upper gastrointestinal bleeding what undergraduates should know ?

UPPER GASTROINTESTINAL BLEEDING

What Undergraduates should know ?

Prof SM ChandramohanProf and HOD

Department of Surgical Gastroenterology andCenter of Excellence for Upper GI Surgery

Madras Medical College andRajiv Gandhi Government General Hospital

Chennai

Can download this presentation from www.esoindia.org

Prof SM ChandramohanProf and HOD

Department of Surgical Gastroenterology andCenter of Excellence for Upper GI Surgery

Madras Medical College andRajiv Gandhi Government General Hospital

Chennai

DEFINITION

CAUSES

EVALUATION

TREATMENT

PLAN

OF

THE

TAL

K

DEFINITION

CAUSES

EVALUATION

TREATMENT

PLAN

OF

THE

TAL

K

MEDICALENDOSCOPIC

SURGICAL

DEFINITION

Any bleeding from The gastrointestinalTract above theLevel of ligament of Treitzis upper GI Bleeding

DEFINITIONS

• Acute GI bleed– < 3 days duration– hemodynamic instability– requires blood transfusion

• Overt vs. occult– overt = visible blood (melena, bright red

blood, coffee grounds)– occult = only detected by lab tests

COMMON CAUSES OF UGI BLEEDCAUSE % Peptic Ulcer 38%

Varix 16% Tumor 7% MW Tear 4%

Erosions 4%

Esophagitis 13%

NSAID (1) the risk of gastric ulceration is

increased to a greater extent than that of duodenal ulceration

(2) the risk of bleeding varies with the individual NSAID; for example, the relative risk of bleeding is greatest with piroxicam and less with ibuprofen

(3) the risk of bleeding is dose dependent

-age greater than 75 years, -history of heart disease, -history of peptic ulcer- history of previous gastrointestinal bleeding

Group Relative Risk Control[*] 1.0 Aspirin[†] 1.5-2.5 Other NSAIDs[†] 4-7 COX-2 Inhibitors 1.3-1.5

RISK FACTORS

AIRWAY

BREATHING

CIRCULATION

A

B

C

Examination

Tell tale signs…Chronic Liver DiseasePortal Hypertension

Examination

Not to miss……..Haemodynamic stabilitySigns of coagulation dysfunctionSigns of Liver cell failurePR

Bleeding PR

As he comes………….

Resuscitate and Examine Simultaneously…….

Form a team……….

Wide bore IV line…… preferably central line(take samples at the same time)Naso gastric tubeUrinary Catheter

ALERT OTHERS IN TEAM…….

Blood Sample for

Blood GroupHaemogram including plateletsCoagulation profileLiver function testRenal functionMarkers

Blood Sample

TRY NOT TO TAKE SAMPLES FREQUENTLYExcept for serial evaluation

WHICH TUBE AND WHY?

Naso Gastric Tube orSenstaken tube?

ROLE OF NASOGASTRIC TUBE

10 % of UGIB presents as LGIB

Red blood vs coffee grounds

NGT clears the gastric field for endoscopic visualization

prevent aspiration of gastric content

Endoscopy

When to do?What is Possible?

When not to do???

Endoscopy

One stop ShopDiagnose AssessTreatReassess

ENDOSCOPIC EVALUATION

If Hemodynamically stable

Identify Bleeding site

Delineate cause

Allow endotherapy

ENDOSCOPIC MANAGEMENT

VARICEAL

NONVARICEAL

ENDOSCOPIC VARICEAL LIGATIONA rubber band is placed over the varix which then undergoes thrombosis,sloughing,fibrosis.

