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Upper gastrointestinal haemorrhage
Upper gastrointestinal haemorrhage
Upper gastrointestinal haemorrhage
Upper gastrointestinal haemorrhage
Upper gastrointestinal haemorrhage
Upper gastrointestinal haemorrhage
Upper gastrointestinal haemorrhage
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Upper gastrointestinal haemorrhage
Upper gastrointestinal haemorrhage
Upper gastrointestinal haemorrhage
Upper gastrointestinal haemorrhage
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Upper gastrointestinal haemorrhage

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  • 1. S5 UNIT 2006 MBBS BATCH TRIVANDRUM MEDICAL COLLEGE
  • 2. DEFINITION • Upper GI bleeding is defined as bleeding from a source proximal to the Ligament of Treitz
  • 3. ARTERIAL SUPPLY - STOMACH
  • 4. VENOUS DRAINAGE - STOMACH
  • 5. NERVE SUPPLY - STOMACH
  • 6. BLOOD SUPPLY OF DUODENUM ARTERIES : Upper half - superior pancreaticoduodenal A Lower half - inferior pancreaticoduodenal A VEINS : Superior pancreaticoduodenal V portal V Inferior pancreaticoduodenal V superior mesenteric V
  • 7. PORTAL SYSTEMIC VENOUS ANASTOMOSIS REGION PORTAL CICULATION SYSTEMIC CIRCULATION ESOPHAGUS LEFT GASTRIC VEIN AZYGOUS VEIN RECTAL SUPERIOR RECTAL VEIN MIDDLE AND INFERIOR RECTAL VEIN PARAUMBILICAL PARAUMBILICAL VEIN SUPERFICIAL EPIGASTIC VEIN RETRO PERITONEAL RIGHT, MIDDLE & LEFT COLIC VEIN RENAL, SUPRA RENAL, PARAVERTEBRAL & GONADAL VEIN BARE AREA OF LIVER HEPATIC VENULES PHRENIC AND INTERCOSTAL VEIN
  • 8. PORTO-SYSTEMIC ANASTOMOSIS
  • 9. PORTAL VENOUS SYSTEM
  • 10. • Most frequent cause of upper GI Bleed (40% of all cases) Duodenal Ulcer-gastroduodenal A. PUD Gastric ulcer-left gastric A.
  • 11. Decreased mucosal protection NSAID’s Steroids Hypersecretion of acid H.pylori (75% of gastric ulcers caused by this) Smoking and Alcohol correlation Gastrin (Zollinger-Ellison)
  • 12. Modified Johnson classification for gastric ulcer
  • 13. • Mallory-Weiss syndrome refers to bleeding from tears (a Mallory-Weiss tear) in the mucosa at the junction of the stomach and esophagus, usually caused by severe retching, coughing, or vomiting. • Mallory-Weiss tears account for 5% to 10% of cases of upper GI bleeding.
  • 14. Mechanism  Forceful contraction of the abdominal wall against an unrelaxed cardia, resulting in mucosal laceration of the proximal cardia as a result of the increase in intragastric pressure. Causes ALCOHOLISM HIATUS HERNIA
  • 15. • Appearance of multiple superficial erosions of the entire stomach, most commonly in the body Stress Gastritis decrease splanchnic mucosal blood flow altered gastric luminal acidity
  • 16. Seen in… NSAID users Sepsis Respiratory failure Hemodynamic instability Head injuries with I.C.T (Cushing ulcer) Burn injuries (Curling ulcer) Multiple trauma
  • 17. Osophagitis (or esophagitis) is inflammation of the esophagus.
  • 18. Causes GERD Inflammation c/c Blood loss Infectious agents in immunocompromised hosts.
  • 19. Other causesCROHN’S DISEASE
  • 20. • Vascular malformations along the lesser curve of the stomach within 6 cm of the GEJ • represent rupture of unusually large vessels (1-3 mm) in the gastric submucosa. • Erosion of the gastric mucosa overlying these vessels leads to hemorrhage.
  • 21. • “watermelon stomach” • collection of dilated venules appearing as linear red streaks converging on the antrum in longitudinal fashion, giving it the appearance of a watermelon.
  • 22. • usually associated with chronic anemia or hemoccult-positive stool • Occasionally, malignancies present as ulcerative lesions that bleed persistently. • most characteristic of the GIST • Also occur with leiomyomas and lymphomas.
