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UPPER GASTROINTESTINAL BLEEDING

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ORIGINAL

PROF-808

UPPER GASTROINTESTINAL BLEEDING;


ASSESSMENT OF CAUSES AND COMPARISON WITH OTHER RELEVANT STUDIES

MAJOR DR. JAVED IQBAL MBBS, FCPS (Medicine) Medical Specialist CMH Pano Aqil Cantt (Sindh)

ABSTRACT ... jdiqbal2000@yahoo.com Objective: To determine incidence of different causes of upper


Gastrointestinal (UGI) bleeding in reference to UGI endoscopy in one hundred patients and to compare the results with similar studies conducted globally. Design: Prospective, comparative study. Place and duration of Study: The department of medicine, Combined Military Hospital Peshawar during the period of one year from June 2002 to June 2003. Patients and Methods: First consecutive one hundred patients were selected with symptoms and signs of UGI bleeding and endoscopy was performed within 48 hours of start of symptoms. Results of the study were compared with similar studies conducted at other centers in Pakistan and abroad. Results: Major cause of UGI bleeding was found to be esophageal varices (39%) followed by duodenal ulcer (19%), gastric ulcer (9%), superficial mucosal lesion (20%), neoplasia (4%). In 9% patients no cause of UGI bleeding was found on endoscopy. Conclusion: Major cause of UGI bleeding in our set up is esophageal varices while peptic ulcer is less common compared with western world. This reflects high prevalence of chronic liver disease due to viral hepatitis. Key words: Upper Gastrointestinal bleeding, esophagogastroduodenoscopy, esophageal varices.

INTRODUCTION
Upper gastrointestinal (UGI) bleeding is a common medical condition that results in high morbidity, mortality and medical care cost. Acute UGI bleeding is a frequent cause of hospitalization1. In a study from a large maintenance organization, the annual incidence of hospitalization for acute UGI bleeding was 102 per 100,000 population; the incidence was twice as common in males as in females, and it increased
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with age2. UGI endoscopy is the diagnostic modality of choice for acute UGI bleeding3. It is highly sensitive and specific for locating and identifying bleeding lesions in UGI tract. This study was planned to find out the etiology of UGI bleeding in 100 patients who were admitted in medical unit 1 Combined military hospital (CMH) Peshawar during the period from June 2002 to June 2003.

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PATIENTS & METHODS


Endoscopy was performed with Olympus GIF Type E, on patients who were admitted with UGI bleeding or were referred from other units of CMH or CMHs of NWFP fulfilling the following criteria.

sweating, anemia, signs of chronic liver disease like spider naevi, gynaecomastia, testicular atrophy, ascities, prominent abdominal veins, loss of body hair, splenomegaly and shrunken liver. Protocols for endoscopic examination were established. Before doing endoscopy informed consent was obtained and all the patients were subjected to laboratory investigations like blood Complete Picture, Urinalysis, Stool for occult blood, ova, cyst, Serum LFTs, HBsAg, HCV Antibody, bleeding profile including BT, CT, PT/INR, blood Urea Creatinine, Electrolytes. Abdominal Ultrasound, ECG and chest X-ray were performed. UGI endoscopy was performed within 48 hours of onset of bleeding symptoms. Local throat anaesthesia with 4% xylocain spray followed by injection atropine and injection valium 10 mg IV were given. The site of lesion was documented by visualizing active bleeding lesion. Blood clot or a brown or black slough adherent to the base or part of the base or a margin of an ulcer was taken into account where no active UGI bleeding was visualized. Cases where endoscopy did not reveal any abnormality were classified as due to undetermined cause.

The inclusion Criteria as under: < < <


Patients of either sex, 15 years of age and above. History of hematemesis on presentation. Hematemesis witnessed by medical personnel. Patients with malenic tarry stools witnessed by naked eye examination consecutively for 2 days

The exclusion Criteria as followed. < <


History of sore throat, cough, and on examination pharyngitis tonsillitis and epistaxis History of chest pain, congestive cardiac failure, bleeding diathesis, corrosive ingestion, chronic renal failure and terminally ill patients. Patients with history of accident or trauma, post operative with stress ulcers.

