upper G I Bleed (non variceal)
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upper G I Bleed (non variceal) upper G I Bleed (non variceal) Presentation Transcript

  • Dr. Balvir Singh Professor P. G. Deptt. Of medicine S.N. Medical College ,Agra
  • UGI BLEED  It is defined as bleeding from gastrointestinal tract proximal to ligament of Trietz.  It usually manifests as hematemesis or melena, and when severe, may even lead to hematochezia.  Clinical guidelines are recommended to predict out -come, including rebleeding, and mortality.  Stigmata of a recent hemorrhge are endoscopic finding that predict outcome.  Endoscopy can provide the diagnosis,prognosis, and the potential for therapy. Medicine update 2013 API
  • Features Hemoptysis Haematemesis Definition Coughing out of blood Vomiting out of blood Symptoms Symptoms of pulmonary and CVS disease Symptoms of upper GI tract diseases Content & colour Mixed with sputum & bright red in colour Mixed with food particles & coffee-ground in colour Premonitory symptoms Cough, salty sensation in throat Nausea , vomiting, retching, abdominal discomfort. Melaena Does not occur Usually followed by melaena the next day Amount Relatively less Huge in amount Reaction Alkaline(Blue litmus remain unchanged) Acidic(Blue litmus remains unchanged
  • UGI BLEED  Upper vs Lower GI bleeding = 5:1  Incidence: 170 patients/ 100,000 population /year(usa data).  40% due to peptic ulcer(Most common).  80% are self-limited.  Pts on anti platelet therapy has two fold increase in bleed as compared to normal ones(annual UGI Bleed incidence-.13%).  20% of pts of moderate to high risk, who have recurrent bleeding (within 48-72 hrs) have poor prognosis.  The mortality rate is 5% to 10% for severe UGI bleed. (Barkun A, Sabbah S, Enns R, et al:Am J Gastroenterol 2004; 99:1238-46) Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition :(Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013)
  • Clinical Features 1)Features due to blood loss : 1.Haemetemesis,malena or haematochezia , Hyperactive bowel sound. 2.H/O CLD presenting with shock. 3. H/O ESRD with sudden derange RFTs. 4. Features of co-morbid illnesses - IHD, COPD, CHF,SEPTICEMIA,PT ON VENTILLATORY SUPPORT. O/E: 1. Anemia 2.Orthostatic changes of BP and HR 3.Shock Other Clues -Raised BUN (Due to volume depletion and absorption of blood protein)
  • b ) Features due to underlying cause: Cause Features Peptic ulcer Epigastric burning pain Varices Vague right upper quadrant pain, fever, nausea, vomiting, ascites, edema. Features of hepatic failures Oesophagitis Heartburn, regurgitation, chest pain, dysphagia, odynophagia, and globus sensation. Mallory weiss tear Excessive retching,Vomiting, or coughing preceding hematemesis after alcohol intake. Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • CAUSES OF SEVERE UGI BLEED Peptic ulcer 38 % Esophagitis 13 No cause found 8 Upper gastrointestinal tract tumor 7 Angioma 6 Mallory weis tear 4 Erosions 4 Dieulafoy’s lesion 2 Other 2 Variceal bleed Non variceal bleed Oesophageal varices & Gastric varices 16% Barkun A, Sabbah S, Enns R, et al Am J Gastroenterol 2004; 99:1238-46
  • Uncommon Causes of non variceal bleed (< 5%)  Gastroesophageal reflux disease  Trauma from foreign body  Esophageal ulcer  Cameron lesion  Stress ulcer  Drug induced erosions  Angioma  Watermelon stomach  Portal hypertensive gastropathy  Aorta-enteric Fistula  Radiation telangiectasis/ Enteritis  Benign tumours  Malignant tumour  Blue rubber bleb nevus syndrome  Osler-Weber-Rendu syndrome  Haemobilia  Hemosuccus pancreatitis  Infections(CMV,HSV)  Stomal ulcer  Zollinger-ellison syndrome :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013
  • DIAGNOSIS HISTORY EXAMINATION EMERGENCY ENDOSCOPY???
