The study of
UPPER
GASTROINTESTINAL BLEEDING
Dr. Rajesh Kashyap (M.D.)
Part 1 ........
INTRODUCTION
Upper gastrointestinal bleeding is defined as the bleeding from GI tract above the ligament of treitz's. It can manifest as hematemesis or melena or both1.
Upper Gastrointestinal bleeding is one of the common gastrointestinal emergency in day to day practice. With systematic approach to management 9 out of 10 patients with massive gastrointestinal bleed can ultimately be saved and most of them return to useful existence. The initial diagnosis and management of upper gastrointestinal bleeding is in the province of physicians.
Bleeding lesions in the upper gastrointestinal tract are in adverse environment for haemostasis for which several factors contribute. The pathological characteristics of a bleeding chronic gastric ulcer were first clearly described by French pathologist JEAN CRUVEILHIER in 1829. He reported a post mortem study of a young carpenter who died after several upper gastrointestinal bleeds7.
The most common causes of upper Gastrointestinal bleeding include duodenal and gastric ulcers, gastric erosions, varices and Mallory Weiss tears. Other causes include esophagitis, neoplasm and angiodysplasia8.
Since Cruverlhier's time, several authors have noted the association between major peptic ulcer haemorrhage and exposed vessels in the ulcer crater. The rigid and semi flexible gastroscopes of the 1930's and 1940's offered a limited view of upper gastrointestinal tract although the drawings revealed that the early endoscopist identified the "visible vessel" in patients presenting with upper GI bleeding9.
The advent of fibreoptic endoscopy in 1970 allowed the source of bleeding to be accurately identified and prognostic significance attached to lesions with identifiable stigmata of recent haemorrhage. Endoscopists again reported identification of the visible vessel, although this is a misnomer. The underlying artery in an ulcer base is generally invisible, and only the protuding clot is visible. Histological studies have confirmed that the endoscopic visible vessel does represent a small artery.
Peptic ulcer remains the commonest cause of gastro intestinal bleeding in nearly all series. But there is considerable variation in proportion of patients with variceal bleeding which tends to be low in U.K. series and high in those of the United States10.
Endoscopy remains the diagnostic tool for the diagnosis of upper gastrointestinal bleed. In the upper gastrointestinal bleed the mainstay of treatment is medical or surgical, although 85% of the bleeding episodes subside with supportive therapy alone. In medical therapy it is the supportive treatment and therapeutic endoscopy which helps to resolve the problem. Surgical treatment is required only if the bleed continues.
The immediate prognosis of gastrointestinal bleed depends upon the proximity of good medical and surgical treatment and adequate supply of blood transfusion. Upper gastrointestinal bleeding can be life threatening and it is usually managed in the hospital where vigorous resuscitation haemodynamic monitoring, urgent endoscopy and surgical intervention are available. The age of the patient and nature of the underlying lesion strongly affect the outcome. Older patients those with the ulcer bleeding and those with varices are at higher risk. Most deaths result not from the exsangunation but from a complication provoked by the bleeding such as renal failure or shock, or as a result of surgery for the bleed.
Since the problem of upper GI bleeding is quite common in our state, this study was undertaken to know the present clinical profile of various causes of upper GI bleeding and their management in our institution and its outcome.
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