The study of
UPPER
GASTROINTESTINAL BLEEDING
Dr. Rajesh Kashyap (M.D.)
Part 5 .......
OBSERVATIONS
This study was conducted in I.G.M.C. Hospital. All patients presenting with History of Upper GI bleed was included from Dec. 1998 to April 2000. A total number of 111 patients were admitted in I.G.M.C. during the period and all were included.
TABLES OF OBSERATION
TABLE NO. 1
| Male | Female | Total |
| 87 | 24 | 111 |
In our study there were 111 patients out of which 87 (78.4%) were males and 24 (26.4%) were females.
TABLE NO. 2
AGE DISTRIBUTION
| Age Group | >20 | 21-30 | 31-40 | 41-50 | 51-60 | 61-70 | >70 |
| No.of Pts. | 2 | 11 | 17 | 27 | 26 | 16 | 12 |
| % of Pts. | (1.8%) | (9.9%) | (15.3%) | (24.3%) | (23.4%) | (14.4%) | (10.8%) |
The distribution of patient age in our study is shown in the Table 2. Most of the patients fall between 41-60 years (47.7%).
TABLE 3
MODE OF PRESENTATION OF PATIENTS IN OUR STUDY
| Symptom | Melena | Hemetmesis | Both |
| No. of Patient | 16 | 32 | 63 |
| Percentage of pts. | 14.4% | 28.8% | 56.8% |
The presentation of most of patients in our study was both hemetmesis and melena 63 patients(56.8%).
TABLE 4
FREQUENCY DISTRIBUTION OF PATIENTS WITH DRUG INTAKE WITHIN 48hrs PRIOR TO ONSET OF UPPER GI HAEMORRHAGE
29 26.1
| DRUGS | PATIENT NO. | PERCENTAGE OF PATIENTS |
| NSAID | 29 | 26.1% |
| Asprin | 9 | 8.1% |
| Other | 5 | 4.5% |
There is no history of any drug intake in most of the patients 68 (61.3%) in our study within 48 hours of symptoms.
TABLE 5
DRUG INTAKE FREQUENCY WITHIN 2-7 DAYS PRIOR TO ONSET OF UPPER GI HAEMORRHAGE
DRUGS |
NO. OF PATIENTS |
% OF PATIENTS |
NSAID |
16 |
14.4% |
Aspirin |
6 |
5.4% |
Others |
2 |
1.8% |
Nil |
87 |
78.4% |
Similarly there is no history of any drug intake between 2-7 days in most of the patients in our study 87 (78.4%).
TABLE 6
FREQUENCY DISTRIBUTION OF ALCOHOL INTAKE IN PATIENTS PRIOR TO UPPER GI HAEMORRHAGE
ALCOHOL INTAKE |
NO. OF PATIENTS |
% OF PATIENT |
No Alcohol intake |
98 |
88.3% |
Within 48 hours |
8 |
7.2% |
Between 2-7 days |
5 |
4.5% |
There is no history of alcohol intake in 98 (88.3%) of patient.
TABLE 7
TABLE SHOWING SYMPTOMATOLOGY PRIOR TO UPPER GI BLEED
SYMPTOMS |
NO.
OF PATIENTS |
PRESENT
NO. OF PATIENTS |
ULS |
78 (70.3%) |
33 (29.7%) |
Portal HTN |
9 (8.1%) |
102 (91.9%) |
Mallory Weiss Syndrome |
11 (9.9%) |
100 (90.1%) |
Tumors |
0 (0%) |
111 (100%) |
Erosive mucosal disease |
2 (1.8%) |
109 (98.2%) |
History of past upper GI bleed |
13 (11.7%) |
98 (88.3%) |
In our study there is no co-morbidity in most of the patients 82 (73.9%). There was associated illness of cardio vascular symptoms in 7 (6.3%), respiratory illness in 12 (6.3%). Renal disease in 4 (3.6%). History of liver disease in 2 (1.8%) and other illness in 4 (3.6%) of patients of upper GI bleed.
In our study out of 111 patients 69 (62.2%) patients were hemodynamically stable and 42 (37.8%) were unstable at the time of admission.
In our study of 111 patients, there was history of treatment with Antacid in 2 (1.8%), H2RA 15 (13.5%), PPI 2 (1.8%) prior to admission to our institution. No history of any treatment in rest of the patients.
Mild bleed was in 49 (44.1%) patients and severe bleed in rest of the patients 62 (59.9%).
TABLE 8
CLINICAL IMPRESSION AND FINAL DIAGNOSIS PRIOR AND AFTER ENDOSCOPY
DISEASE |
NO. OF PATIENTS |
|
Prior to Endoscopy |
After Endoscopy |
|
DU |
56 (50.5%) |
48 (43.9%) |
GU |
7 (6.3%) |
19 (17.1%) |
PHTN |
11 (9.9%) |
12 (10.8%) |
EMD |
24(21.6%) |
13 (11.7%) |
MW Synd |
12 (10.8%) |
12 (10.8%) |
Reflux Oesphag |
1 (.9%) |
3 (2.7%) |
Tumors & others |
0 (0%) |
4 (3.6%) |
In our study of upper GI bleed most patients are of peptic ulcer disease followed by portal HTN, EMD and MW syndrome.