  •  History  Helpful to find out the site and cause  History suggestive of acid – peptic disease  Alcoholic liver diseases / chronic hepatitis / Cirrhosis  History of anticoagulant / anti platelets / NSAIDS / Alcohol binge intake / steroids  History of Coagulation disorder / Blood Dyscrasias  History of Epistaxis or Hemoptysis to rule out the GI source of bleeding  Patients of CVA, BURN, Sepsis, Head Trauma may have stress ulcers
  • ON EXAMINATION  VITALS  Pulse = Thready,BP = Orthostatic Hypotension  SKIN changes  Cirrhosis – Palmer- erythema, spider angioma  Bleeding diasthasis – Purpura /Echymosis  Coagulation Disorder – Haemarthrosis, Muscle Hematoma  ENT :- Look for clots (To rule out epistaxis P.N BLEED)  P/A :-  Liver , Spleen, Caput Medusa = Cirrhosis  Epigastric Tenderness = APD/ Ulcer  Respiratory, CVS, CNS  For comorbid diseses
  • Diagnostic Workup  CBC  Bleeding &Coagulation profile (BT, CT,PT, a PTT)  Liver Function Test  Complete S. Biochemistry  Relevant lab test for underlying disease BLOOD INV. ENDOSCOPY RADIO-IMAGING • Barium Meal F.T. • Arteriography • USG/ Doppler USG • Radio nucleotide study (Tagged RBC scan)
  • RISK FACTORS AND RISK STRATIFICATION -To identify patients with nonvariceal UGI bleeding at greatest risk for mortality and rebleeding. -Pts may be categorised as low, intermediate and high risk Pre-endoscopy scoring systems Postendoscopy scoring system Blatchford Score: BP,BUN level, Hb, Heart rate , syncope, Melena ,liver disease , Heart failure Clinical Rockall Score: Patient’s age , shock & coexisting illnesses Artificial neural network score: 21 variables Complete Rockall Score: Clinical Rockall score + endoscopic findings. * Correlates well with mortality & risk of rebleeding. Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • Blatchford scoring system( pre endoscopic assesment) Variables Points * SBP(mm Hg) 100-109 1 90-99 2 <90 3 * BUN (mg/dl) 39.0-47.4 2 48.0-59.4 3 60.0-149.4 4 >150 6 * Hb(men;g/dl) 12.0-12.9 1 10.0-11.9 3 <10.0 6 * Other variables pulse >100 1 Presentation with melena 1 Hepatic disease 2 Cardiac failure 2 Most patients need intervention if their score is 6 or higher. Blatchford O, Murray WR, Blatchford M: Lancet 2000; 356:1318-21.
  • ROCKALL SCORING SYSTEM Variable Points 0 1 2 3 Age(yr) <60 60-79 >80 - Pulse rate <100 >100 - - Systolic BP Normal >100 <100 - Comorbidity None - IHD, Cardiac failure. Renal failure, hepatic failure , metastatic cancer. Diagnosis Mallory Weiss tear or no lesion observed All other diagnosis Malignant lesions - Endoscopic stigmata No stigmata or dark spot in ulcer base - Blood in UGI tract , visible vessel etc - Rockall TA, Logan RF, Devlin HB, Northfield TCGut 1996; 38:316-21.
  • Total score Mortality rate(%) Rebleeding rate(% 0 0 4.9 1 0 3.4 2 0.2 5.3 3 2.9 11.2 4 5.3 14.1 5 10.8 24.1 6 17.3 32.9 7 27.0 43.8 ≥8 41.1 41.8 Risk category: High (> 5) Intermediate (3–5) Low (0–2) Rockall TA, Logan RF, Devlin HB, Northfield TCGut 1996; 38:316-21.
  • Management as per risk  1- Low risk(0-2)-Usually 80 % of the pt recovers spontaneously with medical Tt( PPI)+ Hospitalisation for 24 hrs and may be discharge if uneventful.  2-Intermediate risk(3-5)- same Tt + Hospitilisation for atleast 72 hrs.  3- High risk(>5%)- Same Tt+ Hospitilisation in I.C.U. :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013
  • Objectives in Acute GI bleeding: Immediate Assessment Stabilization of hemodynamic status Identify the source of bleeding Stopping the active bleeding Treat the underlying Prevent recurrent bleeding
  • Management of UGIB GENERAL MEDICAL MANAGEMENT TYPE OF BLEEDING VARICEAL BLEEDING NON VARICEAL BLEEDING MEDICAL ENDOTHERAPY SURGICAL INERVENTION PRESSURE TECHNIQUES