  • 23. abdominal aortic aneurysm repair pseudoaneurysm at the proximal anastomotic suture line Infection fistulization into the overlying duodenum “sentinel bleed”
  • 24. • typically associated with trauma, recent instrumentation of the biliary tree, or hepatic neoplasms. • suspected in anyone who presents with hemorrhage, right upper quadrant pain, and jaundice
  • 25. • bleeding from the pancreatic duct. • typically caused by erosion of a pancreatic pseudocyst into the splenic artery. • presents with abdominal pain and hematochezia • past history of pancreatitis
  • 26. • may follow therapeutic or diagnostic procedures • common causes of iatrogenic bleeding – endoscopic sphincterotomy percutaneous transhepatic procedures • 2% of cases • It is often mild and self-limited
  • 27.  Inc. risk of Rebleeding transfusion hospital stay mortality  Freq. massive  6 wk mortality rate 20 %
  • 28. VARICEAL BLEEDING Isolated gastric varices Gastroesophageal varices (90%) Hypertensive portal gastropathy (5%) SARIN CLASSIFICATION
  • 29. GASTRO OESOPHAGEAL VARICES PHTN Dil. S/M veins in oeso. & stomach Mucosa tenuous & excoriated Bleeding
  • 30. HYPERTENSIVE PORTAL GASTROPATHY PHTN c/c gastric congestion Multiple punctuate erythema Bleeding
  • 31. Isolated gastric Varices Mechanism Sinistral PHTN – Splenic vein thrombosis Causes  Pancreatic pseudocyst  Pancreatic Trs  Pancreatitis
  • 32.  Red – Fresh blood  Coffee ground – altered blood (acid haematin)  Differentiate from Haemoptysis Bleeding from Pharynx , nasal passage
  • 33.  Black tarry offensive stools 1) Gastric acid 2) Digestive enzymes 3) Luminal bacteria  Feature of UGI bleed  Can be seen in LGI bleed also  Atleast 14 hrs in GIT  Non GI bleed – swallowing  Oral Fe Bi mimics melaena
  • 34.  10 % of upper GI bleed  Acute massive bleeding  transit time  Crampy abd. pain  Rt. Upp. quad. pain - haemobilia  Hemosucuss pancreaticus  Peptic ulcer  Malignancies
  • 35.  Presents with features of c/c blood loss  Suspected in pt with Fe def anaemia Test for occult blood COLONOSCOPY ENDOSCOPY Enteroscopy , Capsule endoscopy (--) (--) (+)
  • 36.  Rapid severe blood loss syncope pre syncope angina dyspnoea  Peptic ulcer , GERD Pain Dyspepsia Heartburn
  • 37.  Mallory Weiss tears Antecedent vomiting & retching binge drinking ?  Slow Blood loss Fatigue Anaemia  Malignancy Wt loss Dysphagia Early satiety Features of obstruction
  • 38.  Previous episodes of GI bleed sentinel bleed  H/O instrumentation  H/O head injury  Co-morbid Conditions Liver Disease Renal Disease Cardiovascular Disease Chronic respiratory conditions
  • 39.  Alcoholism  Wt loss  Anorexia
  • 40.  Salicylates/ NSAIDs  Anticoagulants  Corticosteroids  Anti TB Drugs  Oral Fe, Bi ( mimic melaena )
  • 41.  Pallor , signs of dehydration , Shock  Icterus  Clubbing  Oedema  Lymphadenopathy Virchows node  Vital Signs tachycardia hypotension tachapnoea }Liver d/s
  • 42. • Caput medussae • Ascites • Fetor hepaticus • Spider naevi • Palmar erythema • Dupuytrens contr. • Leuconychia • Gynecomastia, testicular atrophy • Bleeding manifestations
  • 43. INSPECTION Distention , Dil. Veins Swelling Visible peristalsis PALPATION Tenderness HSM, secondary mets Mass PERCUSSION Shifting dullness HSM AUSCULTATION Absent BS Cruveilhier-Baumgarten venous hum
  • 44.  Haemarroids  Melaena , blood  Blumer shelf
  • 45. • Laboratory investigations • Imaging • Endoscopy