TABLE 9
TYPE OF THERAPY GIVEN AFTER DIAGNOSIS IN HOSPITAL
TYPE OF THERAPY |
NO. OF PATIENT |
% OF PATIENTS |
PPI |
99 |
83.8% |
H2RA |
4 |
9.0% |
EVL |
2 |
1.9% |
Sclerotherapy |
5 |
4.5% |
Somatostatin/octerotide |
2 |
1.8% |
Injection therapy in Peptic ulcer disease patients with stigmata of recent hemorrhage |
10 |
90% of 11 pts. |
in most of the patients PPI was given either alone or in the form of triple therapy. EVL in two patient, sclerotherapy in five patients and somatostatin was used in two patients in our study. Stigmata of recent bleed was present in 11 (9.9%) of the patients out of 111 study group. Out of 11 patients injection therapy was given to 10 patients.
TABLE 10
NUMBER OF BLOOD TRANSFUSION GIVEN TO PATIENTS OF UPPER GI BLEED
NO. OF PATIENTS |
NO. OF BLOOD TRANSFUSION (UNITS) |
% OF PATIENTS |
45 |
0 |
40.5% |
19 |
1 |
17.1% |
19 |
2 |
17.1% |
7 |
4 |
6.3% |
3 |
5 |
2.7% |
10 |
>5 |
11.1% |
In our study 45 (40.5%) did not require blood transfusion and only 20 required four or more than four units of blood to keep the patient hemodynamically stable. Four or more than 4 units are required in 8 patients of DU, 5 patients of GU, 3 patients of variceal bleed, 2 patients of EMD and 2 patients of MW.
TABLE 11
FINAL OUTCOME OF PATIENTS OF UPPER GI BLEED IN GENERAL
SURGERY |
DEATH |
RECOVERED |
TOTAL PTS. |
3 (2.7%) |
7 (6.3%) |
101 (91%) |
111 (100%) |
In our study surgery was required in 3 (2.7%) of patients and death occurred 7 (6.3%) patients and rest of the patients managed conservatively.
TABLE 12
RELATION OF VARIOUS CAUSES OF UPPER GI BLEED WITH AGE
DISEASE |
||||||||
Age in yrs. |
DU |
GU |
PHTN |
EMD |
MW |
Reflux |
Tumors |
Total |
20 yrs |
|
|
|
2 |
|
|
|
2 |
21-30 |
4 |
2 |
2 |
3 |
|
|
|
11 |
31-40 |
9 |
1 |
2 |
|
4 |
1 |
|
17 |
41-50 |
11 |
6 |
4 |
3 |
1 |
|
2 |
27 |
51-60 |
10 |
6 |
3 |
3 |
2 |
1 |
1 |
26 |
61-70 |
9 |
4 |
|
1 |
2 |
|
|
16 |
>71 |
5 |
2 |
1 |
2 |
1 |
1 |
1 |
12 |
Total |
48 |
19 |
12 |
13 |
12 |
3 |
4 |
111 |
Most of the patients of DU lies in the age group of 41-60 years. GU patients most of them also fall in the same age group. None of the patients of DU and GU found in less than 20 years age group only two patients of EMD were found in less than 20 years age group.
x2 = 42.42, p = > 0.05
TABLE 13
DISTRIBUTION OF VARIOUS DISEASES IN RELATION TO SEX
SEX |
DISEASE |
|||||||
DU |
GU |
PTN |
EMD |
MW |
Reflux |
Tumor |
Total |
|
Male |
40 |
16 |
8 |
8 |
9 |
2 |
4 |
87 |
Female |
8 |
3 |
4 |
5 |
3 |
1 |
24 |
|
Out of 87 male patients, the most common cause was peptic ulcer disease followed by Mallory Weiss syndrome and portal HTN and EMD. Out of 24 females most common cause is peptic ulcer disease followed by EMD and Portal HTN.
x2 = 5.65, p > 0.05
TABLE 14
RELATION OF VARIOUS CLINICAL PRESENTATION WITH VARIOUS CAUSES OF UPPER GI BLEED
CLINICAL PRESENTATION |
DISEASES |
||||||
DU |
GU |
PHTN |
EMD |
MW |
Reflux |
Tumors |
|
Hematemesis & Melena |
32 |
8 |
6 |
||||
Hemetmesis |
5 |
11 |
3 |
4 |
3 |
1 |
3 |
Melena |
11 |
9 |
1 |
3 |
9 |
2 |
1 |
The commonest presentation of DU patient was both hemetemsis and melena in 32 patients out of 48 followed by melena in 11 and hemetmesis in five. In GU patients hemetmesis was the commonest presentation 11 (18) followed by melena in 9 (18) patients. In portal HTN hemetmesis and melena was the commonest presentation 8 (12) followed by hemetmesis 3 (12) and melena 1 (12). In EMD patients hemetmesis and melena both was the commonest presentation 6 (13) followed by hemetmesis 4(13). In MW syndrome melena was the commonest cause 3 (4).