  • ENDOSCOPIC MODALITIES AVAILABLE FOR THE MANAGEMENT OF U.G.I. BLEED  INJECTION  Adrenalin  Fibrin glue  Human Thrombin  Sclerosants  Alcohol  THERMAL  Heater Probe  Bicap Probe  Gold Probe  Argon plasma coagulation  Laser therapy  MECHANICAL  Haemoclips  Banding  Endoloops  Staples  Sutures Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • NON VARICEAL BLEED Mt ENDOSCOPIC MANAGEMENT 1.INJ.EPINEPHRINE 2.HAEMOCLIPS 3.LOOP LIGATION 4.CAUTERY : • MONOPOLAR • BIPOLAR • APC OTHERS 1.INTERVENTIONAL RADIOLOGICAL PROCEDURES 2.TRANS CATHETRAL ARTERIAL EMBOLISATION Ripoll C, Banares R, Beceiro I, et al 2004; 15:447-50 : 3.SURGICAL INTERVENTION • WITH ENDOSCOPE • WITHOUT ENDOSCOPE
  • AUGIB Rapid Assessment Monitor Hemodynamic Status Fluid Resuscitation Ryle;s tube for Gastric Lavage Self Limited Hemorrhage (80%) Continued bleeding (10-25%) Urgent endoscopy Recurrent Hemorrhage Elective Endoscopy (With in 24 – 48 hours) Definitive Therapy (If Necessary) Site not localized Localized Further Assessment (Extended EGD, Radio-isotope scan, Arteriography, Exploratory Laprotomy) Definitive Therapy
  •  FLUID RESUSCITATION  Vitals are monitored  Assessment of severity of blood loss :- An orthostatic decrease of 20 mm Hg in systolic blood pressure or increases in the pulse of 20 beats / min. indicate – 10% blood loss, if pt is pulsless and in shock- > 20% loss.  Order hemoglobin, hematocrit, BUN, grouping and cross matching of blood.  Insertion of central venous line may be beneficial to measure adequacy of fluid replacement and perfusion of vital organ .  Monitor urine output.  Fluid resuscitation is done by crystalloids such as normal saline or RL if hypoalbuminemia is detected use colloids.  Placing the patient in trendelenburg position to maintaine cerebral blood flow. General Management :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013
  • General Management 1.Oxygen support to prevent hypoxia of tissues 2.IV route - Crystaloid solution/Colloids|blood. 3. Blood transfusion:  maintain Hct at 30% in the elderly, esp. with comorbid deseases eg. CHF, CRF, IHD,COPD)  20-25% in younger pt  25-28% in portal HTN  administration of vit k 4.In symptomatic thrombocytopenia (<50000 )infused platelets. 5.FFP-The transfusion of plasma should not be based solely on the patient’s abnormal INR and/or PTT. The decision to transfuse should be based on the patient’s clinical condition. Wong et alBCMJ, Vol. 49, No. 6, July, August 2007, page(s) 311-319 Articles Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • A. MEDICAL THERAPY  H2B vs PPI  H2 blockers are not as effective as PPI *Proton pump inhibitors- -its use is widely adopted and is mandatory in all UGIBleed. -PPIs are the only drugs that can maintain a gastric pH >6 and thus prevent fibrinolysis of clot - In patients initially treated with a bolus infusion of omeprazole/ pantaprazole 80 mg followed by a continous infusion 8mg/hr ,and the need for endoscopic therapy has reduced. - PPI+ Endotherapy shown the best results in terms of rebleeding, morbidity and mortality.(Sung JJ, Mossner J, Barkun A, et alAliment Pharmacol Ther 2008; 27:666-77. : )
  • - OMEPRAZOLE/PANTOPRAZOLE- 80 mg bolus followed by 8 mg/h infusion for 72 hrs.(Khuroo MS, Yattoo GN, Javid G, et al: N Engl J Med 1997; 336:1054-8.) - ? H2 antagonist /Sucralfate has not been shown to be effective in UGI bleed * Octreotide/Somatostatin: -A meta-analysis has suggested that intravenous administration of somatostatin or its long-acting form octreotide decreases the risk of rebleeding from peptic ulcers when compared with placebo or an H2 receptor blocker.(A meta-analysis. Ann Intern Med 1997; 127:1062-71)  The use of octerotide should be considered in pts who have persistent bleeding even on optimal medical management. - :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013 (Collins R, Langman M: Treatment with histamine H2 antagonists N Engl J Med 1985; 313:660-6).