  • 46. • Full Blood Count- Hb, Platelet • PCV* • Coagulation Profile • Liver Function tests • Serum urea and electrolytes • Blood urea nitrogen • Cross matching of blood. • Serial ECG
  • 47. • PCV* : decreased only by 24 to 72hrs, after bleed
  • 48. • Renal Function Tests • Gastrin level • Nasogastric aspiration 1. Red blood-current bleeding 2. Coffee ground-recent 3. Continuous aspiration-severe active bleed Lavage not +ve- i) bleeding has stopped ii) beyond pylorus
  • 49. CXR –1) Aspiration pneumonia –2) Pleural effusion
  • 50. 1) Aspiration pneumonia
  • 51. 2) Pleural effusion
  • 52. II) Abdominal X-Ray - Perforations
  • 53. • USS and CT SCAN – Liver disease, hemorrhagic pancreatitis & cholecystitis, aorto-enteric fistula etc. • Nuclear Scan - Areas of active hemorrhage • Arteriography - Site of bleeding if endoscopy fails
  • 54. • Most important component of investigation • 90% accuracy In diagnosis if done with in 24 hours
  • 55. • Classification based on actual appearance of peptic ulcer at endoscopy • The first 4 are called the Stigmata of recent bleed FI Active bleeding FII a Ulcer with visible vessel or pigmented protuberance (40 – 80%) FII b Ulcer with an adherent clot (20%) FII c Ulcer with a pigmented spot (10%) FIII Ulcer with clean base (rarely bleeds)
  • 56. FI- active bleeding FIIa-visible vessel.(40-80%)
  • 57. FIIb-adherent clot(20%) FIIc- pigmented Spot.(10%)
  • 58. FIII-clean ulcer base (rarely bleeds)
  • 59. A typical esophageal cancer
  • 60. Pre pyloric ulcers due to use of NSAIDs
  • 61. Snake skin appearance
  • 62. •Examination of whole bowel possible •Indicated in GI bleeding of obscure source
  • 63. Bipin Thomas Panicker
  • 64. NON VARICEAL BLEEDING Mechanical methods Injection Therapy Thermal therapy
  • 65. Airway: –Secure to prevent aspiration – Endotracheal tube *Give oxygen
  • 66. • Breathing –support respiratory function • Circulation- expand circulatory volume 2 i/v lines large bore cannula
  • 67. Class I & II Shock ( upto 30% blood loss ) – Crystalloids ( 3 – 1 Rule ) – Ringer lactate or 0.9% Normal saline
  • 68. Class III & IV Shock ( >30% blood loss ) – IV bolus followed by maintenance therapy – Crystalloids and – Blood transfusion, packed red cells
  • 69. Correct any coagulopathy with – 10 - 15 ml/kg of FFP (if PT INR > 1.5) and/or – platelet transfusions (if platelet count < 50,000/cu.mm) Monitor: skin color, peripheral temperature Pulse Rate, BP Respiratory Rate, O2 saturation of blood Urine output (Foley’s Catheter)
  • 70. • NSAIDS.SSRIs.Smoking. • PPIs 15-30mgOD 20-40mg OD
  • 71. • H.pylori Treatment-TRIPLE THERAPY • 1000mgBD 40mgBD 500mgBD
  • 72. • Supportive therapy. bcoz....90% episodes are self limiting mucosa heals within 72hrs • Ongoing bleeding-local endoscopic therapy
  • 73. • Significant bleed rarely encountered ventilator support>48hrsgroup highrisk group coagulopathy • Resuscitation
  • 74. stress gastritis-prophylactic therapy antacids.. PPIs.. H2 antagonists..
  • 75. acid suppressive therapy endoscopic therapy endoscopic control endoscopic therapy antrectomy surgical resection
  • 76. ligation of aorta removal of infected prosthesis angiographic embolisation distal pancreatectomy percutaneous endoscopic gastrotomy
  • 77. Pharmacotherapy for portal hypertension vasopressin + nitroglycerine Somatostatin Mech of axn splanchnic blood flow portal & variceal pressure
  • 78. 50 mcg stat followed by 25mcg/h for two days or till bleeding stops
  • 79. The Key Early identification and surgery for patients in who other lines of management are likely to fail.
