Upper gi bleeding

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Information about Upper gi bleeding
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Published on April 6, 2014

Author: drvicky666

Source: slideshare.net

Dr.Vignesh.S Resident in Internal Medicine Guided by Prof.Dr.R.L.Meena RNT Medical college and Hospital

 Upper GI Tract ◦ Proximal to the Ligament of Treitz ◦ 70% of GI Bleeds  Lower GI Tract ◦ Distal to the Ligament of Treitz ◦ 30% of GI Bleeds

 Initial Assessment and Resuscitation  History and Physical Examination  Assessment of the bleeding source  Differential Diagnosis  Investigations  Management ◦ Conservative ◦ Therapeutic

 Airway, Breathing and Circulation  Vital Signs: ◦ Pulse, BP, Temperature, Respiratory Rate  Fluid and Resuscitation Plan ◦ Co-morbidities

Estimated Fluid and Blood Losses in Shock Class 1 Class 2 Class 3 Class 4 Blood Loss, mL Up to 750 750-1500 1500-2000 >2000 Blood Loss,% blood volume Up to 15% 15-30% 30-40% >40% Pulse Rate, bpm <100 >100 >120 >140 Blood Pressure Normal Normal Decreased Decreased Respiratory Rate Normal or Increased Decreased Decreased Decreased Urine Output, mL/h 14-20 20-30 30-40 >35 CNS/Mental Status Slightly anxious Mildly anxious Anxious, confused Confused, lethargic Fluid Replacement, 3-for-1 rule Crystalloid Crystalloid Crystalloid and blood Crystalloid and blood Ref: Sleisinger and Fordtrans Gastrointestinal and Liver disease

 Confirm the GI Bleed - Hemoptysis or Hemetemesis ???  Manner of Presentation of a GI Bleed ◦ Hemetemesis ◦ Malena ◦ Hematochezia ◦ Occult Blood loss ◦ Symptoms of Blood loss  Is it only the GI Bleed ??  Assessment of the bleed ◦ Dizziness, Syncope, Chest Pain, SOB

Bleeding etiology Leading History Mallory-Weiss tear Multiple Emesis before hematemesis, alcoholism Esophageal ulcer Dysphagia, Odynophagia, GERD, Peptic ulcer Epigastric pain, NSAID or aspirin use Stress gastritis Patient in an ICU, gastrointestinal bleeding occurring after admission, respiratory failure, multiorgan failure Varices, portal gastropathy Alcoholism, Cirrhosis Gastric antral vascular ectasia Renal failure, cirrhosis Malignancy Recent involuntary weight loss, dysphagia, cachexia, early satiety Angiodysplasia Chronic renal failure, hereditary hemorrhagic telangiectasia Aortoenteric fistula Known aortic aneurysm, prior abdominal aortic aneurysm repair

 Anticoagulation (warfarin/heparin)  Use of Drugs NSAIDs,Steroids,Bisphosphonates  Similar episodes before  H/o Jaundice in past  H/o Abdominal Surgery  H/o Alcoholism  H/o Smoking or Tobacco abuse  H/o Cocaine abuse

 Pt’s Consciousness, Orientation  Pallor, Icterus, Clubbing, Pedal Edema  Lymphadenopathy, JVP  Signs of Liver Failure  Systemic Examination ◦ Abdomen, CVS, RS, CNS

 Alopecia, Pallor, Icterus, Fetor Hepaticus, Glossitis, Parotid Swelling  Leukonychia, Clubbing, Palmar Erythema, Dupuytren’s Contracture, Asterexis  Loss of Axillary hair, Spider naevi, Gynaecomastia,  Ascitis, Spleenomegaly, Caput Medusae  Testicular Atrophy, Loss of Pubic Hair  Pedal Edema

Gynaecomastia Ascitis

Virchow’s node Palmar Tylosis Special Cases

 Major causes  Peptic ulcer disease  Esophageal and gastric varices  Hemorrhagic gastritis  Esophagitis  Duodenitis  Mallory-Weiss tear  Angiodysplasia  Upper gastrointestinal malignancy  Anastomotic ulcers (after bariatric surgery)  Dieulafoy lesion

