In South and Central Africa, and in most of the developing world, a bleeding peptic ulcer is the commonest cause of bleeding from the upper intestinal tract, but there are parts of East Africa and India where bleeding varices as the result of portal hypertension are more common. They may be the result of cirrhosis of the liver, schistosomiasis causing noncirrhotic periportal fibrosis, or extrahepatic portal vein obstruction. Other causes of bleeding include stress ulcers, hiatus hernia, uraemia, gastric carcinoma, a tear in the lower oesophagus following a forceful vomit (the Mallory[nd]Weiss syndrome, 25.16), and multiple shallow erosions following aspirin or some other drugs. In all these conditions the patient vomits bright blood or ''coffee grounds', or he passes melaena stools, or occasionally bright blood, from his rectum.
Aim to: (1) Resuscitate him, (2) make the diagnosis, (3) assess his risk status, and (4) control bleeding.
Try to make the diagnosis epidemiologically and clinically, because you are unlikely to have a fibre-optic gastroscope, although you may be able to do barium studies (34.5). The important distinction is whether or not he has oesophageal varices, because you will not want to operate on these, whereas you may need to operate for most of the other causes. A large spleen is the most useful sign. Fortunately, in contrast to the situation in Western countries, if a patient in India has portal hypertension and oesophageal varices, he is unlikely to be bleeding from an ulcer. Even the best surgical centres cannot find a cause for the bleeding in about 10% of cases. You will need plenty of blood.
UPPER GASTROINTESTINAL BLEEDING HISTORY. A history of peptic ulceration is suggestive only. There is at least a 25% chance that the patient has a peptic ulcer and no symptoms. Has he been taking aspirin, phenylbutazone, indomethacin, or steroids? All these can cause ulcers.
EXAMINATION. Look for signs of anaemia. A pulse of 120 or more is a reliable sign of recent blood loss. Take his blood pressure. If you are not sure if he is hypovolaemic or not, do the ''pulse test' for orthostatic hypotension (66.1). Examine him for epigastric tenderness. Examine him rectally to make sure that a history of black tarry stools is correct. Look for malignant deposits. Measure his blood urea.
DIAGNOSIS. The following three conditions account for 90% of cases. Other causes, such as hiatus hernia, gastric carcinoma, or the Mallory[nd]Weiss syndrome are rare (25.16).
Suggesting bleeding oesophageal varices[md]a large spleen, a firm enlarged irregular liver, or a small hard one; anastomotic vessels on his abdomen, ankle oedema. Ascites is common in cirrhosis, less common and often not marked in periportal fibrosis, and very uncommon in extrahepatic obstruction. Spider naevi, and palmar erythema are uncommon in India and Africa. He may be drowsy or in coma from hepatic encephalopathy (made worse by the digestion of the blood in his gut). His liver function tests are abnormal in cirrhosis, but are often normal in the other causes of bleeding varices.
Suggesting a duodenal or gastric ulcer[md]a history of epigastric pain.
Suggesting gastric mucosal erosions[md]the recent ingestion of alcohol or analgesic tablets.
Suggesting Schistosomiasis mansoni causing periportal fibrosis[md]he is from an endemic area and has a large liver, and blood in his stools. There is little point in looking for ova in a rectal snip, because in an endemic area everyone has them.
Suggesting non-cirrhotic portal fibrosis or a thrombosed portal vein[md]his only abnormal sign is an enlarged spleen.
Use his history and physical signs to form some estimate of how much blood he has lost, and over how long. Decide if his blood loss has been mild, moderate, or severe.
RESUSCITATION. Group and cross-match blood for him. Sedate him heavily 4-hourly with diazepam 5 to 10 mg intravenously, or chlorpromazine 25 mg. Avoid morphine. Cimetidine is of no value, because it does not affect bleeding.
Depending on his condition, set up 1 or 2 intravenous drips of 0.9% saline or Ringer's lactate, with large-bore needles. If he has bled severely, give him 1 to 4 litres of fluid, or more, until his blood pressure returns to 100 mm Hg. He may need at least 3 units of blood and possibly many more. If you have a colloid plasma expander, give him a litre or two while you wait for blood, or even continue with it, if HIV is a high risk in your area.
If you don't have blood, or enough blood, don't hesitate to give him large quantities of saline or Ringer's lactate[md]his great need is for fluid to fill his vessels.
