The incidence of upper gastrointestinal bleeding is about 100 to 200 per 100 000 inhabitants, that is to say about 65 000 cases in France each year.
These hemorrhages increase in frequency with age and overall mortality remains high in the order of 14%, slightly modified mortality despite advances in endoscopic techniques, 8 000 deaths in France.
About 80% of gastrointestinal bleeding are followed by hospitalization.
DIAGNOSIS:
Interview and clinical examination:
The upper gastrointestinal bleeding have conventional originated damage upstream of the angle of Treitz. Eighty percent of these hemorrhages externalize by hematemesis, 20% of them only by melena.
The patient interview or entourage rule allows to distinguish hematemesis hemoptysis or a nosebleed swallowed.
We must immediately make clear the starting time of bleeding, and this is the first episode.
Search melena should be systematic with the DRE.
The pathological context is to evaluate quickly, including the possibility of cirrhosis, peptic ulcer history. Taking gastrotoxic drugs (nonsteroidal anti-inflammatory drugs, aspirin) is primarily look at the interrogation.
In the absence of externalization by high way, insertion of a gastric tube is imperative for the presence of blood in the stomach.
The importance of bleeding is assessed using pulse, tension and shock peripheral signs.
Further examination:
Resuscitative measures being taken, an endoscopy must be proposed within 6 to 12 hours after onset of bleeding, gesture whose urgency is even greater than the signs of deglobulisation are important.
The precocity of its realization has determined a sharp drop in surgical indications in this situation.
The need for prior gastric lavage is recommended, but is not systematic, Endoscopic a washing being possible.
It is not necessary to conduct a general anesthesia, local anesthesia is sufficient. Tracheal intubation is essential if there is impaired consciousness to avoid false routes. Endoscopy in good conditions used to specify the source of bleeding in 90-98% of cases.
Etiologies:
The main causes of upper gastrointestinal bleeding are presented in Box 1.
Box 1. Causes of upper gastrointestinal bleeding in order of frequency
Peptic ulcers: 35-50%
Esophageal varices: 30%
Erosive gastritis: 10-20%
Mallory Weiss syndrome: 5-10%
Benign or malignant tumors: 5%
Reflux esophagitis or hiatal hernia: 5%
Simplex ulceration Dieulafoy: 1-2%
Vascular ectasia: <1%
Wirsungorragies or hémobilies: <1%
Fistula aortoduodénale (prosthesis): <1%
Peptic ulcer:
Diagnosis:
It’s the most common causes of upper gastrointestinal bleeding corresponding to about 36% of cases.
The ulcer can be either gastric duodenal that.
This is the most common complication of gastric ulcers (2% of cases). Bleeding may be abundant, but stops spontaneously in about 80% of cases (Fig. 1, see also included in the color specifications).
These hemorrhages are often triggered by taking aspirin or anti-inflammatory (10 to 30% of cases).
The bleeding prognostic factors are age (over 60 years), the existence of a collapse at admission or if rebleeding.
Endoscopy allows to highlight the ulcer, the presence or absence of active bleeding or signs of recent bleeding (Box 2).
Box 2. Forest classification
Stage 1: active bleeding
a1. Hemorrhage jet
a2. Oozing diffuse
Stage 2: indirect signs of recent hemorrhage
B1. Visible vessels no longer bleeding
B2. Clots members
B3. Pigmented spots on the crater floor
The risk of recurrence is even greater if the patient has a history of bleeding ulcer if ulcer has a diameter greater than 2 cm, if it is located on the posterior surface of the bulb or in Part upper stomach.
The presence of blood in the gastric cavity during endoscopy, the need to transfuse blood units over five, age greater than 65 years and comorbidity are relapse risk factors.
Treatment:
The indication of a haemostatic gesture at the ulcer is indicated in patients with active bleeding or if bleeding recent sign.
Several techniques are possible: either the injection of sclerosing or vasoconstrictor (adrenaline) or the use of a thermistor or the laser or finally the laying of hemostatic clips. These methods were compared and seem to show similar efficiencies.
The diluted epinephrine injection 1/10 000th to the advantage of a low cost and a very simple realization especially in the context of the emergency.
The sclerosing injection reduces by 87% the risk of emergency surgery for hemostasis.
The acidity in the stomach gene primary hemostasis, so it is important to raise the pH in the stomach: the use of inhibitors of proton pump intravenous (omeprazole, Mopral®) Dose 40 mg / day is essential, secondarily associated with the eradication of Helicobacter pylori (if it is present) that promotes healing and prevents relapse.
