Management of upper gastrointestinal bleeding

Abstract

In lieu of an abstract, here is a brief excerpt of the content: •88• Chapter 9 Management of Upper Gastrointestinal Bleeding E. Q. Archampong. Introduction Upper gastrointestinal bleeding (UGIB) is usually an acute emergency which is defined as bleeding originating from the gastro-intestinal tract, proximal to the ligament of Treitz and made manifest by the symptoms of haematemesis and or melaena. Presentation is however not always clear cut and the bleeding may take unusual forms that may not be readily distinguishable from haemorrhage from lower reaches of the bowel. The approach to the control of the latter category of bleeding differs in several significant respects, and is therefore tackled in a subsequent paper; its consideration is nonetheless less essential in the initial assessment of all forms of gastrointestinal haemorrhage. This presentation focuses on the current management of the principal causes of upper gastrointestinal haemorrhage in our practice emphasizing the need for urgent accurate assessment, patient triage and resuscitation, diagnosis and concerted action to influence outcome. Epidemiology The relative frequency of causes of upper GI bleeding varies in different regions of the world. In most parts of Africa, chronic peptic ulceration1 (chronic duodenal and gastric ulcer (Du/Gv: 60/10) accounts for 50-90 per cent of cases. Notable exceptions to this are some East and Central African countries - Tanzania, Zimbabwe, Kenya - where oesophageal varices constitute a more common cause of bleeding than chronic peptic ulceration8 . In Accra over a period of two years, some 552 cases of haematemesis and melaena referred to the endoscopy centre showed the following aetiological spread and symptomatology (Tables 9.1 and 9.2). •89• Management of Upper Gastrointestinal Bleeding Clearly these are not population-based figures; the availability of the endoscopic expertise may have attracted to the centre a disproportionate number of bleeding cases. There is also a preponderance of bleeding from oesophageal and gastric varices, amounting to 30 percent, almost equal to the figures for combined gastric and duodenal ulcers, and almost approaching the pattern in East and Central Africa. Whether this is a reflection of latent high prevalence of subacute hepatic disease in the population or a selection phenomenon, occasioned by the location of the endoscopy centre, needs to be established by a purpose-designed and appropriately powered prospective study. Notwithstanding the geographical variation in the causes of UGIB, in terms of frequency, in West Africa, as elsewhere, three categories are discernable.1 The common or major causes: duodenal/gastric ulcers and stress ulcers (including gastritis mucosal erosions) and oesophageal varices. The less common: oesophagitis (GORD) Mallory-Weiss Syndrome, benign and malignant tumours of the oesophagus, stomach and duodenum, and the rare group: invading pancreatic tumours aortoenteric fistulae, blood dyscrasias hereditary telangiectasias angiodysplasias and anticoagulant therapy, and Dieulafoy’s lesion. The real incidence of these latter lesions is difficult to assess in the context of our practice, because even when endoscopic facilities are available at the appropriate point in time, these lesions are more often than not missed, even when they have been responsible for massive UGI bleeding. Table 9.I Causes of Upper GI Haemorrhage in Accra Causes Number Percentage (%) DU 88 15.9 Prepyloric GU Lesser Curve (Type 1) 36 28 64 6.5 5.1 11.6 Gastric Erosions 2 0.4 Duodenal Erosions 7 1.3 Oesophagitis 15 2.7 Gastritis 10 1.8 •90• Chapter 9 Gastric Polyps 4 0.7 Duodenal Polyps 2 0.4 Oesphageal Polyps 1 0.2 Oesophageal Varices 169 30.6 Gastric Varices 4 0.7 Negative Findings 78 14.1 Total 552 100 Clinical Presentation UGIB is announced by haematemesis (vomiting of bright red or dark blood – coffee grounds) and/or melaena (passage of black, tarry stools) or frankly bloody stools. Usually, haematemesis is generally indicative of oesophageal and gastric bleeding while melaena suggests duodenal haemorrhage; nonetheless duodenal episodes may manifest as haematemesis while gastric and oesophageal bleeding may manifest as melaena only. Since the bleeding is usually acute and the loss significant in many cases, even in the mild cases, the presentation rapidly builds up into a resuscitation and risk assessment, even before diagnosis of presumptive origin is made. Table 9.2 Symptoms on Presentation Symptoms Number Percent (%) Haematemesis 360 65.2 Melaena 96 17.4 Bleeding P.R. 22 4.0 Haematemesis and Melaena 31 5.6 Not indicated 43 7.8 Total 552 100.0 Initial Management Appropriate haemodynamic assessment involves careful measurements of pulse, blood pressure, estimates of intravascular volume status, to Contd. from pg. 89:Table 9.I Causes of Upper Gi Haemorrhage...