The study of
UPPER
GASTROINTESTINAL BLEEDING
Dr. Rajesh Kashyap (M.D.)
Part 4.....
DEFINITIONS OF TERMS
UPPER GI BLEEDING : Patient must have either (a) history of evident gastrointestinal bleeding on admission (b) a history of having bleed within 10 days of admission.
HEMATEMESIS : Will be defined as vomiting of blood or blood clots (Coffee ground vomit will be accepted as evidence of hematemesis only if witnessed by medical staff).
MELENA : Will be defined as the passage of dark tarry stools and again will only be accepted if witnessed by medical staff.
CONTINUING BLEEDING : Will be defined as having occurred, if one of the following happens : (a) bleeding continues for over 24-36 hours (b) Hemetemesis of sufficient nature as to warrant urgent surgical intervention. Evidence of continued gastrointestinal bleeding will be high pulse rate and low blood presssure with no obvious cause, continued hemetemesis, the passage of fresh melena and failing Hb level more than would be expected by hemodilution.
REBLEEDING : A patient will be defined as having rebleed, if the signs of hematemesis occur any time in the first 10 days after admission. However, to be classified as having rebled, the patient must first of all give evidence of having ceased their initial onset of bleeding. Bleeding will be considered to be ceased or controlled when (1) Gastric aspirate becomes clear or light brown; (2) The pulse rate falls to below 100 per minute; (3) the systolic bleeding stabilised at or above 100mmHg and (4) the rise of hemoglobin level correspond with the amount of blood transfused. This state must last for a minimum of 24 hours.
SEVERITY OF GASTROINTESTINAL BLEED
MILD GASTROINTESTINAL BLEED : Patient presenting with upper gastrointestinal bleed, with no signs of shock.
MASSIVE OR SEVERE GASTROINTESTINAL BLEED : Patient presenting with upper gastrointestinal bleed with signs of shock i.e., Systolic blood pressure less than 100mmHg in an otherwise normotensive person : a drop of more than 10-15mmHg from lying to sitting posture; pulse rate of more than 120 in sitting posture; Hemoglobin of less than 8gms or blood transfusion requirement of 500ml per eight hours or more to maintain blood pressure above 100mmHg and pulse below 100 per minute.
All the relevant data was collected in prescribed proforma. Non-surgical and surgical management were decided by mutual agreement between treating team of gastroenterologist and surgeons. Treatment with defined management protocol was followed.
The data collected from the present study was analysed from time to time. This data has revealed the pattern of diseases presenting with upper gastrointestinal bleed and also suggest how we can improve upon immediate management and outcome of such patients in our hospital.
PROTOCOL FOR MANAGEMENT
Resuscitation
Two good intravenous lines of saline.
Rapid assessment of patient including severity of gastrointestinal bleed. Vital signs monitoring.
Investigative work-up including blood grouping and cross matching.
Blood transfusion : Indications : state of shock; continuing bleed; has less than 30%. Aim; (i) to restore normal systolic blood pressure; (ii) to restore Hct 30-35% once bleeding stops. EMPIRIRAL TREATMENT
Once the patient was hemodynamically stabilised nasogastric tube gastric lavage was done in selected patients i.e., in those patients who were actively bleeding and before taking the patient for upper GI endoscopy.
Gastric Lavage : Saline or tap water, 100ml - 250ml at a time, half hourly till gastric aspirate is clear or maximum for a period of two hours.
UPPER GASTROINTESTINAL ENDOSCOPY
Once the patient became hemodynamically stable, early endoscopy was planned to know the site and cause of upper GI bleed.
SPECIFIC THERAPY was considered whereever it was indicated.
PEPTIC ULCER DISEASE
1. Proton pump inhibitors OMEPEPRAZOLE 40mg twice daily for three to five days was given.
2. Endoscopic hemostasis if visible vessel, injection therapy was instituted.
Once the bleeding stopped ulcer disease management including anti H.pylori therapy was given.
3. Surgery.
EROSIVE MUCOSAL DISEASE (EMD)
(A) Drug induced EMD : To stop offending drug plus measures to neutralise gastric acidity or to enhance gastric mucosal resistance.
(B) Stress induced EMD : Management of underlying responsible illness plus measures to neutralise gastric acidity or to enhance gastric mucosal resistance was done.
(C) Duration of therapy was decided by underlying cause responsible for EMD.
1. Parenteral H2 receptor antagonist : Rantidine 50mgm. IV bolus dose, 12.5mgm/hour/IV infusion was given.
2. Sucralfate : 1gm dissolved in 30ml saline six hourly.
3. Surgery.
ESOPHAGEAL BLEED
If due to cirrhosis liver : Prophylaxis for hepatic encephalopathy; to look for sepsis; to assess for severity of cirrhosis.
1. Endoscopic sclerotherapy (EST) intra-variceal injection or endoscopic variceal ligations (EVL): was done at the time of diagnostic endoscopy. If rebleeding was there then maximum two sittings of EST within a week was given. If EST/EVL fails then other options were undertaken.
2. Octerotides/Somastatin Infusion
(a) Octerotide 50-100µgm IV bolus, followed by an infusion at 25-50µgm/hr for 48 hours to five days.
(b) Somatostatin 250µgm IV Bolus followed by 250µgm/hr in infusion for 48 hours to five days.
3. Surgery.
MALLORY WEISS-TEAR
Inhibitors of acid secretion (H2 receptor antagonists or proton pump inhibitors)
If visible vessel: Endoscopic injection therapy was given
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