Hemorrhage from ruptured esophageal varices:
Diagnosis:
It is the second cause of upper gastrointestinal bleeding. Varicose veins can either sit in the lower third of the esophagus, or at the fundus (10% of cases).
The prognosis of gastrointestinal bleeding due as much to the importance of bleeding and risk of recurrence than the underlying liver disease, the latter being most often the direct cause of death.
Treatment:
On suspicion of hemorrhage from ruptured esophageal varices, the rule is to use as first-line treatments vasopressors.
Terlipressin has been demonstrated to be effective, the alternative being somatostatin which has the advantage of being better tolerated than terlipressin (cons-indicated in patients with hypertension, arrhythmia, arteritis and insuffi growth coronary).
Their use as first-line often determines the bleeding stops allowing endoscopy few hours in good conditions.
Endoscopy three hemostatic gestures on varices endoscopic sclerosis, rubber band ligation or injection of biological glue (Fig 2 and 3, see also figures in the color booklet.).
The sclerotherapy in varicose veins have been shown to be effective but are burdened with a number of complications and side effects, which is currently prefer the realization of elastic ligatures, easy to install thanks to improved equipment available. The biological glues are less common practice because of its difficulties in implementation and its side effects. This is the only feasible technique on gastric varices at this level sclerosing injections and ligatures are indeed against-indicated because of the risk of recurrence.
The waning of the endoscopic procedure, to prevent infection and encephalopathy, routine antibiotic coverage fluoroquinolones has been demonstrated effective. If resistance to previous hemostatic measures, it can be considered exceptionally placing a balloon catheter hemostasis (Blakemore tube) or the realization of a transjugular intrahepatic shunt (TIPS).
Bleeding from ruptured esophageal varices account for 25% of deaths during cirrhosis.
The prevention of bleeding, once mastered the acute episode, based on the non-cardioselective beta-blockers such as propranolol (Avlocardyl®). They aim to reduce by 25% in heart rate, however, which must remain above 55 beats / min.
Hemorrhagic erosive gastritis:
It is the third cause of high hemorrhage, often favored by anti-inflammatory drugs or aspirin. Often superficial lesions may regress rapidly, so that endoscopy performed late may not find obvious mucosal lesion.
Inhibitors of proton pump are proposed, associated of course with the judgment of gastrotoxic drugs if they were caught.
Mallory Weiss syndrome:
Mallory Weiss syndrome may be responsible for excessive bleeding linked to a longitudinal laceration of the gastroesophageal junction on the occasion of retching.
A local procedure endoscopic hemostasis may be required. Most of the time, evolution is favorably toward healing without treatment, but he vomiting.
Simplex ulceration Dieulafoy:
Simplex ulceration Dieulafoy are mucosal ulceration opposite an abnormally artery located beneath the epithelium.These ulcerations can exist both in the stomach as the small intestine and colon.
In the stomach, they serve primarily in the fundus.
They may be responsible for excessive bleeding, which often require endoscopic haemostatic gesture.
Ulceration of the neck of a large hiatal hernia:
Ulceration of the neck of a large hiatal hernia are responsible for 3% of upper gastrointestinal bleeding, as a rule unimportant.
They are more often responsible for microcytic anemia.
Antral vascular ectasia:
Antral vascular ectasia to be associated with cirrhosis (as part of portal hypertension gastritis) is associated with systemic diseases (scleroderma ) are responsible for 1% of gastrointestinal bleeding.
Coagulation of these vascular ectasia may be considered in case of recidivism or major bleeding using the argon plasma.
You Die:
Malignant or benign tumors are responsible for 5% of upper gastrointestinal bleeding.
It can be an adenocarcinoma of the stomach, lymphoma or a stromal tumor (formerly called leiomyomas or schwannoma).
Endoscopy can in 5% of cases prove nothing. We must think in the context of the possibility of a hemobilia or a wirsungorragie.
CONCLUSION:
Upper gastrointestinal bleeding is a common emergency in which mortality has remained relatively constant (15%), despite diagnostic and therapeutic advances in endoscopy.
Endoscopy, performed as quickly as possible in case of heavy bleeding, is the best solution to avoid the use of hemostatic surgery. The prognosis is of course dependent on the terrain, age or associate cirrhosis being the main factors.
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