 Minor causes  Gastric antral vascular ectasia (watermelon stomach)  Portal hypertensive gastropathy  Gastric polyps  Aortoenteric fistula  Connective tissue disease  Postprocedural: nasogastric tube erosions, endoscopic biopsy, endoscopic polypectomy, endoscopic sphincterotomy

Sources of Bleeding Proportions of Patients % Ulcers 31-67 Varices 6-39 Mallor Weiss Tears 2-8 Gastroduodenal Erosions 2-18 Erosive Oesophagitis 1-13 Neoplasm 2-8 Vascular ectasias 0-6 No source identified 5-14 Ref :Harrison Table 41-1

 Massive bleeding cause significant risk for myocardial infarction from coronary artery hypoperfusion from hypovolemia.  It is estimated that 16% who had severe gastrointestinal bleeding had ended up with myocardial infarction.  Patients who have myocardial infarction consequent to massive bleeding often do not experience chest pain, or the chest pain may be misinterpreted as epigastric pain

 Complete Blood count, ESR,  Liver and Renal Function Tests, Electrolytes  Prothrombin Time and INR  BUN / Creatinine – ratio > 30 sensitivity of 68% and a specificity of 98%  Stool Occult Blood Test  Grouping and Cross Matching  ECG, Cardiac enzymes(if essential)  HIV, HbsAg, AntiHCV Markers

 Explain NSP  Nil by Mouth  NG Tube insertion and Lavage  Hemodynamically Unstable – Hypotension, Tachycardia, Postural Changes Urgent Endoscopy  Hemodynamically Stable  Plan Early Endoscopy  IV PPI Therapy

 A grossly bloody aspirate in the atraumatic NG intubation CONFIRMS a UGI Bleed  The type of bleed  Red blood - active bleeding  Coffee ground - recently active bleeding.  Continued aspiration of red blood - severe, active hemorrhage.  Clears the field for endoscopic visualization  Prevent aspiration of gastric content  However, lavage may not be positive if bleeding has ceased or arises beyond a closed pylorus.

• PPI Infusion  IV Omeperazole 80mg bolus then 8mg/hr infusion • Endoscopic Therapy  Bipolar Coagulation, Heater Probe, Injection Therapy(Absolute Alcohol, 1:10,000 epinephrine), Hemoclips  Medical Management ◦ Antacids, H2 receptor Antagonists, PPIs, ◦ Cytoprotective Agents - Bismuth Preparations, Prostaglandin Analogues ◦ H.Pylori Eradication  Surgical Management ◦ Duodenal Ulcer ◦ Gastric Ulcer

 Primary Prophylaxis – Beta Blockade  Prevention of Rebleeding  Medical Management ◦ Vasoconstricting Agents  Baloon Tamponade – Sengstaken Blakemore Tube  Endoscopic Management ◦ EVL, Sclerotherapy(CyanoAcrylate)  Surgical Management ◦ TIPSS, Oesophageal Transection, Suguira Procedure ◦ Liver Transplantation

 A transthoracoabdominal oesophageal transection, ◦ paraoesophageal devascularisation, oesophageal transection and reanastomosis, splenectomy, and pyloroplasty.  The prognosis - liver function left at the time of operation but not on whether operation was done as an emergency, elective, or prophylactic measure.

 Hemodynamic instability despite vigorous resuscitation (>6 units transfusion)  Failure of endoscopy  Recurrent hemorrhage after initial stabilization  Shock associated with recurrent hemorrhage  Continued slow bleeding with a transfusion exceeding 3 units/day  Oneofthecriteriausedtodeterminetheneedforsurgicalinterventionis thenumberofunitsoftransfusedbloodrequiredtoresuscitatethepatient. Themoreunitsrequired,thehigherthemortalityrate(Larson,1986). Operativeinterventionisindicatedoncethebloodtransfusionnumber reachesmorethan5units,asnotedinthefollowingtable(Larson,1986). NumberofUnits Transfused Needfor Surgery,% Mortality Rate,% 0 4 4 1-3 6 14 4-5 17 28 >5 57 43

