Management Harim Mohsin
Management <ul><li>Evaluation/ Assessment </li></ul><ul><li>Stabilization </li></ul><ul><li>History </li></ul><ul><li>Phys...
Stabilization & assesment <ul><li>Initial management begins with assessing and addressing the ABCs. </li></ul><ul><li>Asse...
<ul><li>In patients with significant bleeding large bore (16-18-guage) I/v lines should be maintained prior to further dia...
<ul><li>Pass nasogastric tube to perform an aspirate to determine whether the GI bleeding is emanating from above or below...
<ul><li>Rockall Scoring for </li></ul><ul><li>risk of re-bleeding  &  death after hospital </li></ul><ul><li>admission for...
Baylor Bleeding Score
History & examination
Specific management
<ul><li>Medical treatment </li></ul><ul><li>Endoscopic treatment </li></ul><ul><li>Surgical treatment </li></ul>
Medical treatment <ul><li>Reduction of acid production   </li></ul><ul><li>H2RA -Histamine Receptor antagonists (eg Cimeti...
Medical treatment <ul><li>H ea mostatic drugs - </li></ul><ul><li>Transexemic acid(antifibrinolytic agent) - reduction of ...
Endoscopic Treatment <ul><li>Endoscopy , should be performed immediately after hemodynamic stabilization & evaluation with...
Endoscopy of stomach
Endoscopic treatment <ul><li>The endoscopic appearance of the bleeding lesion has been used to identify patients at high r...
Endoscopic treatment <ul><li>Topical treatment </li></ul><ul><li>Injection treatment </li></ul><ul><li>Mechanical treatmen...
Topical treatment <ul><li>Tissue adhesives  </li></ul><ul><li>Blood clotting factor s  (throbin,fibrinogen) </li></ul><ul>...
Injection therapy <ul><li>Injection therapy consists of using solutions injected into and around the bleeding lesion to at...
Mechanic al  treatment <ul><li>Loops - Easy, precise and cost-effective variceal ligation.  The loop ensures a firm and pr...
Thermal treatment <ul><li>Laser  ph otocoagulation - </li></ul><ul><li>uses an Nd:YAG laser to create hemostasis by genera...
Management after endoscopy <ul><li>Careful monitoring is needed after endoscopy for UGIB (pulse, blood pressure, urine out...
Surgical intervention <ul><li>Surgical intervention is required  </li></ul><ul><li>when endoscopic techniques fail or are ...
Surgery types <ul><li>Transjugular intrahepatic portosystemic shunt  (TIPS)-  </li></ul><ul><li>A self-expanding metal ste...
Surgical treatment <ul><li>Surgical shunts: </li></ul><ul><li>decompression of the high-pressure portal venous system into...
Surgical treatment <ul><li>Local operation </li></ul><ul><ul><li>Suture </li></ul></ul><ul><li>Local operation + vagotomy ...
Variceal bleeding <ul><li>Cirrhosis  </li></ul><ul><li>- Billiary </li></ul><ul><ul><li>- Alcoholic </li></ul></ul><ul><li...
Treatment of variceal bleeding <ul><li>Balloon tamponade </li></ul><ul><li>Sclerotherapy  </li></ul><ul><li>Oesophageal tr...
Non-variceal bleeding <ul><li>Peptic ulcer </li></ul><ul><li>Mallory-Weiss tear </li></ul><ul><li>Erosive gastritis/duoden...
Treatment of Non-variceal bleeding <ul><li>Repeat endoscopy  </li></ul><ul><li>Emergency surgery </li></ul><ul><li>Transca...
 
Complications
<ul><li>Specific to the cause of UGIB </li></ul><ul><li>May arise from interventional tools.  </li></ul><ul><li>Rebleeding...
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Management Of Ugib Final

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Management of a patient with upper GI bleeding.

