Upper Gastrointestinal System (GIS) bleeding is bleeding caused by localizations between the upper part of the esophagus and the level of the Treizt ligament in the duodenum. GIT bleeding is a common reason for admission to hospital emergency departments. Gastrointestinal system bleeding; It is a clinical problem that has high mortality, high diagnosis and treatment costs, frequently requires hospitalization and intensive care follow-up, and not rarely has difficulties in diagnosis and differential diagnosis, and may require multidisciplinary work.
Upper GIS The incidence of bleeding is 40-150/100,000. Mortality rates vary between 6-10%. This rate is 30% in varicose bleeding and 2.8% in non-varicose bleeding. In 80% of cases, bleeding stops spontaneously, and in 20% it continues or recurs. In cases with ongoing or recurrent bleeding, the need for surgical intervention can reach 15-30% and mortality rates can rise to 30-40%. This high mortality rate is due to delay in emergency approach to the patient and incorrect assessment of the amount and rate of bleeding.
Upper GIT bleeding; It may be in the form of occult or overt bleeding. It presents with findings such as occult bleeding, occult blood positivity in the stool, and iron deficiency anemia. Obvious bleeding manifests itself with hematemesis, melena and/or hematochezia findings. Upper GIbleeding may present with hypovolemic shock due to severe blood loss. 40-50% of patients have hematemesis, 75-80% have melena, and 15-20% have hematochezia.
Hematemesis;
The complaint of bloody vomiting is called hematemesis. Hematemesis appears as bright red, fresh blood or brown like coffee grounds due to digestion. When blood stays in the stomach for a while; Hemoglobin is converted to hematin by the effect of hydrochloric acid and the color darkens to coffee grounds or even blackish. Hematemesis is seen in bleeding above the level of the Treitz ligament.
Hematemesis form is caused by vomiting after reaching the stomach, whether the bleeding is from the gastrointestinal tract, nasopharyngeal or pulmonary area. It is seen in Rarely, blood from the pancreatico-biliary duct may reflux into the stomach and present as hematemesis. The presence of hematemesis always indicates upper GI bleeding. The absence of hematemesis does not exclude upper gastrointestinal bleeding.
Melena;
A black, slimy, tar-like substance containing blood digested by the effect of hydrochloric acid, intestinal bacteria and enzymes. It is a smelly stool. Melena-shaped defecation is usually seen in upper GIT bleeding. However; Melena can also be seen in bleeding from the proximal levels of the small intestines and even the colon. 50-100 ml. can cause blood melena. In cases of duodenal ulcer bleeding, the blood turns completely black within 8 hours and the stool turns into melena. After the bleeding stops, defecation in the form of melena continues for 1-3 days and then the color of the stool improves. Occult blood positivity is seen in the stool for 7-10 days after bleeding. Occult blood in the stool rarely occurs after 4-5 days. While it becomes negative in days, it can sometimes continue positive for up to 3 weeks. It should not be forgotten that stool color may turn black with medications containing iron and bismuth.
Hematokezia
It is fresh, bright red bloody stool from the rectum. It is usually seen in bleeding at levels lower than the ileo-cecal valve. In cases of intense upper gastrointestinal bleeding, since bowel movements will accelerate, the blood reaches the rectum without being digested and can be seen as hematochezia (10%). It is also seen in upper GIT bleeding of more than 1000 ml.
Occult bleeding;
The symptom is positive occult blood in the stool. These are mild and insidious bleedings. In patients; Complaints related to iron deficiency anemia are prominent. These complaints are pallor, dyspnea, decreased exercise capacity, and anginal pain.
The Body's Response to Bleeding
The body's response to blood loss depends primarily on the speed and amount of bleeding. In the acute loss of 15% of the blood volume in a healthy person, interstitial fluid moves into the capillaries from the first hour and this fluid transition may take 36-40 hours. While the intravascular volume deficit is repaired with this "transcapillary transition", the interstitial fluid deficit develops. In the second stage after bleeding, renin-angiotensin formation occurs due to blood volume deficit. The enzyme system is activated and renal sodium retention begins. Since more than 80% of sodium is in the interstitial space, the interstitial fluid deficit is tried to be closed by Na+ retention. In the last stage, the response of the bone marrow is seen. Initially, leukocytosis and thrombocytosis develop against the stress of bleeding. A few hours after bleeding begins, erythrocyte production begins. However, only 15-50 ml per day. Since cell volume can be increased, blood replacement may take 2 months. If the volume loss is less than20%; It is clinically silent or orthostatic tachycardia and/or tachycardia at rest may occur. If the heart rate increases more than 20 beats per minute when the lying patient stands up, this is called "orthostatic tachycardia". Patients have orthostatic hypotension with 20-25%volume loss. Blood pressure is normal or slightly low when the patient is lying down. It is observed that systolic blood pressure decreases by at least 15 mmHg by standing up. When the volume loss is between 25-35%, there is hypotension in the supine position and oliguria is present. When volume loss is greater than 35%, there is profound hypotension and cardiovascular collapse. It is a life-threatening condition. The severity of blood pressure changes in a person with bleeding varies depending on the degree of volume loss and compensatory response. It is necessary to be careful as the early compensatory response may be delayed in cases of advanced age, diabetes mellitus, renal failure, beta blocker and vasodilator treatment.
