Upper GI haemorrhage

'
Upper Gl haemorrhage is haemorrhage above the ligament of Trietz .

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Types Non varied Bleed C. 701 .
-80%3

Uariceal Bleed Laois

Non variceal haemorrhage

- Causes ① Peptic Ulcers [ Duodenal > Gastric ] (most common cause]

② Gastritis ( and most common cause )

③ Mallory Weiss tear

⑨ GAVE (Gastric Antral Vascular Ectasia )

-
female > males
.
A1W autoimmune disorders / Collagen vascular disorders .

-
Presence of dilated venues in antrum .

. Endoscopy : Watermelon stomach i fundus is spared Strawberry stomach

Mx Argon Photo coagulation
'
:
snake skin
app .

>
If recurrent Iserere > Ahtrectomy

⑤ Mehetrier 's disease :

Hypertrophy Mucosal Folds

'
of Gastric
-
Mediated by TGF a
-
Earliest clinical feature -

protein losing entropathy

'
A risk of cancer

. DX Endoscopy
m Cetuximab Total
'
> fails >
Gastronomy

⑥ Dieulafoy lesions
. Dilated tortuous submueosal arterioles .

-
Males > Females [ seen in elderly]
'
similar to Angio dysplasia of colon .

normal Endoscopy [difficult to diagnose]

'
mucosa appears on

coagulation
'
Mx :
Endoscopic of vessel .

① Tumors

GAVE -

Portal Hypertensive Gastropathy

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Fundus Not involved '
Fundus Involved
.
Endoscopy : watermelon stomach .
Snakeskin 1 strawberry stomach
 Variceal haemorrhage
-
HVPG Hepatic Venous pressure Gradient :

-
HVP4= Wedge Hepatic Venous pressure -
free hepatic Venous pressure
[ inflated balloon) ( deflated balloon]

[ almost equal to sinusoidal pressure]

'
HVPG values I -5mm Hg Normal
-
-

710mm Hg -

clinically significant portal Hypertension

712mm Hg
-

A risk of varied bleeding

.
Portal HTN causes iprehepatic : .
portal vein thrombosis
splenic vein thrombosis
.

.
Massive spleen omegaly
.
Hepatic
Pre sinusoidal sinusoidal Post sinusoidal
'
schistosomiasis .
cirrhosis -
Hepatic sinusoidal obstructions
-
Congenital Hepatic fibrosis .
Hepatitis Alcoholic
'
sarcoidosis -

Infective
Autoimmune
Dost Hepatic : Budd Chiari syndrome
- . -

.
Inferior vena carat webs
.
Cardiac Restrictive cardiomyopathy
constrictive pericarditis
severe congestive heart failure

- DX . HVPG measurement
-
Endoscopy to visualise varices
•

Splenoportovenography

.
Primary prophylaxis → Reduce portal pressure and prevent bleeding .

> Non selective B blocker [ Dropanolol]

Baveno Classification small elevated

. :
minimally varices above esophageal mucosal surface

Medium Tortuous 5113 of

- :
varices occupying oesophageal surface

-
Large : Varices occupying 7113 of oesophageal surface -

.
Left sided portal HTN → splenic vein thrombosis

Causes Gastric varices

[Not oesophageal]
 '
MX .
Manage Airway ,
breathing ,
circulation

. Insert a large bore IV lines IV fluids

IVTerlipress.in/IVoctreotideCIVpropanoIol
not used]

Early endoscopy Band ligation Sderolherapy

'
→ 7

Band ligation rubber band base

placing of constricting at of varix
-

: .

Highly effective

Sderotherapy :
Agent used sodium tetradecyl sulphate ; Ethanol amine oleate
-

>
Disadvantages : Gastric varices can't be managed
- .

Chances of ulceration and perforation

-

can cause mediastinitis

High chances of Re bleed
-

- .

Outcomes of Endoscopic management

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Bleeding stops the bleeds

1 v

monitor for 24 hrs 2nd trial of Endoscopic Mx

V V

If No re bleed . Discharge fails

1
Oral Propanolol for prophylaxis Drip are for TIPSS I surgery
correct coagulation profile
Balloon Tamponade to temporarily
control bleeding

Balloon
Tamponade.sengstak@nBlakemoretubei.to
-

Eosophageal
channels -

Balloon channel
Gastric Balloon channel

Gastric aspiration channel

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Gastric balloon inflated 1st with 250 -300mi air

.
Oesophageal balloon inflated with 40 -60mL air
.
Oesophageal balloon is deflated every 12 hours to prevent necrosis

- Minnesota Tube :

Modification of above tube with 1 extra

channel for oesophageal aspiration .

 - TIPSS Transjugular Intra hepatic Portosystemic stent shunt :

stent placed between a hepatic vein branch and a

portal vein branch
✓

Decompression of Portal system

V

Reduced portal pressure and controlled bleeding -

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Uses not controlled
Varied Haemmorhage after 2 attempts of Endoscopic Mx
-

Intractable Ascites

. Contraindications :
portal vein thrombosis .

-
complications :
MK early :
Hepatic Encephalopathy (confusion
MIL long term : Blockade of stent → Rebleed .

-
Porto systemic shunts -
Indications : child 's Pugh A and B with recurrent bleed .

.
Selective shunt : Distal Spleno renal shunt -
Warren 's shunt

.
Non selective shunts :

Proximal stolen orenal shunt : Linton shunt

-
End to end Dortocaval shunt : ECK Fistula
-
Side to side spleno renal shunt : Mitra 's shunt
-

Left gastric venocaval shunt : Inokuchi shunt

-
Devascularisation Sx .
Oesophageal transaction -
Milnes Walker operation .

'
Gastric transaction of Tanner

Sugiura Futagawa operation

I splenectomy
-
and
Devasoularisation of greater ¢ lesser curvature

oesophageal transaction and end to end anastomosis

 Prognostic criteria for upper GI bleed

BLEED . B- Ongoing Bleeding

. L -

low systolic BP
' E- Elevated prothrombin time
-
E- Erratic Mental status
.
D comorbid disease ICU admission
requiring
-
.

Forrest classification tells

classification of upper 41 haemorrhage which about risk of re bleeding .

Grade class RiskofReb

I Acute Haemorrhage
-

IA Active ,
pulsatile bleed [ spurting Haemorrhage ] High
IB Active Non
,
]
pubatile bleed [Oozing Haemorrhage High

-
I Signs of Recent Haemorrhage
IA Non Bleeding visible vessel High
IB Adherent clot Intermediate
IIc Ulcer with Black spot Low

-
II No signs of recent Haemorrhage low

[ Clean Non
.
bleeding ulcer bed]

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Rockall score GI haemorrhage
Identify patients with poor prognosis following upper

-
GIasgowBIatchfordS Identifies patients with low risk who are candidates for outpatient management .

AIMS 65 score Determines risk hospital mortality

.
of in .