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Management Of Ugib Final

  1. 1. Management Harim Mohsin
  2. 2. Management <ul><li>Evaluation/ Assessment </li></ul><ul><li>Stabilization </li></ul><ul><li>History </li></ul><ul><li>Physical examination </li></ul><ul><li>Specific Treatment </li></ul><ul><li>Follow-up </li></ul>
  3. 3. Stabilization & assesment <ul><li>Initial management begins with assessing and addressing the ABCs. </li></ul><ul><li>Assessment of hemodynamic status </li></ul><ul><li>Severe bleeding -Systolic bp <100- any HR </li></ul><ul><li>Moderate loss- HR >100 + systolic bp >100 </li></ul><ul><li>Mild loss- Normal bp & HR </li></ul><ul><li>Portal hypertension & tachycardia are useful but may be due to other causes. </li></ul>
  4. 4. <ul><li>In patients with significant bleeding large bore (16-18-guage) I/v lines should be maintained prior to further diagnostic tests. </li></ul><ul><li>In case of hemodynamic compromise give Ringer’s lactate or normal saline & cross-matched blood. </li></ul><ul><li>Plasma substitutes such as Haemaccel may also be used. </li></ul><ul><li>Give Oxygen therapy to any patient in shock. </li></ul><ul><li>Send blood for : </li></ul><ul><li>Complete blood count </li></ul><ul><li>PT </li></ul><ul><li>Serum creatinine </li></ul><ul><li>Liver enzymes </li></ul><ul><li>Cross-matching </li></ul>
  5. 5. <ul><li>Pass nasogastric tube to perform an aspirate to determine whether the GI bleeding is emanating from above or below the ligament of Treitz . </li></ul><ul><li>Aspirate by color: </li></ul><ul><li>Red or coffee ground- active bleeding </li></ul><ul><li>Clear gastric fluid- duodenal site of bleeding possible. </li></ul><ul><li>Bile without blood- UGIB less likely </li></ul>
  6. 6. <ul><li>Rockall Scoring for </li></ul><ul><li>risk of re-bleeding & death after hospital </li></ul><ul><li>admission for acute </li></ul><ul><li>UGIB </li></ul>
  7. 7. Baylor Bleeding Score
  8. 8. History & examination
  9. 9. Specific management
  10. 10. <ul><li>Medical treatment </li></ul><ul><li>Endoscopic treatment </li></ul><ul><li>Surgical treatment </li></ul>
  11. 11. Medical treatment <ul><li>Reduction of acid production </li></ul><ul><li>H2RA -Histamine Receptor antagonists (eg Cimetidine, Ranitidine)- decrease cAMP </li></ul><ul><li>PPI -Proton pump inhibitors-Inhibit parietal cell H+/K+- ATPase pump (eg Lansoprazole, Omeprazole)- (I/v 80mg followed by 8mg per hour for 72 hours) </li></ul><ul><li>Octreotide - continuous Infusion reduces splanchnic blood flow & portal blood pressure effective initially in bleeding due to portal hypertension. </li></ul>
  12. 12. Medical treatment <ul><li>H ea mostatic drugs - </li></ul><ul><li>Transexemic acid(antifibrinolytic agent) - reduction of the level of fibr in ogen fragments improving platelet function. </li></ul><ul><li>TXA stabiliz es haemostatic clots by (1) preventing b in d in g of plasm in ogen to fibr in in blood clots </li></ul><ul><li>(2)preventing activation of plasm in ogen to active plasm in. </li></ul><ul><li>Other drugs used: </li></ul><ul><li>Vasopressin- produces mesenteric vasoconstriction and thus decreases portal venous inflow and pressure </li></ul><ul><li>Somatostatin </li></ul><ul><li>Volume and blood replacement as required </li></ul>
  13. 13. Endoscopic Treatment <ul><li>Endoscopy , should be performed immediately after hemodynamic stabilization & evaluation within 12 hours. </li></ul><ul><li>This is useful for: </li></ul><ul><li>Diagnosing the cause of bleeding </li></ul><ul><li>Estimating prognosis </li></ul><ul><li>Therapeutic haemostasis </li></ul><ul><li>Contraindications to upper endoscopy </li></ul><ul><li>Uncooperative patient </li></ul><ul><li>Acute myocardial infarction (unless haemorrhage life-threatening) </li></ul><ul><li>Perforated viscus </li></ul>
