Most common presenting symptom of non-cirrhotic poal hypeension is
Acute upper gastrointestinal haemorrhage This is the most common gastrointestinal emergency, accounting for 50-170 admissions to hospital per 100 000 of the population each year in the UK. The moality of patients admitted to hospital is about 10% but there is some evidence that outcome is better when individuals are treated in specialised units. Risk scoring systems have been developed to stratify the risk of needing endoscopic therapy or of having a poor outcome . The advantage of the Blatchford score is that it may be used before endoscopy to predict the need for intervention to treat bleeding. Low scores (2 or less) are associated with a very low risk of adverse outcome. Clinical assessment Haematemesis is red with clots when bleeding is rapid and profuse, or black ('coffee grounds') when less severe. Syncope may occur and is caused by hypotension from intravascular volume depletion. Symptoms of anaemia suggest chronic bleeding. Melaena is the passage of black, tarry stools containing altered blood; it is usually caused by bleeding from the upper gastrointestinal tract, although haemorrhage from the right side of the colon is occasionally responsible. The characteristic colour and smell are the result of the action of digestive enzymes and of bacteria on haemoglobin. Severe acute upper gastrointestinal bleeding can sometimes cause maroon or bright red stool.Management The principles of emergency management of non-variceal bleeding are discussed in detail below. . 1. Intravenous access -The first step is to gain intravenous access using at least one large-bore cannula. 2. Initial clinical assessment Define circulatory status. Severe bleeding causes tachycardia, hypotension and oliguria. The patient is cold and sweating, and may be agitated. Seek evidence of liver disease . Jaundice, cutaneous stigmata, hepatosplenomegaly and ascites may be present in decompensated cirrhosis. Identify comorbidity. The presence of cardiorespiratory, cerebrovascular or renal disease is impoant, both because these may be worsened by acute bleeding and because they increase the hazards of endoscopy and surgical operations. These factors can be combined using the Blatchford score , which can be calculated at the bedside. A score or 2 or less is associated with a good prognosis, while progressively higher scores are associated with poorer outcomes. 3. Basic investigations Full blood count. Chronic or subacute bleeding leads to anaemia but the haemoglobin concentration may be normal after sudden, major bleeding until haemodilution occurs. Thrombocytopenia may be a clue to the presence of hypersplenism in chronic liver disease. Urea and electrolytes. This test may show evidence of renal failure. The blood urea rises as the absorbed products of luminal blood are metabolised by the liver; an elevated blood urea with normal creatinine concentration implies severe bleeding. Liver function tests. These may show evidence of chronic liver disease. Prothrombin time. Check when there is a clinical suggestion of liver disease or patients are anticoagulated. Cross-matching. At least 2 units of blood should be cross-matched if a significant bleed is suspected. Ref Davidson edition23rd pg781
Ascites
Chronic liver failure
Encephalopathy
Upper Gaastrointestinal bleeding
G.I.T