  • Identify bleeding source (Pre- requisites for endoscopy): Bloody endoscopy field 1. Naso-gastric tube(RT. esp. Wide bore) –  coffee coloured/clots/fresh blood  aspirate may categorize these pts- Low/ Intermediate/High 2. Gastric Lavage –  saline with or without H2O2  prokinetic(erythromycin, metchlopromide) agents may be used.  color and rapidity of clearing: clear fluid indicates absence of GH and pt may be subjected for endoscopy. 3. Risk of aspiration (insure airway/ E.T tube). Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • NASOGASTRIC LAVAGE  Benefits of lavage :  Better visualization during endoscopy.  Give crude estimation of rapidity of bleeding.  Prevent the development of porto systemic encephalopathy in cirrhosis.  Increases PH of stomach and hence decreases clot desolution due to gastric acid dilution  During gastric lavage use saline and not use large volume of to avoid water intoxication.  Gastric lavage should be done in alert and cooperative patient to avoid broncho-pulmonary aspiration Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • NASOGASTRIC LAVAGE  If gastric aspirate either is grossly bloody or yields coffee ground effort should be made to lavage the stomach before proceeding to diagnostic or therapeutic endoscopy.  The presence of bloody gastric aspirate confirms UGI Bleed.  A negative aspirate (16%) does not exclude an upper bleeding. For Example in case of duodenal ulcer due to absence of duodenogastric reflux aspirate is clear Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • B. Endoscopic therapy 1. Urgent vs elective endoscopy: < 12 hrs 2. Studies have not found overall advantage of early endoscopy (<12 hrs) in terms of rebleeding, need for surgery or mortality. 3. However persistent active bleeding may recquire urgent endotherapy. 4. Elective endoscopy: Within 24-48 hrs of bleeding. :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013
  •  Endoscopy can offer therapeutic options including: injections , cautery , placement of endoclips or a combination of therapies. 1. ENDOSCOPIC STIGMATAS OF RECENT bhhaahahahhhHHAEMMHEMORRHAGE:Stigmata Risk of rebleeding (%) Mortality(%) Prevalence (%) Active arterial bleeding 55-90 11 10 Non bleeding visible vessel 40-50 11 25 Adherent clot 20-35 7 10 Oozing 10-25 NA 10 Flat spot <10 3 10 Clean ulcer base <5 2 35 :Acute upper gastrointestinal bleeding in adults. Author. John R HAEMORRHAGE
  •  2.UTILITY OF ENDOSCOPIC THERAPY  Must for diagn.&therapeutic * Endoscopic therapy resulted in a significant improvement in: Hemostasis , number of units of blood transfused , no. of emergency interventions, hospital stay & hospital costs. * In the managment of adherent clots ,endoscopic therapy show improvement when compared with PPIs * Mortality rate is lower in group treated with endoscopic therapy + PPI as compared to alone. .(Sung JJ, Mossner J, Barkun A, et al Aliment Pharmacol Ther 2008; 27:666-77. : ) :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013
  •  3.OPTIMIZING ENDOSCOPIC VISUALIZATION * Visualization of blood within the GI tract is a challenge in managing patients with GI bleed. * This problem can be overcome by using: - double channel or large channel endoscopes, which allow for vigorous aspiration. - i.v erythromycin(250mg bolus) can be used as a prokinetic drug to clear the stomach of blood, it is given 30-120 minutes prior to endoscopy :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013
  •  4. METHODS TO CONTROL BLEEDING Current endoscopic modalities are: * Injection therapies (primarily with dilute epinephrine) * Contact thermal therapies – heater probes,mono & bipolar cautery. * Noncontact thermal methods (argon plasma coagulation) * Mechanical treatments- endoclips,loop/ band ligation techniques. * Combination of above treatment modalities :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013
  •  INJECTION THERAPY * Reduce blood flow by local tamponade. * Use of vasoconstricting agents, eg epinephrine further reduce blood flow. (inject 0.5- to 1.0-mL aliquots of epinephrine (1 : 20,000) via a sclerotherapy needle into four quadrants of the ulcer within 1 to 2 mm of the bleeding site ) * Other agents used – sclerosants like ethanolamine & thrombogenic agents( less efficacious). * injection therapy not as efficacious as other modalaties of monotherapies. :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013
  •  CONTACT THERMAL THERAPY monopolar cautery – currently not in use * Bipolar cautery - Thermal modality used most extensively. * It has the advantage over heater probes as it can be used perpendicularly or tangentially. * Bleeding vessel is compressed and then coagulated. * Low wattage (10-15 watts in duodenum; 15-20 in stomach) is used for a prolonged time (8-12 second pulses) . * End point of treatment is when involoved vessel flattens out & there is no bleeding. :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013
  •  MECHANICAL TREATMENT - therapy of choice in obvious arterial bleeding. * Endoscopic hemoclips are widely used. * Has theoretical advantage over cautery of not causing further tissue damage. * Rebleeding rates are reduced with endoclips  COMBINATION THERAPIES * Typically involve injection therapies with thermocoagulation technique. * Combination therapy appears to provide durable control of bleeding than monotherapies :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013
  •  SECOND LOOK ENDOSCOPY * Routine second-look endoscopy is not recommended for most patients with peptic ulcer bleeding. * Typically done 24 hours after the initial endoscopy. * Any persistent stigmata of haemorrhage are treated. * It is beneficial in certain circumstances, especially after injection monotherapy. :Acute upper gastrointestinal bleeding in adults. Author. John R Saltzman,:current gastroenterology updates 2013 Barkun A, Bardou M, Marshall JK: Ann Intern Med 2003; 139:843-57.
