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CAUSES OF UPPER GI BLEED: VARICEAL OR NON-VARICEAL

.. Objectives: To determine the frequency of esophageal variceal bleed in patients with upper GI bleed presenting in a tertiary care hospital. Study Design: Cross sectional survey. Setting: Department of Medicine, Mayo Hospital, Lahore and Madinah Teaching Hospital, Faisalabad. Period: 6 months from 01-06-2018 to 31-12-2018. Material & Methods: Two hundred patients with upper GI bleed were included in the study. All the patients had upper GI endoscopy to determine the esophageal variceal bleeding which was documented as frequency distribution table. Results: Esophageal variceal bleed was seen among 108 (54%) patients while it was not present among 92 (46%) patients. Conclusion: Esophageal variceal bleeding is frequently present among patients with upper GI bleeding and should be suspected in every patient with upper GI bleeding.


INTRODUCTION
Patients presenting with bleeding from any point proximal to the anatomical landmark i.e. ligament of Treitz is labeled as upper gastrointestinal bleeding although some also include the proximal jejunum. 1 Among the most common causes of upper GI bleeding are peptic ulcer disease (35 -62%), gastro esophageal varices (4 -31%) due to chronic liver disease, Mallory Weis tear (4 -13%), gastro duodenal ulcers or erosions, esophagitis (2 -8%), gastric neoplasm (1 -4%) and others as angiodysplasia, Dieulafoy's lesions, aortoentric fistula, hemobilia, hereditary hemorrhagic telangiectasia, uremia and coagulation disorders. 2 Most of the cases of UGIB like gastritis, esophagitis, Cameron erosions, varices and ulcers can lead to anemia due to iron deficiency, but almost none of them present with simple pallor or anemia in the emergency department. These patients come to emergency with complaints like bleeding through vomiting (hematemesis -mostly massive bleeding), black stools (melena), fresh bleeding through stools (hematochezia) and/or with shock and hypothension. [3][4][5] The incidence of UGIB along with their causes varies from populations to populations, with an estimated prevalence of about 100 cases in a population of one lakh per year. 6 UGIB is four times more common when compared to the incidence of lower GI bleed. Morbidity and mortality is also more for UGIB patients. According to an estimate the mortality from UGIB has reached to 10% in the developing countries. 6 Diagnosis and management of non-variceal UGIB has revolutionized since the last 5 years. Endoscopic techniques with medical therapy till the surgical therapy as last resort after the failure of medical therapy. 7 Esophageal varices are the dilated tortuous veins due to increased pressure in the esophageal plexus due to development of portal hypertension after impairment in the portal venous flow inside the hepatic system with the development of chronic liver disease and liver cirrhosis. The flow of blood is diverted to the esophageal sub epithelial and submucosal veins through coronary stomach veins. 8 A retrospective study conducted in England showed that in hospital mortality of patients with cirrhosis and variceal bleed decreased from 43% in 1980 to 15% in 2000 in concurrence with an early and combined use of pharmacological, endoscopic therapy and short term antibiotic prophylaxis. 9 Gastroesophageal varices occur in 30% cases of compensated chronic liver disease (CLD) and more than 50% of decompensated CLD cases. 10 Esophageal variceal bleed (EVB) occurs in average 15% patients of CLD in a year and it is a medical emergency with significant morbidity and mortality. 11 Advanced techniques with medication improve about 2/3 rd episodes of variceal bleed. 12 Chronic liver disease is more common in our part of world due to high prevalence of liver cirrhosis. In one study, out of 892 patients, esophageal varices were seen in 580 (65%) cases and gastric erosions in 133 (14.96%) cases 13 , 44% was reported by another study with PUD 14 and 22.75% in a local setting of Pakistan. 15 The aim of this study was that there was marked variability in data regarding frequency of esophageal variceal bleed in patients presenting with UGIB in local studies, so reassessment is required time to time.

MATERIAL AND METHODS
This cross sectional survey was conducted in the Medical Unit-III of Mayo hospital, Lahore and Medicine Department of Madinah Teaching Hospital, Faisalabad six months after approval from the respective hospital's ethical review committees. Patients of both genders aging between 15 to 70 years having history of UGIB (hematemesis or melena or both) for less than 48 hours confirmed by endoscopy were included in the survey. Esophageal varices were considered as dilated collaterals in the lower esophagus that interconnect portal and systemic circulation in patients with portal hypertension.
Endoscopically, esophageal varices were defined as irregular, serpiginous, bluish structures running longitudinally in the submucosa of esophageal wall. Bleeding from upper part of the gastrointestinal tract i.e. from esophagus down to the first part of duodenum, which was manifested by hematemesis, melena or both, is defined as upper gastrointestinal bleeding on basis of upper GI endoscopy. Patients with history of bleeding in the upper or lower respiratory tract assessed by history of epistaxis or blood in sputum, patients not fit for endoscopy due to cardiac disease like recent myocardial infarction and heart failure assessed by history, physical examination, ECG and Chest X-ray including those who had drug history of beta blockers or nitrates and patients who had systolic B.P <90mmHg and diastolic B.P<60mmHg. Data was entered and analyzed by Statistical Package for Social Science (SPSS) version 11. Mean ± S.D was calculated for quantitative variables like age while qualitative variables like gender and presence of esophageal variceal bleed were calculated for frequencies/ percentages. Stratification was done for age and gender to control the effect modifiers.

RESULTS
Two hundred patients with diagnosis of upper GI bleeding were included in the study. The mean age of the patients was 41.34 + 17.01 years. The age range was from 15 years to 70 years. (Table-I   Main cause of CLD with cirrhosis is viruses, proven on many studies. [25][26][27][28][29][30] In the management of acute episodes, multidisciplinary approach which should include anesthetics, critical care, endoscopist and hepatologist lead to significant reduction in the morbidity and mortality. 24

CONCLUSION
Esophageal variceal bleeding contributes a major bulk of patients with UGIB on upper GI endoscopy. So, it is recommended that every patient with UGIB should have upper GI endoscopy and should be suspected of having esophageal varices as a commonest cause of bleeding. This is also suggested that more studies should be carried on in this context in different setups. Paper writing.
Data entry, Data analysis, Paper writing.