A 40-year old male presents with history of vomiting of blood 2 hours ago. The volume of vomitus was estimated to be 500 ml. His BP was 90/58 mm Hg and pulse was 110/min. On abdominal examination, the spleen was palpable 5 cm below the costal margin. The most likely cause of the bleeding is:
Ans. a. Portal hypertension (Ref: Sabiston 19/e p1164)Splenomegaly and massive bleeding leading to hypotension and tachycardia in the patient are in favor of portal hypertension.Common Causes of Upper Gastrointestinal HemorrhageNon-variceal Bleeding(80%)QPortal Hypertensive Bleeding(20%)QPeptic ulcer disease (MC)Q30-50%QGastroesophageal varicesQ>90%QMallory-Weiss tears15-20%Hypertensive portal gastropathy<5%Gastritis or duodenitis10-15%Isolated gastric varicesRareEsophagitis5-10% Arteriovenous malformations5% Tumors2% Other5% Portal HypertensionDefinition: Portal pressure >10 mm HgQMC cause of portal hypertension in United States: CirrhosisQ.Consequence of both increased portal vascular resistance and increased portal flowQ.Portal hypertension results in splenomegaly with enlarged, tortuous, and even aneurysmal splenic vessels.Splenomegaly frequently is associated with hypersplenism, causing leukopenia, thrombocytopenia, and anemia.Cruveilhier-Baumgarten murmurQ: Audible venous hum in caput medusaHyperdynamic portal venous circulation seems to be related to the severity of the liver failureQ.Upper G.I. bleeding is caused by the portal hypertension in about 90% of instances.Most bleeding episodes occur during the first 1 to 2 years after identification of varicesQ.Colour Doppler is the investigation of choice for evaluation of PHT.About one third of deaths in patients with known esophageal varices are due to upper GI bleedQA larger proportion dies as a result of liver failureQ.MC causes of death in cirrhosis patients: Hepatic failureQ2nd MC causes of death in cirrhosis patients: variceal hemorrhageQ
Portal hypertension
Gastric ulcer
Duodenal ulcer
Drug-induced mucosal erosion
Abdominal Injury