  • Impact of anticoagulation on rebleeding  Anticoagulation should be stopped immediately.  The prescence of mild to mod anticoagulation(INR 1.3- 2.7) did not appear to alter the outcomes of endoscopic therapy.(wolf AT,Wasan SK,saltzman JR 2004;99:1238-1246)  Patients who require an antiplatelet medication and have a history of ulcer bleeding will have less chance of recurrent bleeding if they take aspirin 81 mg and a PPI daily compared with clopidogrel alone. Chan FK, Ching JY, Hung LC, et al: Clopidogrel versus aspirin and esomeprazole N Engl J Med 2005; 352:238-44
  • Adverse prognostic factor in UGIB 1. Age over 60 2. Shock(SBP<100mmhg), pulse >100 3. Malignancy or varices as bleeding source. 4. Sever coagulopathy 5. Comorbid medical illness 6. Continued or recurrent bleeding 7. Severe active Bleeding (Hypotension, multiple transfusion, bright red nasogastric aspirate) 8. Endoscopically identified arterial bleeding or visible vessel 9. Ulcer location 10. Emergency surgery if surgical complication Medicine update 2013 API
  • Treatment of Pt with recurrent Gastrointestinal bleeding Initial Control Endoscopic therapy Permanent Control Rebleeding Endoscopic therapy Rebleeding Surgery Angiography Permanent Control 80-90% 50% :Acute upper gastrointestinal bleeding in adults. Author. John R
  • TAKE HOME MESSAGE  Early Resucitation.  Nasogastric wash + look for GH.  High dose PPI therapy for at least 72 hrs.  Urgent Endoscopic therapy for mod to severe UGI bleeding.  Nonvariceal bleeding should be treated with either: - Combination therapy using an injection of dilute epinephrine combined with a thermocoagulation OR - Endoclip (with or without injection therapy)  Combination therapy preffered along with medical management.  Relook endoscopy should be preffered only for mod to severe bleeding.  Pt should also be treated for specific cause/disease.
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  • PEPTIC ULCER  PATHOGENESIS: Due to decrease in mucosal defense mechanism: aspirin, other NSAIDS, H.Pylori or both. H.PYLORI: NSAIDS: * involves antrum * gastric ulcers > common *duodenal ulcers * 15-45% patients develop * 3%(USA) & 25%(Japan) ulcers on regular use lifetime risk of peptic ulcer Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • PEPTIC ULCER SOURCE PREVALENCE DUODENAL ULCER 24.3% GASTRIC EROSIONS 23.4% GASTRIC ULCER 21.3% MALLORY-WEISS TEAR 7.3% ESOPHAGITIS 6.3% EROSIVE DUODENITIS 5.8% :American society for gastrointestinal endoscopy bleeding survey of 2225 pts
  •  Endoscopic risk stratification: (FORREST classification)- IA: Active spurting bleeding IB: Oozing bleeding IIA: Pigmented protuberance IIB: Adherent clot IIC: Flat pigmented spot III: Clean based ulcer Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • Gastric antral ulcer with a clean base
  • Duodenal ulcer with flat pigmented spots
  • Duodenal ulcer with a dense adherent clot
  • Duodenal ulcer with active spurting (arrow)
