CLINICAL APPROACH TO PATIENT WITH UPPER GASTROINTESTINAL

BLEEDING

Features Upper GI bleed

Lower GI bleed

Site Above Ligament of Treitz

Below Ligament of Treitz

Presentation Hemetemesis or Malena

Hematochezia

Nasogastric aspiration

Blood Clear fluid

Bowel sounds

Hyperactive Normal

BUN/ Creatinine ratio

Increased Normal

HISTORY

Presenting Complaints

HematemesisMalenaHematocheziaSymptoms of blood loss-

lightheadedness, syncope, dysnea (Occult blood in stools)

MODE OF ENQUIRY

Onset ,episodesTrue or spuriousBleeding from oral

cavity/nasopharynxH/O retching with non bloody

vomitus followed by hemetemesisH/O anorexia,dysphagia, rapid

weight loss

H/O malenaH/O drug intake NSAIDs, aspirin or

anti coagulantsH/O alcohol intakeAny skin telangiectasias? Any pigmentation? Perioral Diffuse

PAST HISTORY

H/O Chronic Liver DiseaseH/O Peptic ulcer H/O Bleeding disordersComorbidities -Pre existing

CVS/Renal/CNS d/s may be worsened by a/c bleeding

H/O medical illness/surgical intervention

FAMILY HISTORY -hemetemesis

CLINICAL EXAMINATION

General Examination

Built and NourishmentPallor(chronic bleeding)Icterus(CLD)CyanosisClubbingLymphadenopathy(CA stomach)Edema

Vitals

PulseBPHEMODYNAMIC INSTABILITY-

Hypotension, Tachycardia, Postural changes in BP and heart rate

Respiratory RateTemperature

Assessment of Blood Loss

BLOOD LOSS CLINICAL FEATURES

500ml No systemic signs except in elderly and anaemic patients

1000ml(20% reduction in blood volume)

Tachycardia, Orthostatic hypotension, syncope, light headedness, nausea, sweating, thirst

2000ml(40% reduction in blood volume)

Profound shock and possibly death

Also Look For

Any source of bleeding from oral cavity

Telengiectasias in skin, conjunctiva,oral cavity

Perioral/diffuse pigmentationParaneoplastic syndromes

STIGMATA OF CLD

Perioral pigmentation

Skin telengiectasias

Telengiectasia in Eye

STIGMATA OF CLD

Skin, nails and Hands

Spider naevi - small telangiectatic superficial blood vessels with a central feeding vessel

ClubbingLeukonychia - expansion of the paler half-moon at

the base of the nailPalmar erythema - seen on the thenar and

hypothenar eminences, often with a blotchy appearance

BruisingDupuytren's contracture - can occur in the absence

of liver diseaseScratch marks - particularly in cholestatic liver

diseaseFlapping Tremor

Endocrine - due to excess oestrogens

GynaecomastiaTesticular atrophyLoss of axillary and pubic hairTelengiectasias

Others

Hepatic fetor - characteristic sweet-smelling breath

Parotid swelling - particularly in alcohol-related liver disease

Dupuytren’s contracture

Spider naevi

Examination of Abdomen

Any mass lesionHepatosplenomegalyHyperactive bowel sounds

Examination of Lymph nodes

Rockall Score for Risk Stratification in A/C Upper GI Bleeds

Predicts SeverityFinal score 0-11Score<3 good prognosis

Score>6 indication for Surgery

Score>8 high risk of mortality

SCORE 0 1 2 31.Age <60 60-79 >80

2.Shock No shock Pulse>100

SBP<100

3.Comorbidity

No Major CCF, IHD, Major

Renal/Liver Failure

Metastatic cancer

4.Diagnosis after Endoscopy

Mallory Weiss tear or normal

All other diagnosis

GI malignancy

5.Endoscopic Evidence of Bleeding

None Blood in Stomach

Adherent clot, Visible or spurting vessel

THANK YOU

THANK YOU