Pass a large nasogastric tube. This will tell you if he is continuing to bleed, and whether the blood is fresh or altered. If you aspirate clots, irrigate his stomach to wash them out. Then wash out his stomach with ice-cold saline containing noradrenalin every half hour until bleeding stops, as described below. Consider putting 500 mEq of sodium bicarbonate (A 15.1) down the tube 12-hourly. Or, give him magnesium trisilicate mixture 30 ml every 2 hours.
MONITORING. Measure and chart his pulse, his blood pressure, and his peripheral circulation half-hourly. A rising pulse or a sustained tachycardia are more important than isolated readings. Monitor his urine output, and, if possible, his central venous pressure if he is very ill (A 19.2). Early measurements of his haemoglobin and haematocrit will be of little value, except as a baseline with which to compare later ones, because his blood will not yet have had time to dilute. Continued bleeding is suggested by: persistent nausea, tachycardia, pallor, restlessness, very active bowel sounds, and the failure of his haemoglobin to rise in spite of transfusion (a useful sign).
THE OUTCOME. Several things can happen. A gastric ulcer or oesophageal varices are more likely to continue to bleed than a duodenal ulcer. Melaena alone is not as serious as haematemesis, but beware of continuing melaena and unaltered blood in the stools, which indicate continued bleeding.
(1) He may stop bleeding either before he is admitted, or with the above treatment, and not bleed again (75% chance).
(2) He may continue to bleed severely, and vomit up kidney-basin after kidney-basin of fresh or clotted blood, each bleed being accompanied by a wave of weakness and sweating. Or, he may continue to pass large tarry stools. He looks pale, his pulse is rapid ([mt]100), and his blood pressure low ([lt]90 mm), showing that you have been unable to make up for the blood that he has lost.
(3) He may continue to bleed moderately, and respond to the transfusion, but continue to pass small melaena stools, or have small haematemeses, so that his haematocrit drifts downwards. His resting pulse may only be 90, but the least exertion may send it up to 120 or more. Non-operative treatment is dangerous if he stays like this for more than 72 hours.
(4) Bleeding may stop completely and start again in a few hours, or a day or two later. This also is dangerous.
The indicators of low risk and a favourable outcome are: melaena alone, no loss of consciousness, aged [lt]45, BP [mt]100 mm Hg, pulse [lt]120/min.
The indicators of high risk and an unfavourable outcome are: haematemesis, loss of consciousness, aged [mt]45, BP [lt]100 mmHg, pulse [mt]120/min, bleeding varices.
MANAGEMENT depends on his risk status. The following regime comes from India.
If he is at low risk put him to bed for a week, give him 30 ml or more of antacids 2 hourly. He may need 500 mEq of sodium bicarbonate 12-hourly. Later, if possible, refer him for a barium meal and endoscopy.
If he is at high risk management depends on whether or not you suspect varices.
If you suspect varices, insert a Sengstaken tube for 48 hours, then deflate the balloon. If bleeding recurs, reinflate the balloon and refer him.
If you don't suspect varices, continue conservative treatment. If this fails, operate on the indications given below.
INDICATIONS FOR SURGERY. Situations (2), (3) and (4) above and blood shortage are the main indications for surgery. If you are going to operate do so immediately. If he is more than 45, he needs surgery all the more urgently, unless he has some other disease, such as cardiac failure.
If he is not suitable for surgery, or for some reason you decide not to operate, there are two things that may help[md]cold noradrenalin lavage and, if you suspect varices, vasopressin.
COLD NORADRENALIN LAVAGE. Over 10 min run 200 ml of ice- cold saline containing noradrenalin 8 mg into his stomach. Half an hour later, aspirate it and replace it. It will lower the temperature in his stomach, and may cause a bleeding vessel to constrict.
A gastric ulcer has stopped bleeding when the fluid that comes out is no longer bloody. If this has not happened after 4 hours, abandon this method. If he has a duodenal ulcer, blood may not be returned in the effluent, so you will have on rely on his pulse and blood pressure to know when he has stopped bleeding.
VASOPRESSIN. (''Pitressin') constricts the sphlanchnic blood vessels, and is more useful for varices than for an ulcer. Dilute 20 units in 500 ml and and give it over 2[nd]3 hours. Warn him about its side-effects[md]abdominal cramps, headache, and palpitations. It will also raise his blood pressure for a short time. Vasopressin loses its activity in the heat, so, if he does not get abdominal cramps, it is likely to be inactive.