Upper GI bleed
Upper GI bleeding is a major complication of Peptic ulcer disease. It occurs in 1/2000 people each year, of which ½ of these cases are due to PUD. Also remember that patients who take long term aspirin not only have increased risk of ulcer, but that they have a reduced platelet count, so if their ulcer bleeds, they are likely to lose more blood.
- Hematemesis – fresh blood in vomit – caused by a bleed anywhere above the jejunum.
- Melena – altered blood passing from the rectum – i.e. it isn’t fresh. This often has a tar like appearance and a very distinctive smell! Melena is suggestive of an upper GI bleed due to the fact the blood has been altered on travelling through the GIt. It can be caused by a bleed anywhere from the oesophagus to the rectum.
- Hematemesis and melena together
- Abdominal discomfort
- Sudden death!
- Peptic ulcer – 35-50%
- Gastroduodenal erosions – 8-15%
- Oesophagitis – 5-15%
- Varices – 5-10%
- Mallory-Weiss tear – 15%
- Upper GI malignancy – 1%
- Vascular malformation - 5%
- Rare miscellaneous - 5% (e.g. Meckel's, Crohn's disease)
- GORD – Gastro-oesophageal reflux disease – this will produce small volumes of bright red blood. This condition is chronic mucosal damage caused by acid reflux into the oesophagus. It is often caused by incompetence of the cardia or by problems expelling normal gastric reflux from the oesophagus. This condition often results in Barrett’s oesophagus; a condition where the epithelium of the bottom of the oesophagus changes to be more like that of the stomach as a result of prolonged exposure to acid. It can extend up to 10cm up the oesophagus.
- Some people use the term hiatus hernia to mean a similar thing to GORD, but infact this is incorrect. A hiatus hernia is a congenital defect present in about 40% of people where part of the stomach extends above the level of the diaphragm. Normally it causes no problems, but it some people it can be a causatory factor in gastric reflux
- Chemical injury
This will produce large volumes of dark red blood. These are an effect of severe liver disease. In liver disease, the pressure in the portal system will increase greatly. As a result, anywhere where blood can ‘escape’ the portal system and get back to systemic circulation will become overloaded with blood, and the oesophagus as well as the rectum is a place where this can occur. As a result, in liver disease you will get oesophageal and rectal varices. Suspected varices require urgent endoscopy. If on endoscopy you see the white nipple sign (the varices have an obvious white ‘tip’ a bit like a spot), then this is a sign that the varices have already bled, or are about to bleed. This whiteness is caused by a local weakness in the variceal wall. In some people it may appear red.
- They are often sudden onset and painless. There will usually be a history of liver disease, and there will be physical signs of portal hypertension.
- 8% of Upper GI bleeding is due to varices. Varices will develop in 50-60% of cirrhotic patients.
- Varices carry a mortality rate of 50%, and a re-bleeding rate of 60-70%.
- Erosive gastritis – small bleed of bright red blood – may often follow NSAID intake or a bout of stress. There will be a history of dyspepsia
- Gastric ulcer – larger bleed, often painless. The patient may have had previous smaller bleeds – history of PUD.
- Gastric cancer – usually a small bleed – anaemia is common. There will also be weight loss and dyspepsic symptoms.
- Dieulafoy’s disease – spontaneous large bleed – very rare; accounts for <5% of all gastric bleeds. Often occurs in young people. It is caused by little gastric ‘aneurysms’ that occur during development and then rupture.
- Gastric ulcers
- Duodenal ulcers – usually accompanied by a prominent melena.
- Artoduodenal fistula –Massive haematemesis and PR bleed - these are very rare, and are usually a result of a rupture abdominal aortic aneurysm repair. They are nearly always fatal.
- FBC: carcinomas, reflux oesophagitis.
- LFTs: liver disease (varices).
- Clotting: alcohol, bleeding diatheses.
- OGD: investigation of choice. High diagnostic accuracy, allows
- therapeutic manoeuvres also (varices: injection; ulcers:
- Angiography: rare duodenal causes, obscure recurrent bleeds.
- Barium meal and follow through: useful for patients who are unfit for
- OGD (respiratory disease) and ?proximal jejunal lesions.
- If the varices present before they have bled, then you can treat them with ‘banding’ whereby youjust stick a little band around the bulging varices and the weakest part of the vein will be cut off from the rest, and will eventually just drop off. This treatment can be done by endoscopy.
- In acute severe variceal bleeding, where the patient is in immediate danger, you may wish to use a Minnesota tube. This is a tube that is inserted down the oesophagus, into the stomach, and a small bag of air inflated at the bottom with about 300ml of air. This first bag prevents the tube being pulled out of place. There is a second bag that can also be filled with air that sits in the oesophagus. This bag is inflated to around 40mmHg pressure – just above normal venous pressure – and thus this keeps blood in the veins, rather than letting it spurt out into the oesophagus. You must be very careful when inflating the second bag as you can perforate the oesophagus!
- This is only a temporary solution. It is often very uncomfortable for the patient