Management Of Ugib Final

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Information about Management Of Ugib Final

Published on March 4, 2008

Author: blackempress

Source: slideshare.net

Description

Management of a patient with upper GI bleeding.

Management Harim Mohsin

Management Evaluation/ Assessment Stabilization History Physical examination Specific Treatment Follow-up

Evaluation/ Assessment

Stabilization

History

Physical examination

Specific Treatment

Follow-up

Stabilization & assesment Initial management begins with assessing and addressing the ABCs. Assessment of hemodynamic status Severe bleeding -Systolic bp <100- any HR Moderate loss- HR >100 + systolic bp >100 Mild loss- Normal bp & HR Portal hypertension & tachycardia are useful but may be due to other causes.

Initial management begins with assessing and addressing the ABCs.

Assessment of hemodynamic status

Severe bleeding -Systolic bp <100- any HR

Moderate loss- HR >100 + systolic bp >100

Mild loss- Normal bp & HR

Portal hypertension & tachycardia are useful but may be due to other causes.

In patients with significant bleeding large bore (16-18-guage) I/v lines should be maintained prior to further diagnostic tests. In case of hemodynamic compromise give Ringer’s lactate or normal saline & cross-matched blood. Plasma substitutes such as Haemaccel may also be used. Give Oxygen therapy to any patient in shock. Send blood for : Complete blood count PT Serum creatinine Liver enzymes Cross-matching

In patients with significant bleeding large bore (16-18-guage) I/v lines should be maintained prior to further diagnostic tests.

In case of hemodynamic compromise give Ringer’s lactate or normal saline & cross-matched blood.

Plasma substitutes such as Haemaccel may also be used.

Give Oxygen therapy to any patient in shock.

Send blood for :

Complete blood count

PT

Serum creatinine

Liver enzymes

Cross-matching

Pass nasogastric tube to perform an aspirate to determine whether the GI bleeding is emanating from above or below the ligament of Treitz . Aspirate by color: Red or coffee ground- active bleeding Clear gastric fluid- duodenal site of bleeding possible. Bile without blood- UGIB less likely

Pass nasogastric tube to perform an aspirate to determine whether the GI bleeding is emanating from above or below the ligament of Treitz .

Aspirate by color:

Red or coffee ground- active bleeding

Clear gastric fluid- duodenal site of bleeding possible.

Bile without blood- UGIB less likely

Rockall Scoring for risk of re-bleeding & death after hospital admission for acute UGIB

Rockall Scoring for

risk of re-bleeding & death after hospital

admission for acute

UGIB

Baylor Bleeding Score

History & examination

Specific management

Medical treatment Endoscopic treatment Surgical treatment

Medical treatment

Endoscopic treatment

Surgical treatment

Medical treatment Reduction of acid production H2RA -Histamine Receptor antagonists (eg Cimetidine, Ranitidine)- decrease cAMP PPI -Proton pump inhibitors-Inhibit parietal cell H+/K+- ATPase pump (eg Lansoprazole, Omeprazole)- (I/v 80mg followed by 8mg per hour for 72 hours) Octreotide - continuous Infusion reduces splanchnic blood flow & portal blood pressure effective initially in bleeding due to portal hypertension.

Reduction of acid production

H2RA -Histamine Receptor antagonists (eg Cimetidine, Ranitidine)- decrease cAMP

PPI -Proton pump inhibitors-Inhibit parietal cell H+/K+- ATPase pump (eg Lansoprazole, Omeprazole)- (I/v 80mg followed by 8mg per hour for 72 hours)

Octreotide - continuous Infusion reduces splanchnic blood flow & portal blood pressure effective initially in bleeding due to portal hypertension.

Medical treatment H ea mostatic drugs - Transexemic acid(antifibrinolytic agent) - reduction of the level of fibr in ogen fragments improving platelet function. TXA stabiliz es haemostatic clots by (1) preventing b in d in g of plasm in ogen to fibr in in blood clots (2)preventing activation of plasm in ogen to active plasm in. Other drugs used: Vasopressin- produces mesenteric vasoconstriction and thus decreases portal venous inflow and pressure Somatostatin Volume and blood replacement as required

H ea mostatic drugs -

Transexemic acid(antifibrinolytic agent) - reduction of the level of fibr in ogen fragments improving platelet function.

TXA stabiliz es haemostatic clots by (1) preventing b in d in g of plasm in ogen to fibr in in blood clots

(2)preventing activation of plasm in ogen to active plasm in.