<

A detailed history was obtained about hematemesis and melena with particular emphasis on onset, duration and progression of symptoms, recurrent episodic epigastric pain, nocturnal wakening with pain, pain relief with food and antacids, use of NSAIDS or corrosive ingestion. History about abdominal distension, anorexia, weight loss or recurrent jaundice was also enquired. A complete and thorough physical examination was conducted including common signs of blood loss like low blood pressure, tachycardia,
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RESULTS
Among the total of 100 patients the youngest was 15 year old and eldest was 80 years with average age of 40 years. Male to Female ratio was 3:2 (Table I). UGI endoscopy was helpful in identifying site of bleeding in 91% of patients. No mortality or morbidity was reported in relation to endoscopic examination. In descending order of frequency, the study revealed esophageal varices as the cause in 39 cases (39%), duodenal
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ulcer in 19 cases (19%), gastric ulcer in 9 cases (9%), superficial mucosal lesion (SML) in 20 cases (20%) (SML includes esophagitis, gastritis, duodenitis, Mallory Weis syndrome) and neoplasm in 4 cases (4%).
Table-I. Age & sex distribution (n= 100) Age in years 15-30 Male 22 Female 12 Total 34

30-80 Total

38 60

28 40

66 100

Table-II summarizes the frequency of lesions detected. Table III shows comparison of percentage of accuracy of clinical diagnosis with lesions identified by endoscopy.

Table-II. Age distribution and frequency of lesions Age in years Esophageal Varices Duodenal Ulcer 1 11 5 2 19% Gastric Ulcer SML Growth Undetermined

15-20 21-40 41-60 61-80 Total

6 18 13 2 39%

1 2 5 1 9%

4 11 4 2 21%

1 1 2 4%

6 3 9%

Table-III. Comparison between clinical and endoscopic diagnosis Lesion Esophageal Varices Duodenal Ulcer Gastric Ulcer SML Growth Undetermined Total No. 39 19 9 20 4 9 % age 39% 19% 9% 20% 4% 9% Clinical Diagnosis 33 8 2 6 1 0 Endoscopic Diagnosis 39% 19% 9% 20% 4% 9%

Table-IV. Comparison of results with other studies Lesions Kartz 1976 % 15 Silver Stein et al 1981 % 22.8 Person 1981 % 22 Qureshi 1987 % 29.37 Harries 1989 % 16 Lule GN Keneyate NH 1991 % 17 Irshad UH 1993 % 14 Wascuki -A 1997 % 30 Present Study 2003 % 19

Duodenal ulcer

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Gastric Ulcer SML Growth Undeterm

5 37 12

21.9 29.6 8 -

18 6 2 12

10.45 14.05 7.18

7 9 -

17 -

6 30 1 10

20 18 2 6

9 20 4 9

DISCUSSION
This study revealed that our results were somewhat different from various studies conducted in western countries but comparable with studies conducted in Pakistan. Most of endoscopic examinations were well tolerated and were performed with only slight sedation. Sedation and information should be offered to all patients undergoing endoscopy4. At present days endoscopy offer a direct picture of the whole stomach and enable close observation of details. Any change found can be photographed in naturals colors. A early endoscopy in cases of UGI bleeding has considerably altered the older concept of the causes of bleeding but the consequences of the event have remained the same. In this study, in 91% of cases cause of bleeding was correctly determined. Age and sex ratio in the study under discussion was similar to those of other reported studies5. In the National American Society for Gastrointestinal Endoscopic Bleeding Survey (ASGE) on UGI tract involving 2,225 patients, 6 pathological entities were responsible for most bleeding episodes6,7 . These include duodenal and gastric ulcer, acute gastritis, esophageal varices, esophagitis and Mallory Weis syndrome. On comparison with ASGE bleeding survey esophageal varices were present in much higher proportion among our patients i.e. 39% versus 15.4%. In this study esophageal varices were the most
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common cause followed by superficial mucosal lesion and then peptic ulcer. These results were different from studies conducted in Western countries. In the National American Society for Gastrointestinal Endoscopic Bleeding Survey (ASGE) on UGI tract involving 2,225 patients, peptic ulcer was the most common cause, varices were present in 15.4% case compared with 39% in our study 6,7. But our results are comparable with the results of studies from other developing countries e.g., in a study conducted in Kenya at National Hospital esophageal varices was major cause of UGI bleeding. These results are also comparable with studies conducted in Pakistan. The higher incidence of oesophageal varices was due to the high rate of chronic infection with Hepatitis B virus (HBV)and Hepatits C virus (HCV) leading to end stage liver disease (cirrhosis). Lower incidence of peptic ulcer as a cause of bleeding could be due to frequent use of acid suppressing drugs by medical practitioners in patients with symptoms of dyspepsia. Mortality from UGI bleeding was 10-12% in a study conducted at Royal hospital London9 esophageal varices accounted for 62% of cases of upper gastro intestinal bleeding10. Mortality remains high with esophageal variceal bleeding at 40%11,12,13. In most of patients the cause of esophageal varices was portal hypertension due to cirrhosis of liver.
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Only in 2 patients, the cause of portal hypertension was portal vein thrombosis. Alcohol consumption appeared to play little role as a cause of UGI bleeding in this population, most likely due to religious prohibition of alcohol use in the country14. Superficial mucosal lesion was recognized as the second commonest cause of UGI bleeding in this study where the incidence was 20%. Lower incidence of mortality found in patients with duodenal ulcer confirms previously observed trends15.

