Topic: Upper GI Bleeding (Gastric Ca)

Ddx
- PUD (DU/GU)
- Gastritis
- Oesophagitis
- Oesophageal varices (alcoholic liver ds)
- Mallory Weiss Tear
- Oesophageal tumours
- Gastric tumours
- Acute pancreatitis

History
1. When did it start?
2. Is this the first time?
3. Suddenly or gradually?
4. Constantly or comes and go?
5. How often?
6. How much blood?
7. Whats the colour? Bright-red/coffee-ground?
8. Is the bleeding effortless (varices) or started with retching(oesophagitis)?
9. Associated symptoms:
- Nausea?
- Loss of appetite?
- Weight loss?
- Dysphagia?
- Pain on swallowing?
- Heartburn? Bitter taste in mouth?
- Abdominal pain? Swelling?
- Yellow discolouration of eyes/skin?
- Itchiness?
- Change in bowel movement? Pale stool? Blood in back passage?
Colour? Mixed with stool/on the surface/on toilet paper? How
much blood? Any mucus? Pain on bowel movement?
- Confusion?
- Symptoms of anaemia SOB? Dizziness? Faint? Palpitation? Chest
pain? Fatigue/tiredness? Pale?
10. Precipitating factors
11. Relieving factors antacids?

RF
1. Smoking
2. NSAIDs/aspirin/steroids/recreational drugs
3. Alcohol
4. Stress work/study
5. RF of jaundice (travel/iv drug used/hep b or c etc)
6. Diet rich in nitrosamine (pickled, smoked/uncooked fish)
7. Hx of Chronic atrophic gastritis/ PUD
 8. Fhx of cancer
9. Blood group A

Investigations:
1. Hx, exam, FOB x3
2. Bloods FBC, u&e (raised urea), LFTs, serum amylase Coag, group and
Xmatch 2-4units
3. Imaging erect CXR, US abdomen (liver cirrhosis, portal HTN, AAA),
CT-TAP, endoluminal US (staging of carcinoma)
4. OGD + CLOtest + bx - within 24hr
- adrenaline injection/variceal banding/
thermoregulation/haemoclipping/ haemostatic
spray
5. CT angiography if severe bleeding

Management:
1. ABC
2. 2 large bore iv lines bloods
3. fluids resuscitation
4. blood transfusion, aim Hb>7g/dL, CAD Hb>9g/dL
5. NPO, NGT
6. Urinary catheter
7. PPI omeprazole 80mg bolus f/by infusion at rate 8mg/hr x72hr
8. Stop anticoagulations
9. +/- octreotide (effective in portal HTN)
10. +/- prokinetics prior to endoscopy
11. +/- tranexamic acid
12. OGD therapy
13. Angiography with embolization/vasopressin injection if persistent
bleeding
14. TIPS if failed endoscopy tx
15. Sugery if
- Haemodynamically unstable/severe bleeding
- Needs >6-8units of bloods in <24hr
- Laparotomy and control of bleeding

16. Mx of gastric Ca : most patient present w advance ds, nt suitable for surgery

- Total/partial gastrectomy w lymph node dissection

- Chemo for disseminated ds
- Palliative w limited radiation therapy or gastrojejunostomy
to sx relieve

**Gastric Ca marked in RED

**refer also PUD notes for Rockall and Blatcford score
1. Complications of partial/total gastrectomy?

Early (HADAR) Late

- Haemorrhage - Dumping syndrome
- Acute pancreatitis (weakness, faint, sweating)
- Duodenal stump eruption - Bile reflux, vomiting
- Anastomotic leak - Recurrent stomal ulcer
- Resp compromise - Diarrhea
- Fe/B12 def

2. Histology of gastric tumours?

- Mucosa - Adenocarcinoma
- Connective tissue of stomach wall - Gastrointestinal stromal
tumours, GIST
- Neuroendocrine tissue carcinoid tumours
- Lymphoid tissue lymphomas

3. Overall prognosis of gastric cancer?

- Poor wt 5-yr survival in stage 1 disease 66%, stage 3 10%