x2 = 34.69, p < 0.05
TABLE 15
RELATION OF VARIOUS RISK FACTORS AND SYMPTOMS WITH GI BLEED
RISK FACTOR |
DISEASE |
||||||
DU |
GU |
PHTN |
EMD |
MW |
Reflux |
Tumors |
|
Drug Intake in 48 hrs |
18 |
7 |
4 |
7 |
3 |
2 |
|
Within 2-7days |
9 |
6 |
2 |
3 |
2 |
1 |
1 |
Alcohol |
6 |
2 |
1 |
3 |
1 |
||
ULS |
41 |
14 |
3 |
8 |
7 |
2 |
3 |
Portal HTN |
8 |
1 |
|||||
MW |
1 |
1 |
1 |
1 |
7 |
||
History of past bleed |
8 |
1 |
1 |
1 |
1 |
1 |
|
The symptomatology and disease correlation is highly significant with x2 = 19.69, p <0.005 for ULS. Similarly for portal hypertension, x2 = 62.82, p<0.005, for MW x2=36.14, p<0.005 and the correlation with drugs, alcohol and past history of bleed is not statistically significant.
TABLE 16
HEMODYNAMIC STABILITY OF PATIENTS OF VARIOUS CAUSES OF UPPER GI BLEED
HEMO-DYNAMICALLY |
DISEASES |
||||||
DU |
GU |
PHTN |
EMD |
MW |
Reflux |
Other |
|
Stable |
34 |
6 |
5 |
11 |
9 |
3 |
1 |
Unstable |
14 |
13 |
7 |
2 |
3 |
3 |
|
Most of the patients of the DU were hemodynamically stable 34 (48) and that of GU were unstable 13 (19). Similarly patients of portal HTN 7 (12) were unstable.
x2 = 23.50, p > 0.05
TABLE 17
RELATIONSHIP BETWEEN CLINICAL IMPRESSION AND FINAL DIAGNOSIS AFTER UPPER GI ENDOSCOPY
CLINICAL IMPRESS |
DISEASE AFTER ENDOSCOPY |
||||||
DU |
GU |
PHTN |
EMD |
MW |
Reflux |
Tumors |
|
DU (56) |
38 |
9 |
1 |
3 |
2 |
1 |
2 |
GU(7) |
2 |
5 |
|||||
PHTN(11) |
11 |
||||||
EMD(24) |
7 |
3 |
10 |
1 |
1 |
2 |
|
MW(12) |
1 |
2 |
9 |
||||
Reflux(1) |
1 |
||||||
The correlation between clinical impression and final diagnosis is highly significant with x2 = 236.47, p = < 0.001.
TABLE 18
FINAL OUTCOME OF 111 PATIENTS OF VARIOUS CAUSES OF UPPER GI BLEED
FINAL OUTCOME |
DISEASE |
|
||||||
DU |
GU |
PHTN |
EMD |
MW |
Reflux |
Tumors |
Total |
|
Cured |
46 |
18 |
8 |
13 |
12 |
3 |
1 |
101 |
Death |
1 |
4 |
|
|
|
|
2 |
7 |
Surgery |
1 |
1 |
|
|
|
|
1 |
3 |
Out of total 111 patients 101 discharged from hospital on treatment, there are 7 deaths and surgery performed in three patients.
x2 = 19.89, p2 < 0.05 for surgery
x2 = 32.37, p2 < 0.01 for deaths
TABLE 19
TREATMENT MODALITIES IN DIFFERENT CAUSES OF UPPER GI BLEED
TREATMENT |
DISEASE |
||||||
DU |
GU |
PHTN |
EMD |
MW |
Reflux |
Tumors |
|
Sclerotherapy |
|
|
5 |
|
|
|
|
Band ligation |
|
|
2 |
|
|
|
|
H2RA |
|
|
1* |
3 |
1 |
|
|
PPI |
48 |
19 |
4* |
10 |
11 |
3 |
4 |
Somatostatin/octerotide |
|
|
2 |
|
|
|
|
Injection therapy for PUD with stigmata |
6 |
4 |
|
|
|
|
|
* In patients of portal hypertension the H2RA and PPI are given for other associated indications.
x2 = 40.07
p = > 0.05
All rights reserved with the author, including the rights of reproduction in whole or part, in any form. No part of the publication, images, photographs, design or any other content may be reproduced or transmitted in any form or by any means, electronic or mechanical including photocopying, recording, electronic replication, or any information storage and retrieval system, without permission in writing from the copyright holder. However the study may be quoted and referred to in any other research, medical or allied work or/and project without any restriction.
Copyright © reserved with Rajesh Kashyap, Year- 2000