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Upper GI Bleed – Blood Vomitus or Black Stools


Cirrhosis is diffuse permanent damage to the liver. Once somebody develops cirrhosis, they are likely to face some or the other complications in upcoming 3-5 years. It is good to keep oneself aware about possible complications. One of the complications is gastrointestinal bleeding.

Hematemesis means vomiting of blood. Whenever a person has blood in his vomit, we call it as hematemesis. It is major and life-threatening complication of cirrhosis of the liver.

Reason for Blood in Vomit in cirrhosis

  1. Esophageal Varices
  2. Gastric Varices

Under normal circumstances, the blood that flows from spleen and the intestines enters a vessel known as portal vein and it in turn enters the liver for filtration. The blood from the liver enters the hepatic veins and from where it enters the heart and goes into the systemic circulation. However, when there is cirrhosis of the liver, this liver does not allow the blood to pass smoothly and it provides a resistance to the blood flow because of, which the pressure in the portal vein increases. The blood must reach the heart by an alternative route. In this circumstance as a result, few vessels around your food pipe, what we call as oesophagus, carries the blood from the portal vein into the heart. Now, the calibre of this vessel is quite small as compared to the portal vein.So, the blood, which is supposed to. pass from a large vessel when it passes through a small vessel, the pressure increases significantly. As a result, this starts bulging into the food pipe. Now, whenever somebody has fever and the pressure increases suddenly, or somebody takes a painkiller or a corrosive agent or sometimes even without any intake of any substance, just spontaneously, the pressure increases and because of which there is a rupture of this vessel into the food pipe. The patients vomit this blood out. It is a life-threatening condition. Unless it is urgently treated a patient may lose his life.

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Clinical presentation

  1. Hematemesis

  1. Malena

Not always does the blood enters, the food pipe and is brought out through the mouth. Sometimes a lot of blood enters the stomach, which passes through the intestine and with contact with the acid from the stomach. This blood is converted to dark black colour stools. And as a result, patient starts passing foul-smelling dark black, tarry stools. So, this is another manifestation of bleeding. Sometimes the vessels in the stomach may rupture and may present in a similar fashion.

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Appearance of patient

On examination of this patients, they have rapid pulse rate. The blood pressure starts going down. They are in a State of Shock with profuse sweating and hands and limbs becomes cool and clammy. It is an emergency condition. The person should not wait for anything and directly rushed to the emergency department

Management

He would be resuscitated with blood products, as well as fluids. He would be given antibiotics to prevent other complications of liver disease.He would be planned for an upper GI endoscopy. On endoscopy, the doctor would apply the band (Variceal ligation). If bleeding is from the stomach, glue may be injected. The efficacy of stopping the bleeding is more than 90 percent in a single sitting.

However, he still needs to continue certain drugs, like terlipressin, somatostatin or octreotide to prevent rebleeding for a period of three to five days. The risk of rebleeding is highest in three to five days, and patients are monitored in the hospital for this period. Sometimes the endoscopist feels that the varices are very high risk, and even after adequately achieving haemostasis or being able to stop the bleeding, they still may be able to advise you to undergo shunting. This shunt is called as TIPSS Shunt. TIPSS is a shunt in the liver. As I have described in the pathophysiology that liver cirrhosis provides increased resistance to blood flow. If we pass a shunt between portal vein and hepatic vein, the pressure in food pipe veins decrease. Sometimes even when you are not able to stop the bleeding on an endoscopy, an emergency shunting – TIPSS, must be carried out.


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