 Poor prognosis – 5yr survival rate 5%  Surgical Resection –Oesophagectomy  Radiotherapy – 5500 -6000 cGy for SCC  Chemotherapy - 1or 2 drugs mostly cisplatin  Palliative Gastrostomy, Jejunostomy  Expansive Metal Stents  Endoscopic Fulguration

 Gastric Carcinoma

 Distal - Subtotal Gastrectomy  Proximal – Near total Gastrectomy  Radioresistant – RT only for palliation of Pain  Chemotherapy ◦ 5FU + Leucovorin ◦ Cisplatin + Epirubicin/Docetaxel  Debulking the primary – best Palliation

 Mucosal lacerations at the gastroesophageal junction or in the cardia of the stomach  A/w repeated retching or vomiting and are another important cause of nonvariceal UGIB in Alcoholics  2% to 8% of acute UGIB are secondary to Mallory-Weiss tears  Some cases are self-limited and do not require endoscopic hemostasis  Some cases could be severe enough to require blood transfusions, endoscopic hemostasis, surgery.

Oesophagitis Angiodysplasia

 Vascular ectasia - Angiomas, AV malformations and Angiodysplasia  Vascular ectasias 5% to 10% of cases and the severity - trivial to severe  Vascular ectasias a/w – Congenital, CRF. The evidence for these associations is limited.  Management is by endoscopic ligation, cauterisation and sclero therapy

 Dieulafoy's lesion is a rare etiology in acute UGIB  Dieulafoy's lesions are difficult to identify endoscopically because they often retract. Their histopathologic description is a “caliber-persistent artery” in the submucosal tissue  On endoscopy, a Dieulafoy's lesion is akin to a visible vessel protruding from an ulcer, yet without an underlying ulcer.

 Age > 60 yrs  Comorbidities (Renal failure, Liver failure, CHF, Malignancy)  Variceal bleeding (as compared with nonvariceal bleeding)  Shock or hypotension on presentation  Increasing number of units of blood transfused  Active bleeding on Endoscopy  Bleeding Ulcer of >2cm or a Spurting vessel  Need for emergency surgery

 No comorbid diseases  Normal vital signs  Normal or trace positive stool guaiac  Negative gastric aspirate, if done  No problem home support  Proper understanding of signs and symptoms of significant bleeding  Immediate access to emergent care if needed  Follow-up arranged within 24 hr

 Blood Urea(mg/dl) ◦ 6.5 - 8 2 ◦ 8 - 10 3 ◦ 10 - 25 4 ◦ ≥25 6  Haemoglobin (g/L) for men ◦ 12-13 1 ◦ 10-12 3 ◦ <10 6  Haemoglobin (g/L) for women ◦ 10-12 1 ◦ <10 6  Systolic BP (mm Hg) ◦ 100–109 1 ◦ 90–99 2 ◦ <90 3 •Other markers Pulse ≥100 (per min) 1 Presentation with melaena 1 Presentation with syncope 2 Hepatic disease 2 Cardiac failure 2 •scores ≥ 6 - 50% risk of needing an intervention. Score Score is"0" if : •Hemoglobin level >12.9 g(men) or >11.9 g(women) •Systolic blood pressure >109 mm Hg •Pulse <100/minute •BUN level <18.2 mg/dL •No melena or syncope •No liver disease or heart failure

Type Endoscopic Characteristics % of Bleeding % of Mortality 1 Active Bleeding 90 11 2a Non Bleeding Visible vessel 50 11 2b Adhereynt Clot 33 7 2c Flat Pigmentation 7 3 3 Clean Base 3 2

 Various Endoscopic Modalities ◦ Inj.Epinephrine,Sclerosants,Thermal Cautery,Argon Plasma Coagulation, Electrocautery, Hemoclips, Bands, Fibrin Glue, Thrombin  Endoscopic Sprays  Post Endoscopic PPI therapy – lowers 30 day rebleeding rate  Second Look Endoscopy – 16-24hrs  Angioembolization – Gelatin Sponges, Polyvinyl Alcohol, Cyano Acrylic Glues, Coils.

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