  •  High risk of rebleeding : *active arterial bleeding(90%) *nonbleeding visible vessel(50%) *adherent clot(33%)  Lower Risks: 1. flat red or black spot 2. clean based ulcer Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  •  Doppler Probe Ultrasound : * passed through working channel of endoscope . * used to determine if blood flow is present beneath a stigma in the ulcer base. * preferred cost minimizing strategy over conventional endoscopic therapy Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • (b) Adherent clots: --endoscopic therapy (5% rebleeding rate) : epinephrine rotatable cold snare to guillotine the clot -- medical therapy (upto 35% rebleeding rate). (c) Clean –based ulcers: --after target irrigation have rebleeding rate of <5% -- do not require endoscopic therapy. -- biopsies should be considered to exclude malignancy Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • ALOGRITHM FOR MANAGEMENT OF ULCERS AND ACUTE GASTROINTESTINAL BLEEDING ULCER OVERLYING CLOT IRRIGATE ADHERENT CLOT CLOT REMOVAL ACTIVE BLEEDING OR VISIBLE VESSEL DARK/PIG MENTED RED SPOT CLEAN BASE MEDICAL THERAPY ENDOSCOPIC INTERVENTION SUCCESSFUL NOT SUCCESSFUL ICU 1 DAY HOSPITAL FOR 3 DAYS ANGIOGRAM OR SURGERY REBLEEDING MEDICAL THERAPY EPINEPHRINE INJ / CLOT REMOVAL :American society for gastroenterology 2001;53:853-
  • PHARMACOLOGICAL THERAPY DRUG TYPE EXAMPLES DOSE ACID SUPPRESSING DRUGS a ) Antacids Mylanta, Tums 100-140 meq/l b ) H2 receptor antagonists Cimetidine 400 mg bid Ranitidine 300 mg hs Famotidine 40 mg hs Nizatidine 300mg hs c) PPIs Omeprazole 20mg/d Lansoprazole 30mg/d Rabeprazole 20mg/d Pantoprazole 40mg/d Esmoprazole 20mg/d MUCOSAL PROTECTIVE AGENTS a) Sucralfate Sucralfate 1g qid b) Prostaglandin analogue Misoprostol 200µg qid c) Bismuth –containing compounds BSS Harrison's™ PRINCIPLES OF INTERNAL MEDICINE Eighteenth Edition
  • Regimens for Eradication of H. Pylori Infection DRUG DOSE TRIPLE THERAPY(14 days) 1.BISMUTH SUBSALICYLATE PLUS 2 TAB. qid • METRONIDAZOLE PLUS 250 mg qid • TETRACYCLINE 500mg qid 2.RANITIDINE BISMUTH CITRATE PLUS 400mg bid • TETRACYCLINE PLUS 500mg bid • CLARITHROMYCIN OR METRONIDAZOLE 500mg bid 3.OMEPRAZOLE PLUS 20 mg bid CLARITHROMYCIN PLUS 250 or 500 mg bid METRONIDAZOLE OR 500mg bid AMOXICILLINE 1gm bid QUADRUPLE THERAPY(7-10 days) OMEPRAZOLE(LANSOPRAZOLE) 20mg(30mg) od BISMUTH SUBSALICYLATE 2 tab. qid METERONIDAZOLE 250 mg qid TETRACYCLINE 500mg qid Harrison's™ PRINCIPLES OF INTERNAL MED 18th Edition
  • ANGIOGRAPHY & SURGERY Indications: * Pt having large ulcer(>2cm) or ulcers in a location associated with large arteries. * Recurrent bleeding despite two sessions of endoscopic hemostasis. * Exsanguinating bleeding * If the endoscopist does not feel comfortable treating a large pulsating visible vessel * Locally confined bleeding malignant ulcerated mass. SURGERY Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition Angiographic interventions/surgery
  • MALLORY WEISS SYNDROME / TEARS  Mallory-Weiss tears are mucosal or submucosal lacerations that occur at the gastroesophageal junction and usually extend distally into a hiatal hernia .  Patients generally present with hematemesis or coffee- ground emesis after alcohol intake.  Typically have a history of recent nonbloody vomiting with excessive retching followed by hematemesis..  Endoscopy usually reveals a single tear that begins at the gastroesophageal junction and extends several millimeters distally into a hiatal hernia sac/within cardiac portion of stomach. Sleisengerand Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • Mallory-Weiss tear at the gastroesophageal junction.