  • 80. Probable non- responders Clinical Findings Shock at presentation Low Hb at presentation Endoscopic Findings Forrest classification Forrest I and IIa Location of ulcer Posterior duodenal wall Gastric ulcer Size of ulcer >2cm
  • 81. Absolute Indications • Hemodynamic instability despite vigorous resuscitation (>6 units transfusion) • Failure of endoscopic techniques to arrest hemorrhage • Recurrent hemorrhage after initial stabilization (with up to two attempts at obtaining endoscopic hemostasis) • Shock associated with recurrent hemorrhage • Continued slow bleeding with a transfusion requirement exceeding 3 units/day
  • 82. Relative Indications • Rare blood type or difficult crossmatch • Refusal to transfusion • Shock at presentation • Advanced age • Severe comorbid diseases • Bleeding chronic gastric ulcer where malignancy is a possibility
  • 83. Priorities •Control Hemorrhage !! • Definitive procedure for the underlying pathology
  • 84. Duodenal Ulcers • Exposure of bleeding site – Longitudinal duodenostomy – Pyloroduodenostomy • Hemostasis • Anterior ulcer – 4 quadrant suture-ligation • Posterior ulcer – suture ligature of the vessel proximal and distal to the ulcer
  • 85. Gastric Ulcer • Exposure of bleeding site – Gastrostomy • Control of bleeding – Suture ligation
  • 86. Definitive Procedures
  • 87. Definitive procedures • Gastric ulcer resection (malignancy) • Distal gastrectomy • Proximal or near-total gastrectomy • Distal gastrectomy combined with resection of a tongue of proximal stomach to include the ulcer • Wedge resection • Simple oversewing of ulcer
  • 88. Distal Gastrectomy or Antrectomy or Hemi Gastrectomy
  • 89. BillRoth I Gastroduodenostomy
  • 90. Sub-total Gastrectomy
  • 91. Billroth II Gastrojejunostomy
  • 92. Acid Reducing Procedures •Truncal Vagotomy •Selective Vagotomy •Highly selective Vagotomy or Parietal Cell vagotomy
  • 93. Truncal Vagotomy
  • 94. Selective Vagotomy
  • 95. Highly Selective Vagotomy
  • 96. Effects of Operations for PUD on Gastric Emptying and Motility Operation Antral Innervation Liquid Emptying Solid Emptying Proximal gastric vagotomy Preserved Fast Normal Truncal vagotomy Divided Fast Slow Truncal vagotomy and drainage Divided Fast Fast Truncal vagotomy and antrectomy Divided Fast Fast
  • 97. Mallory-Weiss Tears • Angiographic embolisation • High gastrostomy and suturing of the mucosal tear
  • 98. Stress Gastritis • Rarely indicated • Vagotomy and pyloroplasty, with oversewing of the hemorrhage, or • Near-total gastrectomy
  • 99. Dieulafoy's lesion • Prior endoscopic tattooing • Gastrotomy • Identifying the bleeding source • Oversewn • Partial gastrectomy
  • 100. Variceal Bleeding
  • 101. Esophageal Balloon Tamponade •Sengstaken – Blakemore tube •Minnesota tube
  • 102. (Deflate every 4 hours for 15 minutes )
  • 103. Complications • Esophageal rupture • Tracheal rupture • Duodenal rupture • Respiratory tract obstruction • Aspiration • Hemoptysis • Tracheoesophageal fistula • Jejunal rupture • Thoracic lymph duct obstruction • Esophageal necrosis • Esophageal ulcer
  • 104. Surgeries for Variceal Bleeding Transjugular intrahepatic portosystemic stent shunts (TIPSS) The role of portal hypertension !!!
  • 105. Surgery for Portal Hypertension • Indications – Child Class A, initial bleed managed by sclerotherapy –Never Prophylactic
  • 106. Surgical Options • Shunt Surgeries • Non-selective – Porto-caval • Selective – Spleno-renal • Esophagogastric Devascularisation • Orthotopic Liver Transplantation
  • 107. Side-to-side Porto-caval Anastomosis
  • 108. End-to-side Porto-caval Anastomosis Eck Fistula !!!
  • 109. Interposition Shunts
  • 110. Spleno-renal Anastomosis
  • 111. Non-selective Shunts Selective Shunts Poor hepatopetal flow Poor Ascites Control Hepatic dysfunction Technically demanding Hepatic encephalopathy Better control of Ascites
  • 112. Interposition Shunts Intricacies of hilar dissection Future Liver transplantation possible Intentional shunt ligation Graft thrombosis !!!!
