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Bleeding from upper GI tract

Differential Diagnosis Schema 🧠

Peptic Ulcer Disease

  • Duodenal ulcer: Pain relieved by food, history of NSAID use, Helicobacter pylori infection
  • Gastric ulcer: Epigastric pain worsened by food, association with older age, smoking

Esophageal Varices

  • Portal hypertension: Commonly in patients with a history of cirrhosis, chronic alcohol abuse, or viral hepatitis
  • Bleeding can be massive and life-threatening

Mallory-Weiss Tear

  • Longitudinal mucosal tear: Often following forceful vomiting or retching
  • Associated with alcohol use or eating disorders

Gastric Cancer

  • Chronic bleeding leading to anemia: Weight loss, early satiety, family history of gastric cancer
  • May present with overt bleeding in advanced stages

Gastritis and Erosions

  • Acute or chronic gastritis: History of NSAID use, alcohol consumption, stress-related mucosal damage
  • Often presents with less severe, chronic bleeding

Vascular Malformations

  • Angiodysplasia: Usually presents with chronic, intermittent bleeding; more common in elderly patients
  • Dieulafoy’s lesion: Sudden massive bleeding, often in otherwise healthy individuals

Esophagitis

  • GERD-related: Associated with acid reflux, burning retrosternal discomfort
  • Infective esophagitis: More common in immunocompromised patients, associated with odynophagia

Key Points in History 🥼

Presenting Symptoms

  • Hematemesis: Vomiting of blood, suggesting upper GI source
  • Melena: Black, tarry stools indicating digested blood, typically from upper GI tract
  • Hematochezia: Fresh blood per rectum, can be from a brisk upper GI bleed
  • Epigastric pain: Can suggest peptic ulcer disease, gastritis
  • Dysphagia or odynophagia: May indicate esophageal pathology

Background

  • Past Medical History: History of peptic ulcer disease, liver disease, previous GI bleeding
  • Drug History: NSAIDs, anticoagulants, antiplatelets, corticosteroids
  • Family History: History of GI cancers or bleeding disorders
  • Social History: Alcohol consumption, smoking, stress, travel history (consider infections)

Possible Investigations 🌡️

Blood Tests

  • Full Blood Count: Look for anemia, leukocytosis, thrombocytopenia
  • Urea and Electrolytes: Raised urea may indicate upper GI bleed
  • Liver Function Tests: Assess for liver disease, synthetic function
  • Coagulation Profile: Important if patient is on anticoagulants or has liver disease

Imaging and Endoscopy

  • Endoscopy: Diagnostic and therapeutic; first-line for upper GI bleed
  • CT Scan: Used if endoscopy is inconclusive or to identify complications
  • Angiography: Can be used in massive bleeding when endoscopy fails to identify source

Other Tests

  • Nasogastric Lavage: To help determine if bleed is ongoing
  • Stool Occult Blood Test: To check for chronic blood loss in unclear cases
  • Helicobacter pylori Testing: Relevant in peptic ulcer disease

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