Basic Rules in the Treatment of Severe Upper GIS Bleeding
1. Appropriate resuscitation and stabilization of the patient
2. Evaluation of the onset and severity of bleeding
3. Localization of the bleeding area
4. Determining the most likely cause of upper gastrointestinal bleeding
5. Preparation for emergency upper GI endoscopy
Diagnostic Endoscopy;
1.Localization and determination of the bleeding site
2. Determining the risk of rebleeding
Therapeutic Endoscopy;
1. Control of high-risk lesions or active bleeding
2. Minimizing treatment-related complications
3. Treatment of persistent or recurrent bleeding
Emergency Resuscitation and Stabilization yon;
After determining the severity of bleeding and the time of onset, the first thing to do is emergency resuscitation and stabilization of the patient in terms of ABC (airway, breathing, circulation)
Haemodynamically impaired (shock, orthostatic hypotension, at least 6% decrease in hematocrit, need to give more than 2 units of erythrocyte suspension), active bleeding (such as hematemesis, hematochezia, fresh blood coming from the nasogastric tube). )patients; He/she must be admitted to intensive care units where arterial blood pressure, ECGmonitoring, close follow-up with pulse oximetry and resuscitation can be performed.
Determination of Bleeding Severity;
Determining the amount of blood loss in a patient with active GIbleeding is the most important parameter. In all patients with volume loss greater than 20%, the patient should be evaluated quickly, regardless of the location and cause of bleeding.
Findings suggesting volume loss greater than 20% ;
1. If the systolic blood pressure is less than 100 mmHg and the pulse rate is more than 100 beats per minute.
The pallor of the skin and the disappearance of the pinkness of the lines on the stretched palm support this idea.
Positive tilt test. (systolic blood pressure drops more than 15 mmHg or pulse rate increases more than 20 beats per minute when a lying patient stands up)
- Orthostatic tachycardia = 20% loss
- Ostostatic hypotension = 20-25% loss
- Supine hypotension = 25-35% loss
- Cardiovascular collapse = more than 35% loss
Volume Replacement;
In acute bleeding, mortality is highest in the first few hours. Therefore, volume replacement should be as early as possible and in sufficient amounts. According to the findings mentioned above, the percentage of estimated volume loss is given and the volume deficit is calculated according to the formula below.
Volume deficit calculation
Normal blood volume estimation
strong>* For men = 70 ml/kg or 3.2 lt/m2
* For women = 60 ml/kg or 2.9 lt/m2
Percentage of volume loss: (estimated based on the above findings)
- Replacement need = Normal volume x % loss
- Whole blood = 1.0 x Volume deficit
- Colloid = 1.0 x Volume deficit
- Crystalloid = 3.0 x Volume deficit
Infusion rate of liquids; It is related to the diameter of the catheter rather than the diameter of the cannulated vein, and the flow rate is higher in short peripheral catheters. For this reason, it should preferably be entered with a needle number 18 and more than one vascular access should be opened. In acute bleeding, correction of hypovolemia and low cardiac output is the first goal, and correction of anemia is the second goal. Crystalloid liquids have a faster infusion rate than colloid liquids. Therefore, crystalloid fluids are more effective than whole blood when rapid volume repair is needed. The main purpose of fluid therapy in mild or subacute bleeding (less than 20%) is; It is to close the fluid deficit in the interstitial area rather than the intravascular area. Saline fluids such as physiological serum (SF) and Ringer's lactate (RL) ensure rapid filling of the interstitial space. If the bleeding is light, these fluids containing electrolytes are preferred and sufficient. In severe bleeding where volume loss is more than 20%, faster expansion of the intravascular area is desired. The first fluid to be selected should be the fluid that will increase cardiac output. Colloid fluids(dextran-40, rheomacrodex)are the fluids that best increase cardiac output. Since 20-30% of crystalloid fluids (SF,RL) will remain in the intravascular bed, crystalloid fluid should be infused 3 times the volume deficit. After cardiac output is corrected, anemia should be corrected and for this purpose, 4-6 units of fresh blood should be prepared immediately in the bag. Since the initial hematocrit value may not accurately reflect the amount of blood loss, it is possible to interpret Hb and Htc values accurately at the end of the 12-24 hour compensatory period. The total amount of blood to be given is determined by the patient, depending on the course of the disease. The amount of blood needed; vital signs, measurable loss, CVP and PKWB measurement are determined based on renal perfusion findings. While trying to keep the hematocrit above 30% in high-risk patients (the elderly, those with other serious diseases, such as coronary disease or cirrhosis), young and otherwise healthy patients are trying to keep their hematocrit above 30%. >25%over t
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