  • 113. Distal Spleno-Renal Shunt Warren Note the left gastric and right gastroepiploic veins
  • 114. Contraindications • Medically intractable ascites • Splenic Vein diameter < 6-7 mm
  • 115. Sugiura Procedure
  • 116. Also… • Left gastric (coronary) vein and the Paraesophageal collateral veins • Portoazygous collateralization
  • 117. Orthotopic Liver Transplantation “ Orthotopic liver transplantation is the most definitive form of therapy for complications of portal hypertension” • Poor hepatic functional reserve – Advanced Child class B or Child C • Non surgical methods during the wait !!!
  • 118. Acute Variceal Bleed Not Controlled Endoscopy TIPS Tamponade, Surgery Controlled!!! Controlled!!! Controlled !!! Controlled !!!
  • 119. Assess Child Class Transplant candidate Don’t Touch the PORTA !!! Mesocaval Interposition or DSRS Not future candidate Intractable Ascites Side-to-Side Porto-caval Ascites absent or manageable End-to-side Porto-caval
  • 120. Rockall Numerical Risk Scoring System 0 1 2 3 age ˂60 60-79 ˃80 shock No tachycardia hypotension comorbid no CF,IHD …… RF,LF,Malign Initial score [Out of 7]
  • 121. Additional criteria [out of11] 0 1 2 3 diagnosis MWT, no lesions seen All other diag Mal of upper GI Stigmata of bleeding None, dark spots only Bld in upper GI Visible vessels, spurting,adherant clot
  • 122. CHILD PUGH’S CRITERIA FOR HEPATIC FUNCTIONAL RESERVE (C) ADVANCED (B) MODERATE (A) MINIMAL MEASURE >32-3<2.0Serum bilirubin (mg/100ml) <33-3.5>3.5Serum albumin (g/100ml) Poorly controlled Easily controlled NoneAscitis Advanced coma MinimalNoneEncephalopathy ˃64-6˂4Prothrombin time [sec prolonged]
  • 123. REBLEED Risk of mortality increases by 10 fold!!!
  • 124. Risk of RECURRENT BLEEDING
  • 125. Prevent rebleeding • Pharmacotherapy
  • 126. • Endoscopic therapy • Combination • Surgery
  • 127. Ravi, 56 yrs, male PRESENTING COMPLAINTS Dark stools – 7 days Vomiting of blood – 1day Abdominal distension – 1 day
  • 128. • Dark, tarry stools • distension of abdomen • Vomiting of blood »2 episodes »Basin full »Frank blood
  • 129. PAST HISTORY DM-past 10 yrs on treatment PERSONAL HISTORY Non smoker chronic alcoholic takes abt 250ml everyday for 30yrs
  • 130. • GENERAL EXAMINATION – Drowsy, – Pallor,icterus PR 140/’ BP 90/50 mm of Hg Cold clammy skin Spider naevi ,ascites
  • 131. • Abdomen soft • Distended • Hepatomegaly • Splenomegaly • Shifting dullness
  • 132. Initial assessment & resuscitation History and physical examination Localisation of site of bleeding Institutionof specific therapy
  • 133. • Assess A, B, C Severity of hemorrhage: • Obtundation • Agitation • Hypotension with cold clammy skin • If resting HR >100 - loss of 20-40% blood volume } loss of >40% blood volume
  • 134. • Orthostatic vital signs should be checked in patients not in shock. • An elevation of pulse rate more than 20 or a fall in BP more than 10mmHg indicates atleast a 20% blood volume loss.
  • 135. • Intubation • Two large bore IV lines- Ringer lactate • Initial lab assessment- Hematocrit & Hb Type & crossmatch Coagulation profile, platelet ct Serum electrolytes, LFT
  • 136. • Urine output • Supplemental Oxygen • Transfusion of packed red cells • Coagulation defects corrected by FFP & platelets
  • 137. • Characteristics of bleeding • Time of onset,volume and frequency • Associated symptoms: syncope,vomiting,dyspepsia,LOW • Medications: salicylates,NSAIDS,Warfarin, LMW heparin • Past medical history- peptic ulcer,liver disease,heart disease
  • 138. • Examination of nose & oropharynx • Abdominal examn-mass,splenomegaly • Stigmata of chronic liver disease
  • 139. • LOCALISATION OF SITE OF BLEEDING by endoscopy • INSTITUTION OF SPECIFIC THERAPY Pharmacologic Endoscopic Surgical modalities

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