at emergency department

1. UPPER GIT BLEEDING
Hamad Emad H. Dhuhayr
10110067

2. Contents
 SOEPEL
 ED

3. SOEPEL
 S A 53 year old woman became confuses 3 days after emergency repair of femoral
hernia. She has one day history of abdominal pain, sudden onset and progressive
course. The vomitus was mixed with blood in most of attacks. on examination: she is
pale, blood pressure 9060, pulse 115 pbm. Abdominal examination: showed tender
epigastrium.
 O taking history and physical examination.
 E Bleeding/perforated peptic ulcer, Mallory–Weiss syndrome and Gastric varices.
 P USG and ECG
 E ----
 L Resuscitation Of The Patient With Massive Upper Gastrointestinal
Bleeding

4. UPPER GIT BLEEDING

5. General causes
 Bleeding disorders. e.q. hemophilia, thrombocytopenia.
 Drugs : anticoagulant therapy.
. The commonest causes of upper Gl hemorrhage are in the following order:
1. Esophageal varices.
2. Acute gastric erosions usually caused by ingestion of NSAlDs.
3. Acute hemorrhagic gastritis.
4. Chronic duodenal ulcer.

6. Management
 ln this emergency situation you should not wait for a diagnosis. Life saving
resuscitative measures should be initiated immediately and are then followed by
diagnosis and definitive treatment.
1. Estimation of severity of bleeding and resuscitation.
2. Localization of the site and cause of bleeding.
3. Treatment of specific lesions.

7. Estimation of severity of bleeding and resuscitation:
 Admit to hospital. severe bleeding cases require ICU admission.
 Repeated clinical and hematocrit assessment.
 ' insert two peripheral venous lines and withdraw blood for cross-matching and blood tests.
 insert a Foley catheter. Urine output is the best monitor of tissue perfusion.
 A central venous line is needed for monitoring in severe cases.
 lV sodium containing fluids is started until blood is available e.9., Ringer's lactate.
 A nasogastric tube is inserted for all cases.
 Correct coagulopathy by FFP and by giving missing factors.
 major cause of morbidity and mortality is aspiration of blood. To prevent this complication
in patients with altered mental status, endotracheal tube intubation should be considered.

8. Localization of the site and causes of bleeding
 History
Previous attacks and their management.
Hepatitis and bilhaziasis.
Medications, particularly NSAIDs.
Peptic ulcer symptoms.
Bleeding tendency
 Examination
Stigmata of cirrhosis; spidre naevi, jaundice, gynecomastia, palmar erythema......
Surgical scars.
Tenderness.

9. Cont…
 Lab test
Hemoglobin percent and hematocrite value will show evidence of hemodilution after
three hours.
Liver functions tests will be disturbed in patients with cirrhosis and esophageal
varices.
Blood urea and creatinine.
Exclude causes of generalize bleeding tendency by the coagulation tests.

10. Cont…
 Fiberoptic endoscopy
Endoscopy is the most important test. lt should be performed as early as possible
once the patient has been resuscitated. The procedure is done under mild sedative
as diazepam.
ln the majority of cases (90-95%) endoscopy will establish the cause of bleeding
and it may reveal the actual bleeding spot. Moreover, in cases of double lesions,
endoscopy will tell which one is bleeding.
o Endoscopy can also be used therapeutically to stop bleeding.
o Barium radiography is loosing favors because it is less accurate than endoscopy.

11. Cont…
 Angiography
in difficult cases where radiography or endoscopy fails to diagnose the lesion that causes
the bleeding, it may be necessary to resort to celiac angiography to reveal the source of
bleeding, e .g., angiomatous malformation of the stomach.
Angiography needs to be performed during active bleeding.

13. References
Baily and love’s—1074
Mattary
Rosen