  •  Occasionally, more than one tear is seen.  The bleeding stigmata of Mallory-Weiss tears can include a clean base, oozing, or active spurting.  Bleeding stop spontaneously in 80 – 90% of the patients  In 0 – 5% of the patient bleeding recurs  Endoscopic electro-coagulation of the tears  Angiography therapy with intra arterial infusion of vasopressin or embolisation.  Operative therapy with oversewing of tear. Sleisengerand Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • HAEMORRAGIC OR EROSIVE GASTRITIS  Stress related mucosal injury  Occur only in extremly sick patients  Ex. Serious trauma  Major Surgery  Burn Covering > 1/3 of Surface area  Major intracranial disease  Severe medical illness (Ventilator dependence, coagulopathy)  Significant bleeding probably does not develop unless ulceration occurs.  Intravenous H2-receptor antagonist is the treatment of choice. Sucralfate also effective  Aspirin and NSAIDS  Half of the patient who chronically ingest NSAIDS have Erosions. (15 – 30% have Ulcers)  Most Frequently and severely affected site is gastric antrum. Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • Treatment of NSAID-Related Mucosal Injury CLINICAL SETTING RECOMMENDATION Active ulcer NSAID discontinued H2 receptor antagonist or PPI NASAID continued PPI Prophylactic therapy Misoprostol, PPI, H.Pylori infection Eradication if active ulcer prresent or there is a past history of peptic ulcer disease. The approach to primary prevention has included avoiding the agent, using NSAIDs that are theoretically less injurious, and/or the use of concomitant medical therapy to prevent NSAID-induced injury. Several nonselective NSAIDs that are associated with a lower likelihood of GI toxicity include diclofenac, aceclofenac, and ibuprofen.Harrison's™ PRINCIPLES OF INTERNAL MEDICINE
  • NSAIDS induced gastric ulcers
  • PORTAL GASTROPATHY  On endoscopic examination mucosa is engorged and friable.  Portal hypertensive gastropathy (PHG) is caused by increased portal venous pressure and severe mucosal hyperemia that results in ectatic blood vessels in the proximal gastric body and cardia and oozing of blood.  Less severe grades of PHG appear as a mosaic or snake skin appearance and are not associated with bleeding.  Watermellon stomach. Sleisengerand Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  •  Usually, patients with severe PHG present with chronic blood loss, but they occasionally can present with acute bleeding. TREATMENT:  β-adrenergic receptor blockers.  TIPS or surgical portacaval shunt.  Endoscopic management has no role unless an obvious focal bleeding site is identified.  The best treatment is liver transplantation. Sleisengerand Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • PORTAL GASTROPATHY
  • Dieulafoy's lesion  It is a large (1- to 3-mm) submucosal artery that protrudes through the mucosa.  It is not associated with a peptic ulcer, and can cause massive bleeding.  It usually is located in the gastric fundus, within 6 cm of the gastroesophageal junction.  Dieulafoy's lesion can be difficult to identify at endoscopy because of the intermittent nature of the bleeding.  the overlying mucosa may appear normal if the lesion is not bleeding. Sleisengerand Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  •  Endoscopic Doppler ultrasound has been used to help identify a Dieulafoy's lesion that is not visualized on endoscopy.  If a Dieulafoy's lesion is found and treated, the site be marked with submucosal injection of ink to tattoo the area in case of rebleeding and the need for retreatment.  Endoscopic hemostasis of a Dieulafoy's lesion can be performed with injection therapy, a thermal probe, or clip device or by band ligation.  Rebleeding after successful hemostasis appears to be rare. Sleisengerand Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • Actively spurting jejunal Dieulafoy's lesion
  • Esophagitis  8% of all UGI bleeding was caused by erosive esophagitis.  independent risk factors for bleeding esophagitis were grade 3 or 4 (moderate to severe) esophagitis.  A history of heartburn was obtained in only 38% of patients.  Severe bleeding from gastroesophageal reflux– induced esophagitis is treated medically with a PPI Sleisengerand Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  •  Upper endoscopy is critical to diagnosing severe erosive esophagitis.  endoscopic therapy generally has no role unless a focal ulcer with a stigma of recent hemorrhage is found.  These patients should be treated with a daily PPI for 8 to 12 weeks and undergo repeat endoscopy to exclude underlying Barrett's esophagus Sleisengerand Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • Upper Gastrointestinal Malignancy  Malignancy accounts for 1% of severe UGI bleeds.  The tumors are usually large, ulcerated masses in the esophagus, stomach, or duodenum.  Endoscopic hemostasis with Monopolar electro cautary, laser, injection therapy, or hemoclips can temporarily control acute bleeding.  Angiography with embolization should be considered for patients with severe UGI bleeding caused by malignancy.  External beam radiation can provide palliative hemostasis for patients with bleeding from advanced gastric or duodenal cancer Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • Gastric Antral Vascular Ectasia  Gastric antral vascular ectasia (GAVE), also described as watermelon stomach.  characterized by rows or stripes of ectatic mucosal blood vessels that emanate from the pylorus and extend proximally into the antrum .  The cause is uncertain.  GAVE is most commonly reported in older womenand also seems to be more common in patients with end- stage renal disease Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  •  GAVE has been associated with cirrhosis and scleroderma.  Patients with GAVE who do not have portal hypertension demonstrate linear arrays of angiomas (classic GAVE).  whereas those with portal hypertension have more diffuse antral angiomas.  Endoscopic therapy with argon plasma coagulation has been shown to be equally (80%) effective in cirrhotic and noncirrhotic patients with GAVE. Sleisengerand Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • Gastric Antral Vascular Ectasia
