MediConsults

Blood Transfusions in Acute Upper Gastrointestinal Bleeding

There was an interesting commentary on best ways of managing patients presenting with acute gastrointestinal bleeding on medscape today. It mainly focused on guiding when a patient should be transfused with blood and when to decide on a more conservative approach.

Usually blood transfusions are indicated if the patient has lost a large amount of blood and when effective circulation requires more red blood cells in the circulation.

The commentary favours the use of more conservative approach in using blood transfusions in patients with Upper GI bleeding. According to a study conducted in UK, There was no adverse out comes when using the more conservative approach. The study had two arms. One arm with the conservative strategy where blood transfusions were given after Haemoglobin (Hb) has dropped below 7g/dl and the other arm with a more liberal approach where blood transfusions where given when Hb dropped below 9g/dl.

It is known that adverse effects such as fluid overload and reactions can complicate the disease conditions of patients undergoing blood transfusions.

But the commentary does not give a clear idea whether this study has taken into account the normal Hb levels of the patient since a Hb level of even 9g/dl could be a significantly low value if the patient had a Hb level of >12 prior to the incident.

Check out the article using following URL for more details.

http://www.medscape.com/viewarticle/779741?nlid=30403_983&src=wnl_edit_medp_surg&spon=14

Common reasons for upper GI bleeding include lower esophageal varices secondary to portal hypertension and Gastric / Duodenal Ulcers. Most common reason for portal hypertension in adults is liver cirrhosis. In children portal hypertension is commonly seen secondary to portal vein thrombosis (pre - hepatic).

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Tracheoesophageal fistula

Tracheoesophageal fistula (A connection between trachea and oesophagus) is a surgical emergency of new born babies. It is usually diagnosed when baby become cyanosed (baby becomes blue) while trying to feed after birth. With improving antenatal diagnostic techniques it is more commonly diagnosed by antenatal ultrasound scans. Once diagnosed it has to be corrected in order to start feeding the child and to prevent aspiration of secretions.

Once diagnosis is made or when an antenatally diagnosed baby with Tracheoesophageal fistula is born, they should be kept nil by mouth (With out feeds). Then NG tube is passed to see if it makes its way to the stomach. Unless there is a H type tracheoesophageal fistula (as shown in the above picture), NG tube will not pass in to the stomach.

Then the chest x-ray will show the coiling up of NG tube with in the esophagus. You will see absence of stomach air and distal air shadows if there is total discontinuity in the oesophagus in case of pure esophageal atresia.

Once the baby is stable, he/she should be transferred to a surgical unit for corrective surgery. A baby with this condition may require ICU care with ventilator support if unstable prior to surgery. Tracheoesophageal fistula repair is ideally carried out as soon as possible in order to allow feeding and to prevent aspiration. Once in a specialized surgical unit baby will undergo further investigations such Ultrasound scans and upper GI contrast studies for definitive diagnosis.

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Pregnancy Induced Hypertension (PIH)

Pregnancy induced hypertension is a condition where a mother develops high blood pressure in later part of the pregnancy (after 20 weeks of gestation). About a third of mothers who develop hypertension during pregnancy can develop a more sinister condition known as pre-eclampsia.

PIH is one of the leading causes of maternal mortality in developed world. It affects the development of fetus resulting in low birth weight babies. It has been found that having hypertension during pregnancy predisposes the mother to pregnancy complications like placental abruption more frequently. Once a mother develops pregnancy induced hypertension, they are at a higher risk of developing chronic hypertension later in life.

Identifying if a mother is having elevated levels of blood pressure is one of the key things done at an antenatal clinic. Once high blood pressures are detected, blood pressure need to be monitored frequently and controlled with appropriate therapy. With these appropriate therapies, healthcare providers try to prevent development of complications and to deliver a healthy appropriately weighing baby as the end result.

Following is a diagnostic work up of a patient detected of having high blood pressure during pregnancy.

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Gestational Diabetes Mellitus (GDM)

Gestational diabetes mellitus or GDM is a condition where there is increased glucose levels in maternal blood. In pregnancy it is quite normal to have an elevated glucose level than a normal adult, thus having positive urine test for glucose is quite normal. But having too much of glucose in blood is detrimental to the fetus.

GDM can cause variety of pregnancy complications as well as problems for the baby in the future. While in pregnancy high glucose levels in maternal blood results in high glucose levels in fetus, thus hormones like insuline, insuline like growth factor and growth hormone are produced in excess. This leads to increased growth and fat deposition in fetus. Intern this increased growth results in a macrosomic baby, who will eventually have problems while delivery such as "shoulder distocia".

Not only the problems at delivery, but these babies may develop developmental stigmata as well. Sacral agenesis is one of the commonest recognized malformations secondary to gestational diabetes mellitus. Just after birth these babies are at a high risk of developing neonatal hypoglycemia as a result of sudden cut off of glucose supply from the mother as well as due to high insuline production by baby's pancreatic beta cells.

As stated earlier, because these babies produce high levels of insuline before birth, they tend to exhaust their insuline reserves (beta cell function) later in life, thus they are at a high risk of developing Diabetes Mellitus as adults. If the baby is a girl, she will have high risk of developing GDM, thus this whole process goes in a vicious cycle.

Over the years there has been many researches on how best to treat gestational diabetes mellitus by many researchers around the world. Currently accepted way of treatment is to meticulously control blood sugar levels while monitoring closely.

As well as treatment, prevention plays a major role in maternal care. High risk mothers need to be identified and screened so that the condition can be diagnosed early and treatment can begin early to minimize any unwanted effects to the baby and the mother.

This diagram shows the protocol which we use to diagnose GDM in high risk, medium risk and low risk mothers.

So you may be wondering, "am i a high risk mother?". Following is a list of criteria we use to identity high risk mothers. If you have any of the following criteria, you should get pre-conceptional advice on the expected pregnancy and you should be screened as early as possible for possible GDM.

Once GDM is diagnosed, treatment should start immediately. Any delay can be detrimental to the fetus. Following a diagram showing a currently accepted treatment regime.

( MNT stands for Medical and nutritional therapy.)

If you have any queries or doubts just drop in a message and we will give you further information on this topic. http://www.mediconsults.com/p/contact-us.html

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