the stomach or esophageal, which could lead to rupture of the vessels. 

Pathogenesis

- it is important to understand the pathogenesis before we understnad the disease. 

- the table below summarise common scenarios that we can see in ward . 

Signs and symptoms 

symptoms: coughing blood, melenic stools, epigastric pain after food relieve by vomiting: PU, absent: variceal bleed, epigastric pain relieve by food : DU

signs: pallor, weak, lethargic, anemic: dizziness, palpitation , syncope

Investigations (Ix):

• FBC: infection, anemia, thrombocytopenia: hypersplenism in liver disease
• -plt count aim at >50x10/L
• RFT: electrolyte imbalance/ AKI, 
• urea increase when absorb products of luminal blood which are supposed to be metabolised in the liver . 
• normal creat, with increase urea= severe bleeding
• LFT: AST, ALP, ALT any disoriented, 
• coag: anticoagulated pt
• is pt on anti coagulants?
• any warfarin used?

• infective screening: 
• hep B , HbsAg- active or not
• OGDS: any bleeding in the esophagus - golden standard
• - forrest grading I(active  bleeding), IIa(oozing)-c(black spot), III(clean base)
• H.pylori:
• - rapid urease test - to confirm if any h.pylori activity
• - serology/ab testing
• - urea breath test: after treatment to confirm eradication: stop abx 4week, stop PPI 2wk prior

ROCKALL score: 

• < 3 good prognosis, >5 high mortality, need icu care

MANAGEMENT (Mx): 

S1. KNBM

• prepare 2 large bore Iv cannula- green

initial clinical assessment: 

• - severe bleeding: shock, tachy, low bp, cold and wet, agitated, oliguria, mental status
• - comorbidities: cardiorespi, cerebrovascular, renal disease
• - seek evidence of CLD (variceal bleed): jaundice, hepatosplenomegaly, ascites

   child pugh score

•         - encephalopathy, alb<2.8, INR>2, Ascites, bil >3 . if score>10 child pugh C

S2. check vital signs: BP, HR, RR

S3. Resus NS crystalloid solution infusion, send for GSH to prepare for blood transfusion(pc and FFP)

+ oxygen

+ whold drugs that causes bleeding: aspirin, warfarin

- indication for blood transfusion: BP<100, HR>110, Hb<8, postural hypotension, chest pain with Hb<10

S4. IVI pantoprazole

- why PPI?

    -irreversibly bing to the H/K ATPase of gastric parietal cells, which helps decrease the H+ secretion into gastric lumen, increase gastric pH (alkali), can slower the PU disease

    - gastric acid prevents cessation of bleeding from PU by inhibition of clot formation, promotion of clot lysis and ongoing tissue damage. thats why PPI and H2 antagonist needed to inhibit gastric acid formation. 

    - PPI helps reduce the number of active bleeding ulcer and increase the number of clean based ulcers. it also helps reducing th need for endoscopic intervention and hospitalization.

S5. other meds

if suspect variceal bleeding: octreotide (somatostatin)/ terlipressin to prevent rebleeding

- Octreotide reduces portal and variceal pressures as well as splanchnic and portal-systemic collateral blood flows [2]. It also prevents postprandial splanchnic hyperemia in patients with portal hypertension [3] and lowers gastric mucosal blood flow in normal and portal hypertensive stomachs

- abx prophylaxis- for 7d: norfloxacin, ciproflocaxin, cephalosporin. 

S6. ideally to get endoscopy within 24hrs. OGDS ligation on the bleeding site. 

S7. H. pylori eradication 7d course: PPI, amoxicillin/metronidazole, clarithromycin

Follow up(F/U) plans

- readmit and re endoscope 6weeks to rule out malignancy. for h.pylori eradication properly

• H. pylori eradication

triple therapy: PPI with clarithromycin and amoxicillin /metronidazole for 7d

- if allergy to penicillin replace with bismuth

• primary prophylaxis

- screening every1-2years

- non selective beta adrenergic antagonist- propanolol, nadolol

    - nitrates

    - blocked beta 1 which cause vaso-constriction and reduce splanchnic blood flow by blocking vasodilation beta 2 receptor

- endoscopic: variceal ligation and injection sclerotherapy

references:

1. https://www.osmosis.org/answers/melena

2. GASTRO cpg malaysia