ENDOSCOPIC SCLEROTHERAPYInvolves injecting a sclerosant Intravariceal/perivariceal

Common sclerosants Ethanolamine oleate Absolute alcohol Sodium morrhuate Sodium tetradecyl Hypertonic saline Polidocanol

GLUE THERAPYCyanoacrylate is a glue that is injected intoGastric varicesActs by forming a Cast over the varix on contactwith blood

Endoclip

DEFINITIVE MANAGEMENT OF NON VARICEAL BLEED

HIGH RISKULCERFORBLEED

SRH/LARGE ULCER >2 cm

ULCERS IN POSTERIOR WALL

BULB-GDA

ULCERS IN THE HIGH LESSER CURVE - LGA

Endoscopic Management

Non-Variceal - Modalities Injection Therapy (a) Adrenaline (b) Sclerosants Thermal Therapy (a) Monopolar (b) Bicap (c) Heater Probe (d) Argon Plasma Coagulation (e) Laser Mechanical Therapy (a) Haemoclips

Endoscopic Management

Bleeding Peptic Ulcer - Stigmata

1a – Spurting vessel 1b – Oozing from a vessel

2 – Clot in the ulcer base 3 – Ulcer without bleed

ForrestClassification

SECOND LOOK ENDOSCOPYIt is repeat endoscopy 24 hours after initial Endoscopic hemostasis

INDICATIONS1 Incomplete first endoscopic examination due to blood obscuring the field2 Patients with clinically significant rebleeding

WHEN TO CALL IT AS

FAILED ENDOTHERAPY?

SURGICAL MANAGEMENT OF UGI BLEEDING

The NeedOnly in Select Situations

Role of Surgery

5-10% of UGI Bleed

Mortality

3% to 14%

TV Vs H.PYLORI Eradication

40% to 70% of patients with a bleeding duodenal ulcers- positive for H. pylori

Bleeding Gastric Ulcer

Simple excision alone -rebleed in 20% of patients

10% incidence of malignancy

Surgical options- Variceal bleeding

ShuntOr Devascularisation

Less Common Causes of UGIB

MALLORY WEISS TEARS

Managed with1 Hemoclips2 MPEC Probes3 PPI

DIEULAFOY’S LESIONlarge submucosal artery that protrudes through mucosaat the gastric fundus.

bleeding can be massive

Endoscopic Doppler USG canhelp localize

Endoscopic hemostasis -injection therapy , Thermal probe, clips.

Dieulafouy’s lesion

PPPRE APC PPPOST APC

Gastric Antral Vascular Ectasia

• Endoscopic therapy - successful in up to 90% of patients

• Failure of endoscopic therapy - antrectomy

SEVERE PORTAL HYPERTENSIVEGASTROPATHY

May present with acute orchronic bleed.

No role for endoscopic management.

Managed with B Blockers, TIPS, Surgical Porto Caval shunt, Liver transplantation.

HEMOBILIAThe diagnosis can be confirmedBy Side viewing Scopy

Ongoing or Recurrent bleed isTreated with angioembolization

CAUSES-HEMOBILIA

Liver trauma

Liver biopsy

ERCP/PTC/TIPS

HCC, CHOLANGIOCARCINOMA

Biliary parasite infestations

HEMOSUCCUS PANCREATICUSThe diagnosis can be made by Side viewing scopy

Management is by angioembolization

CAUSES-HEMOSUCCUS PANCREATICUS

Acute pancreatitis/chronic pancreatitis

Pancreatic pseudocyst

Pancreatic cancer

ERCP manipulation of PD

Rupture of splenic artery pseudoaneurysm into PD

ANGIOEMBOLIZATION

STRESS GASTRITIS

• Surgery - rarely indicated

• Vagotomy and pyloroplasty, with oversewing of the hemorrhage, or near-total gastrectomy - mortality rates as high as 60%

Malignancy

• Endoscopic therapy - successful in controlling hemorrhage, the rebleeding rate is high

• Standard cancer operations - indicated when possible

• Palliative wedge resections – to control bleed

Aortoenteric Fistula

• Ligation of the aorta proximal to the graft• Removal of the infected prosthesis• Extra-anatomic bypass• Defect in the duodenum - small and can be

repaired primarily• Typically, patients with bleeding from an

aortoenteric fistula will present first with a “sentinel bleed.”

MORTALITY

7% to 10%.

• The mortality has decreased only minimally during the last 30 years, despite the introduction of endoscopic therapy that reduces the rate of rebleeding.

– increasing percentage of UGIB occurring in the elderly– frequent use of antiplatelet medications or anticoagulants– frequent comorbid conditions.

Conclusion