the UGI tract. Endoscopy. 1991 Jul; 23 (4): 218-9. 5. Qureshi H, Banatwala NN, Sarwar J, Zuberi SJ, Alam. Em ergency endoscopy in UGI bleeding. JPMA. Feb 1988; 30-38. Silverstein-FE, Gilbert-DA, Ftedesco-FJ et al. The national ASGE survey of UGI bleeding. Part II, clinical prognostic factors. Gastrointestinal endoscopy 1981. 27: 94-102. Kohlar B, Rieman JF. UGI bleeding values and consequences of emergency endoscopy and endoscopic treatment. Hepatogastroenterol 1991; 38: 198-200. Faiza A Qari. Kuwait M edical Journal 2001, 33 (2): 127-130. Holman RAE, Davis M, Gouch KR, Gartel LP, Britton DC, Smith RB. Value of centralized approach in the management of haematemesis and malena. Experience in Dis. General Hospital. Gut 1990; (31): 504-508. G off-JS. Gastroesophageal varices. Pathogenesis and therapy of acute bleeding. Gastroenterol-clinNorth-Am. 1993; 22 (4): 779-800. Stanley AJ, Bouchier-A , H ayes-P C . Pathophysiology and managem ent of portal hypertension. Br. J- Hosp-Med. 1997; 58 (1): 39-43. Jenkin-SA, Baxter-JN, Critchley-M et al. Randomised trial of octreotide for long term m anagem ent of cirrhosis after variceal hem orrhage. BMJ 1997, 315 (72119): 1338-41. Evan TR, Mansi JL. Esophageal varices; A potentially fatal complication of liver metastasis. Eur-J-Surg-Oncol-1995 Apr; 21: 204-5. Saeed ZA. Endoscopic therapy of bleeding esophageal varices. Ligation is still best. Gastroenterology. 110: 635-640. Cook DJ, Fuller HD, Guyatt GH. Risk factors for gastrointestinal bleeding in critically ill patients. Critical care Trials Group. N Eng J Med. 1994; 330.

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CONCLUSION
Esophagogastroduodenoscopy is the only reliable tool for correctly determining the etiology of UGI bleeding. Major cause of UGI bleeding in our set up is esophageal varices while peptic ulcer is less common compared with Western World. This reflects high prevalence of chronic liver disease due to viral hepatitis. Prevention of transmission of hepatitis B and C and vaccination against hepatitis B can significantly reduce burden of chronic liver disease as well as upper GI bleeding.
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REFERENCES
1. Rossi-R, Morelli-M, Rscalla-L, Clemente-A. Gastrointestinal hemorrhage. M inerva chir 1998, 53 (3); 141-5. Jutabha R, Jensen DM. Managem ent of severe upper gastrointestinal bleeding. M ed clin North Am 1996, 80; 1035-40. A dang RP, V ism an JF , T alm on JL . Appropriateness and indications for diagnostic upper gastrointestinal endoscopy: association with relevant endoscopies. Gastro Intest Endosc 1995; 42: 39-395. Probert CS, Jayanthi V, Quinn J, M arberry JF. Inform ation requirem ents and sedation preferences of patients undergoing endoscopy of 12.

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COMPETITION IS KEY TO PROGRESS


Shuja Tahir

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