Definition Etiology
Hemorrhages above the ligament of Treitz (esophagus, stomach and duodenum) are known as upper GI bleeding, while those below the ligament of Treitz (Uejenum, ileum and colon) are known as lower GI bleedings.
It is the most common peptic ulcer among the upper GI bleedings. However, the most severe and mortal cause of upper GI bleeding is esophageal and stomach varices.
Common Causes
peptic ulcer
Esophageal and gastric variceal bleeding
erosive hemorrhagic gastritis
Esophageal and stomach tumors
Mallory-Weis syndrome
Rare causes
Dieulafoy lesion (submucosal aberrant gastric artery)
Aorto-enteric fistula
Gastric-antral vascular ectasia
hemobilia
Clinic
• Upper GI bleeding depending on the localization of the lesion and the rate of bleeding; may present with hematemesis, melena, or hematochezia.
• Hematemesis
Describes bloody vomiting. It can be fresh red (indicating heavy bleeding) or coffee grounds (indicating slow/light bleeding and blood has been in contact with stomach acid for a period of time).
Its presence is almost always associated with upper GI bleeding. However, hematemesis may not develop in every upper GI bleeding.
In mild and short-term bleeding or in upper GI bleeding distal to the pylorus, only melena can be seen without hematemesis.
• Melena
It is black, slimy, sticky and foul-smelling stool in the form of stool.
It is seen in upper GI bleedings and lower GI bleedings up to the proximal parts of the colon. (not expected in transverse and distal colon bleeding) In order for the blood to become melena;
It must remain in the intestines for at least 6 hours and be metabolized by bacteria.
There should be at least 60-70 ml of bleeding.
Frequent melena and increased sluggishness can be considered as an indicator of ongoing active bleeding.
Melena can be seen up to 3-5 days after the bleeding has stopped.
• Hematochezia
It is the discharge of blood (fresh red) that has not lost its physical properties through the rectal route.
Mainly seen in lower GI bleeding, but massive upper GIS
bleeding (especially varicose veins) can sometimes be seen.
In the patient with upper GI bleeding accompanied by hematochezia, hemodynamic stability is usually deteriorated quickly and a rapid decrease in hemoglobin can be observed.
Diagnosis
• First of all, upper and lower GI bleeding should be differentiated in a patient presenting with GI bleeding.
• The presence of blood in the nasogastric (N/G) aspirate is definitely a sign of upper GI bleeding, but the absence of blood does not rule out upper GI bleeding.
• Active bowel sounds and high BUN are in favor of upper GI bleeding.
• The definitive diagnosis of all upper GI bleeding is made by endoscopic methods.
Treatment
• The first thing to do when approaching a patient with suspected GI bleeding is to determine the severity of the bleeding and then to take the necessary precautions accordingly.
Signs of severe GI bleeding
Active hematemesis or hematochezia
Fresh blood not opened with N/G irrigation
Hypotension (BP < 100 mmHg)
Tachycardia (Pulse > 100/min)
Postural hypotension and shock
Increased bowel sounds
frequent melena
High-risk groups in GI bleeding
Patients aged 60 and over
Coagulation disorder / anticoagulation
Concomitant systemic disease
Major ulcer bleeding (> 2cm), bulbus posterior wall ulcer bleeding
Varicose bleeding
Re-bleeding in hospital
Signs of severe bleeding
In patients whose symptoms and signs suggest severe bleeding or who are at high risk for mortality, emergency treatment steps should be started immediately without wasting time.
Emergency steps in GI bleeding
IV catheter, 0%. 9 NaCl or Ringer's lactate
Blood sample (blood bank, examinations)
nasal oxygen
N/G irrigation if needed
Acid suppression with parenteral PPI (for every patient with upper GI bleeding)
• Blood transfusion (if Hb is below 7g/dl or symptomatic)
• Every patient with suspected upper GI bleeding has an indication for endoscopy. Endoscopy can show the cause of bleeding as well as offer treatment.
• After the patient's vital signs are evaluated, emergency approach steps are applied and the patient is stabilized, endoscopy is performed. Endoscopy timing:
In general, it is done within the first 24 hours, but in cases with severe bleeding or high-risk cases, the patient is stabilized and within the first 12 hours.
• Ulcer bleeding in endoscopy is evaluated according to the Forrest classification:
F1: Active bleeding ulcer (la: gushing, Ib: oozing)
F2: Active non-bleeding ulcer (Ila: visible vessel, IIb: sticky fresh clot, ile: hematin at the base of the ulcer)
F3: Ulcer covered with fibrin
• File and FIII lesions are followed without treatment, and endoscopic treatment is performed in other lesions (F1a, F1b, F2a, F2b).
• Patients whose bleeding cannot be controlled with endoscopic treatment or who bleed again during follow-up are treated with surgery.