  • Aortoenteric fistula  Bleeding is usually acute and massive, with a high mortality rate(30-100%).  A primary aortoenteric fistula is a communication between the native abdominal aorta (usually an atherosclerotic abdominal aortic aneurysm) and, most commonly, the third portion of the duodenum.  Often, a self-limited herald bleed occurs hours to months before a more severe, exsanguinating bleed.  On endoscopy obscure site of bleeding. Sleisengerand Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  •  Demonstration of an aortic aneurysm and fistulous track on abdominal CT angiogram.  Secondary aortoenteric fistula between the third portion of the duodenum and the proximal end of the graft but may occur elsewhere in the GI tract.  The fistula usually forms between three and five years after graft placement.  Surgical treatment is required to remove the infected graft.  Therapeutic endoscopy plays no role in the management of bleeding from an aortoenteric fistula. Sleisengerand Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • Cameron's lesions  Cameron's lesions are linear erosions or ulcerations in the proximal stomach at the end of a large hiatal hernia, near the diaphragmatic pinch.  Cameron's lesions are thought to be caused by mechanical trauma and local ischemia as the hernia moves against the diaphragm and only secondarily by acid and pepsin.  May present as slow GI bleeding and iron deficiency anemia.  The long-term medical management is usually with iron supplements and an oral PPI. Sleisengerand Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • Cameron's lesion
  • Varices:  Hepatic venous pressure gradient > 12 mmHg.  In esophageal varices , prefer variceal ligation (with multiband ligator) over endoscopic sclerotherapy.  In gastric varices, injection with a glue will be more beneficial . Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • Management of UGIB GENERAL MEDICAL MANAGEMENT TYPE OF BLEEDING VARICEAL BLEEDING NON VARICEAL BLEEDING MEDICAL ENDOTHERAPY SURGICAL INERVENTION PRESSURE TECHNIQUES
  • Medical Management Of Variceal Bleeding Vasoconstrictors  Vasopresin -0.1 0.5 units/minute for 4 to 12hrs(up to 48hrs) with short acting Nitrates.  Terlipressin-2mg bolus followed by 1mg every 4-6 hrly for 3- 5 days.  somatostatin -250ug bolus then 250ug/hr infusion  Octeotride-50ug bolus then 50ug/hr infusion for 5 days Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • Pressure techniques  Esophageal balloon • Sengstaken blakemore tube, • Minnesota tube • Linton Nicholas tube  Balloon should be inflated for less than 24 hrs. 75% rebleeding rate after balloon deflation.  Most reports suggest that balloon tamponade provides initial control of bleeding in 85% to 98% of cases. Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  •  variceal rebleeding recurs soon after the balloon is deflated in 21% to 60% of patients.  The major problem with tamponade balloons is a 30% rate of serious complications, such as aspiration pneumonia, esophageal rupture, and airway obstruction.  Clinical studies have not shown a significant difference in efficacy between vasopressin administration and balloon tamponade.(Pitcher JL: Safety and effectiveness of the modified Sengstaken-Blakemore tube: A prospective study. Gastroenterology ) Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • ENDOSCOPIC SCLEROTHERAPY  Various sclerosants used are  Na. morrhuate  Ethanolamine  Polidocanol(3%)  Na tetradecyl sulphate  Tissue adhesive glue – N – Butyrl – 2 – cyanoacrylate - prefered in fundal varices. Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  •  Hemostasis can be achieved in 85% to 95% of cases, with a rebleeding rate of 25% to 30%.  Complications include esophageal ulcers, which can bleed or perforate, esophageal strictures, mediastinitis, pleural effusions, aspiration pneumonia.  Band ligation is the preferred endoscopic therapy for variceal bleeding. Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • ENDOSCOPIC BAND LIGATION
  •  A rubber band is placed over a varix, which subsequently undergoes thrombosis, sloughing, and fibrosis.  Place two bands on each esophageal variceal column, one distally near the gastroesophageal junction and another 4 to 6 cm proximally.  Acute hemostasis generally can be achieved in 80% to 85% of cases, with a rebleeding rate of 25% to 30%.  Band ligation is associated with fewer local complications, especially esophageal strictures, and requires fewer endoscopic treatment sessions than sclerotherapy. Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  •  A meta-analysis has reported that variceal band ligation reduces the rates of rebleeding, overall mortality, and death from bleeding compared with sclerotherapy.  Band ligation + sclerotherapy combination has got better results for rebleeding. Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition
  • Surgical Management  TIPS (transjugular intrahepatic porto-systemic shunt): transjugular approach connect portal v. and hepatic v.  reduce portal v. pressure gradient to < 12-15 mmHg  A relook endoscopy should be done to evaluate for an alternative source of bleeding.  Complications include: bleeding, dye-induced renal failure, hemolysis, stent migration, and puncture of the gallbladder or other organs adjacent to the liver. Sleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition