Upper GIT bleeding
Dr. Ali Khairalla 2015
FICMS-FACS
Hematemesis and malena
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It is defined as bleeding from gastrointestinal tract proximal to lig. of Trietz
It usually manifests as hematemesis or melena, and when sever, may even
lead to hematochezia
This affect –in recent years –the old people
Allot of them associated with NSAID
Despite different treatment modality the mortality is 5-10%
Causes of upper GI bleeding
Cause
Ulcer
erosion
Site %
Total %
esophageal
6
60%
gastric
21
duodenal
33
Esophageal
13
Gastric
9
duodenal
4
Mallory –Weiss tear
4
Esophageal varices
4
Tumor
0.5
Other
5
26%
Principle of management
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1-the patient should be resuscitated
2-the patient should be investigated
3-the treatment according to the cause
The resuscitation
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IV should be established ( cannula, or central venous line)
Catheterization of urinary bladder to monitor urine output
Blood should be cross-matched.
Diagnosis
History
Examination
EMERGENCY ENDOSCOPY
Bleeding peptic ulcer
medical and minimal interventional treatment
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All patient receive oral PPI
Therapeutic Endoscopic devices for hemostasis (adrenaline injection ,
heater probe ,and clips )
Surgical treatment
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Indications ;
1-patient who continues to bleed or re-bleed
2-visible vessel in the ulcer base , spurting , or clot in the base
3-elderly and unfit patient
4-patient required more than 6 units of blood
Stress ulceration
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Occurs in patient with major injury or illness or undergone major surgery
It is better to prevent this condition than treat it.
bleeding Peptic ulcer
Gastric erosions
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Most of these patient are on NSAIDs.
Mallory-Weis tear
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It is a longitudinal tear below the gastro-esophageal junction
It is induced by repeated , forceful vomiting.
Dieulafoy’s disease
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It is gastric A-V malformation
It present on of difficult bleeding to control
Tumors
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All gastric tu. Whether benign or malignant
Portal hypertension
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Most varices are amenable to sclerotherapy
Banding of varices
Balloon tamponed by Sengestaken tube to arrest haemorrhage
Octreotide and glypressin reduces portal pressure
Most surgeons prefer to avoid acute surgery
TIPSS (transjagular intrahepatic portosystemic shunt )procedure can be very
usefull
Esophageal varicis
Sengastaken tube
Aortic enteric fistula
Gastric Cancer
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It is one of the most common cause of cancer death in the world.
The etiology is multifactorial, but H pylori is an important factors for distal
gastric cancer.
Clinical features
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Early gastric cancer has no specific features to distinguish from
symptomatic dyspepsia.
Late gastric cancer present with ; bleeding , ulcer, mass and fullness,
anemia, distant metastasis .
Non-metastatic effects of malignancy are seen, particularly
thrombophlebitis (Trousseau’s sign) and deep venous thrombosis. These
features result from the effects of the tumor.
Pathology
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Intestinal gastric cancer
Diffuse gastric cancer
Spread of gastric tumor
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Direct spread; tumor penetrates the muscularis, serosa to the adjacent
organs such as the pancreas, colon and liver.
Lymphatic spread; is by both permeation and emboli to the affected lymph
nodes. This may be extensive, the tumor even appearing in the
supraclavicular nodes (Troisier’s sign).
Heamatogenous spread; first to the liver and subsequently to other organs,
including lung and bone
Transperitoneal spread; is once the tumor has reached the serosa of the
stomach and indicates incurability. The ovaries may be the site of spread
(Krukenberg’s tumors).
Lymphatic drainage
Lymphatic drainage
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The lymphatic of stomach start at submucosa and subserosal plexus
The upper half of stomach, from ant. And post. Surface drains on the Rt.
Side to left gastric LN.
And these drains to LN. around celiac axis.
Lymphatic from lower part
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On Rt. Side (antrum) drains to suprapyloric LN.
And the Lt. side will drain to subpyloric and Rt. Gastro epiploic LN .
Pyloric area: superiorly drains to suprapyloric LN. and inferiorly to subpyloric
LN.
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Lymphatic from subpyloric and Rt. Gastro epiploic LN. drians to superior
mesenteric LN.
Lymphatics around cardia communicate with that around esophagus.
Operability
evidence of incurability is
• Haematogenous metastases,
• Involvement of the distant peritoneum,
• distant nodal disease ,
• Fixation to structures that cannot be removed.
Surgical operations
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Radical surgery : a-total radical gastrectomy
b- partial radical gastrectomy
Palliative surgery : a- partial gastrectomy
b- by-pass procedures( gastrojejunostomy , partial
gastrectomy
Total gastrectomy with reau-in Y anastamoses
Partial gastrectomy
Gastrojejunostomy