Chapter 39 Upper GI Bleeding in a 58-Year-Old Male (Case 24)
Gastric ulcer/erosion | Duodenal ulcer | Gastritis |
Esophageal varices | Mallory-Weiss tear | Gastric neoplasm |
PATIENT CARE
History
• Explore the bleeding hx: Is there frank bloody emesis, coffee ground emesis, melanotic stool, or hx of chronic anemia?
• Explore the past medical hx with attention to the differential:
• Alcohol abuse or other conditions that cause cirrhosis (HepC/Hep B/genetic conditions) could result in varices.
PATIENT CARE
Tests for Consideration
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Clinical Entities | Medical Knowledge |
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Peptic Ulcer Disease | |
PΦ | Peptic ulcer disease is caused by a hyperacidic state or by weakened mucosal defenses; usually associated with the presence of helicobacter pylori bacteria. |
TP | Both gastric and duodenal ulcers are likely to present with melena, hematemesis, and/or epigastric pain. Duodenal ulcers are most common, but incidence of bleeding identical for either. Arterial erosion in ulcer base with vessel greater than 1.5 mm increases mortality. |
Dx | Endoscopy findings. Biopsies performed to rule out malignant potential. Obtain H. pylori titers/biopsy sample to initiate medication if so required. |
Tx | 80% of ulcer bleeds will stop spontaneously. Endoscopic therapy with injection, heater probe, bipolar cautery, or clip application may be effective. Proton pump inhibitors used as adjunct for active healing and prevention. Rebleeds can be treated with endoscopy, but failure of such demands surgical intervention. Choices would be selective vagotomy, vagotomy and pyloroplasty, or vagotomy and antrectomy. Choice depends on speed with which operation can be performed, stability of patient, rate of recurrence, and experience of the surgeon. See Sabiston 46, Becker 26. |
Variceal Bleeds | |
PΦ | Increased portal vein pressure greater than 10 mmHg defines portal hypertension. Varices arise from the diverted flow to portosystemic shunts. A shunt through the coronary vein/esophageal submucosal plexus off the portal vein results in esophageal varices. 50% bleed at some point in a patient’s lifetime, with a mortality rate of 30% to 50%. Patients with normal liver function have better survival rates. Four recognized collateral sites from the portal vein are (1) esophageal submucosal plexus, (2) coronary vein of stomach, (3) retroperitoneal-umbilical system, and (4) the hemorrhoidal system. |
TP | Typically painless hematemesis. May present as a massive hemorrhage with signs of shock, necessitating aggressive resuscitation. |
Dx | Dx is by endoscopy in a patient with a clinical suspicion of cirrhosis. |
Tx | Tx is broadly summarized as (a) pharmacologic therapy, (b) endoscopic therapy, (c) tamponade, (d) decompressive therapy (radiological, surgical), and (e) liver transplantation. The modalities include:![]() Stay updated, free articles. Join our Telegram channel![]() Full access? Get Clinical Tree![]() ![]() ![]() |