Upper GIT bleeding

 Upper GIT bleeding indicates bleding proximal to duodeno-jejunal  junction
    * AETIOLOGY
     1. Oesophageal causes
  - oesophageal variaes :-occur from lower 5cm of oesophagus
 - Oesophagitis
 - Oesophageal carcinoma
 - Mallory -Weiss syndrome :- results from linear tear in the distal oesophagus & proximal stomach. Episode of forceful retching precedes the bleeding.
      2. Gastro-duodenal causes   - Erosive gastritis :- occur after ingestion of NSAIDs & alcohol
 - Stress ulcers
 - Peptic ulcers
 - Gastric carcinoma
      3. Miscellaneous causes
 - Rupture of aortic aneurysm
 - Coagulation defects
       *C/f
 1. Haematemesis &/or melaena
 2. Colour of vomitus  depends on time for which blood was in stomach .
  Bright red - rapid & siseable haemorrhage
  Coffee ground - small bleed
 3. Melaena occurs when > 60ml blood is lost in upper GIT
 4. Haematochezia:- Frank blood per - rectum occurs in massive bleed
 5. Symptoms of blood loss :-         - dizziness ,pallor & shock
   - hypotension & tachycardia
 6. Features suggesting of severe bleeding
    - presence of clots in vomitus
    - fall in SBP > 10mm Hg & rise of pulse rate of > 20 beats /mins on change of posture from lying to sitting position
 
 *DIAGNOSIS
 1. H/o alcohol or drug (NSAIDs) ingestion , trauma , burns or sepsis  -  gastric erosion
 2. H/o peptic ulcer
 3. H /o jaundice ,pedal oedema, ascites , splenomegaly or other features of liver cell failure - variceal bleed
 4. Retching followed  by  Haematemesis  - Mallory - Weiss tear
  5. H/o dysphagia  & wt loss - malignancy
    *MANAGEMENT
  A) massive bleeding :- resuscitate & give IV fluids immediatety
  B) Monitor
    BP
    pulse
    urine output
  C) Blood for grouping cross matching
  D) Gastric Lavage
    Performed by instilling 500ml of ice cold water every 30-60min . Leads to temporary cessation of bleeding
   E) Gastric aspiration
  helps to  1) asses rate of bleeding.  2) Clear the stomach for endoscopy . 3)remove blood from stomach
   F) Endoscopy
  Helps in
1. Early diagnosis
2. Identify rebleed
3. Rx
    - by use lasers, electro-coagulation & heater probe
     -Endoscopic sclerotherapy       G) Balloon tamponade, vasopressin, octreotide
      H) Embolisation of bleeding artery
       I) H2 blocker & proton pump inhibitors
       J) Surgical
   Required when bleeding continues despite medical Rx
    - oesophageal varices.:- shunt surgery
     - gastric erosions :- total gastrectomy or vagotomy with drainage