UPPER GI BLEED
DEMARCATION OF UPPER AND
LOWER GUT


The World Organization of Gastroenerologists defines
acute upper GI bleeding as:


...
ETIOLOGY








Epidemiology
Accounts for 350,000 hospitalizations in U.S.
yearly
Risk factors
Aspirin or NSAID use...
Adults with acute massive GI Bleeding








Duodenal Ulcer (30-37%)
Gastric Ulcer (19-24%)
Esophageal Varices (6-...


Dieulafoy's Lesion (1%)
Artery at gastric fundus may bleed heavily
 Difficult to identify on endoscopy




Gastric a...
Adults with chronic intermittent
GI Bleeding







Gastritis (18 to 35%)
Esophagitis (18 to 35%)
Gastric Ulcer (18 ...
Adults - most commonly missed upper
GI sources




Large Hiatal Hernia Erosions
Arteriovenous malformation
Peptic Ulcer...
POSTERIOPR WALL DUODENAL
ULCER
GASTRIC ULCER IN ANTRUM
VARICEAL BLEED
HISTORY








Has the patient been vomiting or retching before
the episode of haematemesis? -> Mallory-Weiss
tear
...
ASSESSMENT






One should first determine the amount of blood
loss, and the site of bleeding.
The measurement of vita...
PHYSICAL EXAMINATION






Vital signs, in order to determine the severity of
bleeding and the timing of intervention
A...
DIAGNOSIS




Sometimes, the source can be naso-or
oropharyngeal. A careful exam of the nares
and oral pharynx should be...






A positive NG tube aspirate for blood usually
signifies that the site of bleeding is proximal to
the ligament of ...
Upper GI Bleeding Score


Criteria



Blood Urea Nitrogen (BUN)
BUN 18.2 to 22.4 mg/dl: Score 2
 BUN 22.4 to 28 mg/dl: ...



Hemoglobin
Men
Hemoglobin 12 to 13 g/dl: Score 1
 Hemoglobin 10 to 12 g/dl: Score 3
 Hemoglobin <10 g/dl: Score 6
...





Systolic Blood Pressure (SBP)
SBP 100 to 109 mmHg: Score 1
SBP 90 to 99 mmHg: Score 2
SBP <90 mmHg: Score 3







Miscellaneous Markers
Pulse >100 per minute: 1
Presentation with Melena: 1
Presentation with Syncope: 2
Hepat...
Interpretation


Assesses probability for intervention
Endoscopy
 Surgery






Score predicting resolution without i...
MANAGEMENT








INITIAL:
Nasogastric Tube with aspirate
Fresh blood suggests persistant bleeding
Avoid lavage du...
Management: General Measures








Helicobacter Pylori management
Empiric acid reduction (Proton Pump Inhibitor)
N...
Management: Low risk patients









Indications
Hemodynamically stable within 1 hour of
Resuscitation
Minimal Blo...



Protocol
Consider for rapid protocol
Immediate
Upper Endoscopy Evaluation of GI Bleeding
 Discharge to home if low-r...
Management: High risk patients







Indications
Active ongoing bleeding
Hypotension persists despite Resuscitation...








Protocol
General measures as above
Admit to intensive care unit for first 24 hours
Observe in hospital for ...
Outcomes








Overall Mortality: 2-15% (often related to
comorbidity)
Bleeding stops and does not recur: 70% (<2%
M...
Predictors


Bleeding characteristic predictors of poor
outcome




Emesis or nasogastric aspirate contains red blood
...


Comorbid condition predictors of poor outcome









Active Coronary Artery Disease
Congestive Heart Failure
...
Thanks
 upper gi bleed - lecture 1
 upper gi bleed - lecture 1
Upcoming SlideShare
Loading in...5
×

upper gi bleed - lecture 1

1,539

Published on

Published in: Education, Health & Medicine
0 Comments
3 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total Views
1,539
On Slideshare
0
From Embeds
0
Number of Embeds
0
Actions
Shares
0
Downloads
81
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide

upper gi bleed - lecture 1

  1. 1. UPPER GI BLEED
  2. 2. DEMARCATION OF UPPER AND LOWER GUT  The World Organization of Gastroenerologists defines acute upper GI bleeding as:  The anatomic cut-off for upper GI bleeding is the ligament of Treitz, which connects the fourth portion of the duodenum to the splenic flexure of the colon.
  3. 3. ETIOLOGY       Epidemiology Accounts for 350,000 hospitalizations in U.S. yearly Risk factors Aspirin or NSAID use (most common cause) Helicobacter Pylori infection Elderly (especially over age 70 years)
  4. 4. Adults with acute massive GI Bleeding        Duodenal Ulcer (30-37%) Gastric Ulcer (19-24%) Esophageal Varices (6-10%) Gastritis or Duodenitis (5-10%) Esophagitis or esophageal ulcer (5-10%) Mallory-Weiss tear (3-7%) Gastrointestinal malignancy (1-4%)
  5. 5.  Dieulafoy's Lesion (1%) Artery at gastric fundus may bleed heavily  Difficult to identify on endoscopy   Gastric antral vascular ectasia (0.5 to 2%) Longitudinal erythematous stripes on gastric mucosa  Known as Watermelon stomach    Arteriovenous malformation Angiodysplasia of stomach or duodenum,
  6. 6. Adults with chronic intermittent GI Bleeding       Gastritis (18 to 35%) Esophagitis (18 to 35%) Gastric Ulcer (18 to 21%) Duodenal Ulcer (3 to 15%) Angiodysplasia (5 to 23%) Gastric Cancer
  7. 7. Adults - most commonly missed upper GI sources    Large Hiatal Hernia Erosions Arteriovenous malformation Peptic Ulcer Disease
  8. 8. POSTERIOPR WALL DUODENAL ULCER
  9. 9. GASTRIC ULCER IN ANTRUM
  10. 10. VARICEAL BLEED
  11. 11. HISTORY       Has the patient been vomiting or retching before the episode of haematemesis? -> Mallory-Weiss tear Enquire about the colour of the vomitus Was there a previous incident of peptic ulcer or haematemesis/melaena? Heartburn -> Reflux oesophagitis Drug history (including aspirin and over the counter medicines -> peptic ulcer) Alcohol -> Liver failure -> oesophageal varices -> upper GI bleed
  12. 12. ASSESSMENT    One should first determine the amount of blood loss, and the site of bleeding. The measurement of vital signs provides the only accurate assessment of blood loss (orthostatics, heart rate, complaints of weakness or dizziness, syncope). An NG tube should be placed as part of the assessment. The gastric lavage may aid the endscopist to obtain a clear view of the bleeding site. 
  13. 13. PHYSICAL EXAMINATION    Vital signs, in order to determine the severity of bleeding and the timing of intervention Abdominal and rectal examination, in order to determine possible causes of hemorrhage Assessment for portal hypertension and stigmata of chronic liver disease in order to determine if the bleeding is from a variceal source.
  14. 14. DIAGNOSIS   Sometimes, the source can be naso-or oropharyngeal. A careful exam of the nares and oral pharynx should be done. The presence of "coffee ground emesis represents blood altered by gastric contents and usually means that there has been slow bleeding from the region between the esophagus and the duodenum.
  15. 15.    A positive NG tube aspirate for blood usually signifies that the site of bleeding is proximal to the ligament of Treitz. Other characteristics of upper GI bleeding are elevated BUN and hyperactive bowel sounds. The source of bleeding can be identified in 90% of cases if endoscopy is done within the first 24 hours.
  16. 16. Upper GI Bleeding Score  Criteria  Blood Urea Nitrogen (BUN) BUN 18.2 to 22.4 mg/dl: Score 2  BUN 22.4 to 28 mg/dl: Score 3  BUN 28 to 70 mg/dl: Score 4  BUN >70 mg/dl: Score 6 
  17. 17.   Hemoglobin Men Hemoglobin 12 to 13 g/dl: Score 1  Hemoglobin 10 to 12 g/dl: Score 3  Hemoglobin <10 g/dl: Score 6   Women  Hemoglobin 10 to 12 g/dl: Score 1  Hemoglobin <10 g/dl: Score 6
  18. 18.     Systolic Blood Pressure (SBP) SBP 100 to 109 mmHg: Score 1 SBP 90 to 99 mmHg: Score 2 SBP <90 mmHg: Score 3
  19. 19.       Miscellaneous Markers Pulse >100 per minute: 1 Presentation with Melena: 1 Presentation with Syncope: 2 Hepatic disease: 2 Cardiac function: 2
  20. 20. Interpretation  Assesses probability for intervention Endoscopy  Surgery    Score predicting resolution without intervention: <4 Score predicting intervention: >5
  21. 21. MANAGEMENT        INITIAL: Nasogastric Tube with aspirate Fresh blood suggests persistant bleeding Avoid lavage due to aspiration risk If severe bleeding and suspected variceal source See Esophageal Varices Octreotide 50 ug bolus, then 50 ug/hour
  22. 22. Management: General Measures       Helicobacter Pylori management Empiric acid reduction (Proton Pump Inhibitor) Not proven in-vivo to aid clotting No proven benefit in mortality and other outcomes Does not lower overall Incidence of re-bleeding Omeprazole may heal ulcer if near-achlorhydria
  23. 23. Management: Low risk patients       Indications Hemodynamically stable within 1 hour of Resuscitation Minimal Blood Products required (2 PRBC or less) No evidence of active bleeding Nasogastric Tube aspirate without blood No active comorbid medical conditions
  24. 24.   Protocol Consider for rapid protocol Immediate Upper Endoscopy Evaluation of GI Bleeding  Discharge to home if low-risk endoscopy results   Admit if rapid protocol not available   Follow moderate risk patient protocol below General measures as above
  25. 25. Management: High risk patients       Indications Active ongoing bleeding Hypotension persists despite Resuscitation Severe active comorbid condition exascerbation Liver disease exascerbation Endotracheal Intubation for airway protection
  26. 26.        Protocol General measures as above Admit to intensive care unit for first 24 hours Observe in hospital for 48 to 72 hours or more Urgent upper endoscopy when stabilized See Upper Endoscopy Evaluation of GI Bleeding Consider arteriography if source not evident
  27. 27. Outcomes     Overall Mortality: 2-15% (often related to comorbidity) Bleeding stops and does not recur: 70% (<2% Mortality) Bleeding after initially stopped: 25% (10% Mortality) Continued active bleed: 5% (30% Mortality)
  28. 28. Predictors  Bleeding characteristic predictors of poor outcome    Emesis or nasogastric aspirate contains red blood Low initial Hematocrit Coagulopathy (low platelets or high INR)
  29. 29.  Comorbid condition predictors of poor outcome         Active Coronary Artery Disease Congestive Heart Failure Active lung disease Renal Failure Sepsis Metastatic cancer Advanced liver disease Advanced age
  30. 30. Thanks
  1. A particular slide catching your eye?

    Clipping is a handy way to collect important slides you want to go back to later.

×