Other drugs used:

Vasopressin- produces mesenteric vasoconstriction and thus decreases portal venous inflow and pressure

Somatostatin

Volume and blood replacement as required

Endoscopic Treatment Endoscopy , should be performed immediately after hemodynamic stabilization & evaluation within 12 hours. This is useful for: Diagnosing the cause of bleeding Estimating prognosis Therapeutic haemostasis Contraindications to upper endoscopy Uncooperative patient Acute myocardial infarction (unless haemorrhage life-threatening) Perforated viscus

Endoscopy , should be performed immediately after hemodynamic stabilization & evaluation within 12 hours.

This is useful for:

Diagnosing the cause of bleeding

Estimating prognosis

Therapeutic haemostasis

Contraindications to upper endoscopy

Uncooperative patient

Acute myocardial infarction (unless haemorrhage life-threatening)

Perforated viscus

Endoscopy of stomach

Endoscopic treatment The endoscopic appearance of the bleeding lesion has been used to identify patients at high risk for recurrent bleeding. High risk- active bleeding, visible vessels, adherent clots. Low risk- flat, pigmented spots and those that involve a clean ulcer base with no visible vessel. The indication for endoscopic therapy is based on the size, site, and stigmata of recent bleeding.

The endoscopic appearance of the bleeding lesion has been used to identify patients at high risk for recurrent bleeding.

High risk- active bleeding, visible vessels, adherent clots.

Low risk- flat, pigmented spots and those that involve a clean ulcer base with no visible vessel.

The indication for endoscopic therapy is based on the size, site, and stigmata of recent bleeding.

Endoscopic treatment Topical treatment Injection treatment Mechanical treatment Thermal treatment

Topical treatment

Injection treatment

Mechanical treatment

Thermal treatment

Topical treatment Tissue adhesives Blood clotting factor s (throbin,fibrinogen) Vasoconstricting drug s (epinephrin e ) C ollagen (microcrystalline collagen hemostat (MCH)

Tissue adhesives

Blood clotting factor s (throbin,fibrinogen)

Vasoconstricting drug s (epinephrin e )

C ollagen (microcrystalline collagen hemostat (MCH)

Injection therapy Injection therapy consists of using solutions injected into and around the bleeding lesion to attain hemostasis. Scler osant agents ( ethanol, polidocanol, and sodium tetradecyl sulfate ) -induce thrombosis, tissue necrosis, and inflammation at the site of injection Epinephrin e- Causes vasoconstriction Thrombin / Fibrin glue- clot producing agents.

Injection therapy consists of using solutions injected into and around the bleeding lesion to attain hemostasis.

Scler osant agents ( ethanol, polidocanol, and sodium tetradecyl sulfate ) -induce thrombosis, tissue necrosis, and inflammation at the site of injection

Epinephrin e- Causes vasoconstriction

Thrombin / Fibrin glue- clot producing agents.

Mechanic al treatment Loops - Easy, precise and cost-effective variceal ligation. The loop ensures a firm and precise ligation with adjustable ligating force that remains in place for a period of time then leaves the GI tract naturally. Sutures Balloon treatment -The 2 most commonly used tubes are the Sengstaken-Blakemore tube and the Minnesota tube. These tubes have an esophageal balloon and a gastric balloon that are inflated to produce a tamponade effect after confirming appropriate anatomical placement Haemostatic clips - Provide Fast, efficient haemostasis In addition, maintains the integrity of the surrounding tissue.

Loops - Easy, precise and cost-effective variceal ligation. The loop ensures a firm and precise ligation with adjustable ligating force that remains in place for a period of time then leaves the GI tract naturally.

Sutures

Balloon treatment -The 2 most commonly used tubes are the Sengstaken-Blakemore tube and the Minnesota tube. These tubes have an esophageal balloon and a gastric balloon that are inflated to produce a tamponade effect after confirming appropriate anatomical placement

Haemostatic clips - Provide Fast, efficient haemostasis In addition, maintains the integrity of the surrounding tissue.

Thermal treatment Laser ph otocoagulation - uses an Nd:YAG laser to create hemostasis by generating heat and direct vessel coagulation. Coaptive coagulation uses direct pressure and heater probe & electrocoagulation (monopolar & bipolar) therapy to achieve hemostasis. The bleeding vessel is isolated, compressed, and tamponaded, minimizing the depth of tissue injury.

Laser ph otocoagulation -

uses an Nd:YAG laser to create hemostasis by generating heat and direct vessel coagulation.

Coaptive coagulation

uses direct pressure and heater probe & electrocoagulation (monopolar & bipolar) therapy to achieve hemostasis. The bleeding vessel is isolated, compressed, and tamponaded, minimizing the depth of tissue injury.

Management after endoscopy Careful monitoring is needed after endoscopy for UGIB (pulse, blood pressure, urine output). It is imperative to identify rebleeding or continuing bleeding. If patients are stable 4-6 hours after endoscopy they should be put on a light diet as there is no benefit in continued fasting. Repeat endoscopy is required if there is evidence of rebleeding (for example with melaena or unstable observations). Occasionally major rebleeding may be an indication for surgical intervention without further endoscopy.

Careful monitoring is needed after endoscopy for UGIB (pulse, blood pressure, urine output). It is imperative to identify rebleeding or continuing bleeding.

If patients are stable 4-6 hours after endoscopy they should be put on a light diet as there is no benefit in continued fasting.

Repeat endoscopy is required if there is evidence of rebleeding (for example with melaena or unstable observations).

Occasionally major rebleeding may be an indication for surgical intervention without further endoscopy.

Surgical intervention Surgical intervention is required when endoscopic techniques fail or are contraindicated. Clinical judgement is required with expert personnel. I n case of continous or rebleeding

Surgical intervention is required

when endoscopic techniques fail or are contraindicated. Clinical judgement is required with expert personnel.

I n case of continous or rebleeding

Surgery types Transjugular intrahepatic portosystemic shunt (TIPS)- A self-expanding metal stent is placed between the systemic venous system and the portal system. The placement of a TIPS reduces the outflow hepatic resistance, lowers portal pressure, and diverts portal blood flow from gastroesophageal collaterals through the stent. Liver transplantation or decompression should be considered alongside if portal hypertension present.

Transjugular intrahepatic portosystemic shunt (TIPS)-

A self-expanding metal stent is placed between the systemic venous system and the portal system.

The placement of a TIPS reduces the outflow hepatic resistance, lowers portal pressure, and diverts portal blood flow from gastroesophageal collaterals through the stent.

Liver transplantation or decompression should be considered alongside if portal hypertension present.

Surgical treatment Surgical shunts: decompression of the high-pressure portal venous system into a low-pressure systemic venous system and devascularization of the distal esophagus and proximal stomach Non-Selective shunts -completely divert portal blood flow from the liver Selective shunts -decompresses the varices while maintaining hepatopetal blood flow in the remainder of the portal system. Partial shunts- decompresses varices while maintaining hepatic portal perfusion.

Surgical shunts:

decompression of the high-pressure portal venous system into a low-pressure systemic venous system and

devascularization of the distal esophagus and proximal stomach

Non-Selective shunts -completely divert portal blood flow from the liver

Selective shunts -decompresses the varices while maintaining hepatopetal blood flow in the remainder of the portal system.

Partial shunts- decompresses varices while maintaining hepatic portal perfusion.

Surgical treatment Local operation Suture Local operation + vagotomy R esection type operation

Local operation

Suture

Local operation + vagotomy

R esection type operation

Variceal bleeding Cirrhosis - Billiary - Alcoholic Portal hypertension (15-30 Hgmm) Rupture of varicose veins

Cirrhosis

- Billiary

- Alcoholic

Portal hypertension (15-30 Hgmm)

Rupture of varicose veins

Treatment of variceal bleeding Balloon tamponade Sclerotherapy Oesophageal transsection Porto/caval shunt TIPS (Interventional radiology )

Balloon tamponade

Sclerotherapy

Oesophageal transsection

Porto/caval shunt

TIPS (Interventional radiology )

Non-variceal bleeding Peptic ulcer Mallory-Weiss tear Erosive gastritis/duodenitis Esophagitis/ oesophageal ulcer Malignancy Angiodysplasia /vascular malformations Other

Peptic ulcer

Mallory-Weiss tear

Erosive gastritis/duodenitis

Esophagitis/ oesophageal ulcer

Malignancy

Angiodysplasia /vascular malformations

Other

Treatment of Non-variceal bleeding Repeat endoscopy Emergency surgery Transcatheter arteriography followed by transcatheter intervention (usually embolization)

Repeat endoscopy

Emergency surgery

Transcatheter arteriography followed by transcatheter intervention (usually embolization)

 

Complications

Specific to the cause of UGIB May arise from interventional tools. Rebleeding Shock Anemia Aspiration Tachycardia Perforation Death

Specific to the cause of UGIB

May arise from interventional tools.

Rebleeding

Shock

Anemia

Aspiration

Tachycardia

Perforation

Death

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