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Upper gastrointestinal bleeding

Upper gastrointestinal (GI) bleeding refers to hemorrhage in the upper gastrointestinal


tract. The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which
connects the fourth portion of the duodenum to the diaphragm near the splenic flexure of
the colon.

Symptoms and Signs

One of the symptoms of upper GI bleeding is vomiting of blood (hematemesis). If the


blood travels through the GI tract, the stool may appear tarry and black (melena) because
of digested blood, though the stool can still be stained with red blood (hematochezia).
Otherwise, bleeding over time results in anemia, characterized by lower than normal
blood hemoglobin and hematocrit with symptoms like weakness, fatigue, and fainting.
Causative agent
VAP is a difficult disease to characterize because of the wide spectrum of causative
agents. Mixed infections are more commonly reported in patients who have a diagnosis
made by analysis of routine endotracheal aspirates, because there is often leakage of
oropharyngeal secretions around the endotracheal tube that results in bacterial
colonization and tracheobronchitis. The causative agent may vary by time of onset,
patient risk factors, previous hospitalization, or recent exposure to antibiotics

ursing Care of Clients with Upper Gastrointestinal Disorders I. Care of Clients with
Disorder of the Mouth A. Disorder includesλ inflammation, infection, neoplastic lesions
B. Pathophysiology 1. Causes include mechanical trauma, irritants such as tobacco,
chemotherapeutic agents 2. Oral mucosa is relatively thin, has rich blood supply, exposed
to environment C. Manifestations 1. Visible lesions or erosions on lips or oral mucosa 2.
Pain Nursing Care of Clients with Upper Gastrointestinal Disorders D. Collaborative
Care 1.Direct observation to investigate anyλ problems; determine underlying cause and
any coexisting diseases 2.Any undiagnosed oral lesion present for > 1 week and not
responding to treatment should be evaluated for malignancy 3.General treatment includes
mouthwashes or treatments to cleanse and relieve irritation a.Alcohol bases mouthwashes
cause pain and burning b.Sodium bicarbonate mouthwashes are effective without pain 4.
Specific treatments according to type of infection a.Fungal (candidiasis): nystatin “swish
and b.Herpetic lesions: topical or oralλ swallow” or clotrimazole lozenges acyclovir

medical management
The diagnosis and therapy for nonvariceal upper gastrointestinal bleeding (UGIB) has
evolved over the past 3 decades from passive diagnostic esophagogastroduodenoscopy
with medical therapy until surgical intervention was needed to active intervention with
endoscopic techniques followed by angiographic and surgical approaches if endoscopic
therapy failed. Variceal hemorrhage is not discussed in this article because the underlying
mechanisms of bleeding are different and require different therapies.

Endoscopy2

• Ideally, endoscopy should be performed within 24 hours.


• Endoscopy can be used both in diagnosis and therapy.
• Therapy might involve injection of adrenaline or other sclerosants, thermal
coagulation or application of clips.
• Meta-analysis of trials has shown that endoscopic haemostatic techniques reduce
bleeding, reduce the need for surgery and reduce mortality.5
• Endoscopic therapy should be applied to the following:
o Actively bleeding lesion
o Non-bleeding visible vessels
o Ulcers with adherent clot
• The preference is for dual therapy, e.g. injection of adrenaline with thermal
coagulation.
• High dose PPI should be given to those with major peptic ulcer bleeding, i.e.
active bleeding or non-bleeding visible vessel.
• All other patients who do not receive endoscopic therapy should commence oral
PPI post-procedure.

Post-initial endoscopy2

Calculate the full (post-endoscopic) Rockall score:

• Score <3 is associated with low risk of re-bleeding or death and can be
considered for early discharge.
• Full Rockall score >3 indicates patients need further close observation as an
inpatient.
• Careful monitoring is needed after endoscopy for UGIB (pulse, blood pressure,
urine output). It is imperative to identify re-bleeding or continuing bleeding.
• Repeat endoscopy (within 24 hours) is needed if the initial endoscopy was sub-
optimal, e.g. poor visualisation or in patients in whom re-bleeding is likely to be
life-threatening.
• Occasionally major re-bleeding may be an indication for surgical intervention
without further endoscopy.
• If patients are stable 4-6 hours after endoscopy they should be put on a light diet,
as there is no benefit in continued fasting.