  14. 14. Endoscopy of stomach
  15. 15. Endoscopic treatment <ul><li>The endoscopic appearance of the bleeding lesion has been used to identify patients at high risk for recurrent bleeding. </li></ul><ul><li>High risk- active bleeding, visible vessels, adherent clots. </li></ul><ul><li>Low risk- flat, pigmented spots and those that involve a clean ulcer base with no visible vessel. </li></ul><ul><li>The indication for endoscopic therapy is based on the size, site, and stigmata of recent bleeding. </li></ul>
  16. 16. Endoscopic treatment <ul><li>Topical treatment </li></ul><ul><li>Injection treatment </li></ul><ul><li>Mechanical treatment </li></ul><ul><li>Thermal treatment </li></ul>
  17. 17. Topical treatment <ul><li>Tissue adhesives </li></ul><ul><li>Blood clotting factor s (throbin,fibrinogen) </li></ul><ul><li>Vasoconstricting drug s (epinephrin e ) </li></ul><ul><li>C ollagen (microcrystalline collagen hemostat (MCH) </li></ul>
  18. 18. Injection therapy <ul><li>Injection therapy consists of using solutions injected into and around the bleeding lesion to attain hemostasis. </li></ul><ul><li>Scler osant agents ( ethanol, polidocanol, and sodium tetradecyl sulfate ) -induce thrombosis, tissue necrosis, and inflammation at the site of injection </li></ul><ul><li>Epinephrin e- Causes vasoconstriction </li></ul><ul><li>Thrombin / Fibrin glue- clot producing agents. </li></ul>
  19. 19. Mechanic al treatment <ul><li>Loops - Easy, precise and cost-effective variceal ligation. The loop ensures a firm and precise ligation with adjustable ligating force that remains in place for a period of time then leaves the GI tract naturally. </li></ul><ul><li>Sutures </li></ul><ul><li>Balloon treatment -The 2 most commonly used tubes are the Sengstaken-Blakemore tube and the Minnesota tube. These tubes have an esophageal balloon and a gastric balloon that are inflated to produce a tamponade effect after confirming appropriate anatomical placement </li></ul><ul><li>Haemostatic clips - Provide Fast, efficient haemostasis In addition, maintains the integrity of the surrounding tissue. </li></ul>
  20. 20. Thermal treatment <ul><li>Laser ph otocoagulation - </li></ul><ul><li>uses an Nd:YAG laser to create hemostasis by generating heat and direct vessel coagulation. </li></ul><ul><li>Coaptive coagulation </li></ul><ul><li>uses direct pressure and heater probe & electrocoagulation (monopolar & bipolar) therapy to achieve hemostasis. The bleeding vessel is isolated, compressed, and tamponaded, minimizing the depth of tissue injury. </li></ul>
  21. 21. Management after endoscopy <ul><li>Careful monitoring is needed after endoscopy for UGIB (pulse, blood pressure, urine output). It is imperative to identify rebleeding or continuing bleeding. </li></ul><ul><li>If patients are stable 4-6 hours after endoscopy they should be put on a light diet as there is no benefit in continued fasting. </li></ul><ul><li>Repeat endoscopy is required if there is evidence of rebleeding (for example with melaena or unstable observations). </li></ul><ul><li>Occasionally major rebleeding may be an indication for surgical intervention without further endoscopy. </li></ul>
  22. 22. Surgical intervention <ul><li>Surgical intervention is required </li></ul><ul><li>when endoscopic techniques fail or are contraindicated. Clinical judgement is required with expert personnel. </li></ul><ul><li>I n case of continous or rebleeding </li></ul>
  23. 23. Surgery types <ul><li>Transjugular intrahepatic portosystemic shunt (TIPS)- </li></ul><ul><li>A self-expanding metal stent is placed between the systemic venous system and the portal system. </li></ul><ul><li>The placement of a TIPS reduces the outflow hepatic resistance, lowers portal pressure, and diverts portal blood flow from gastroesophageal collaterals through the stent. </li></ul><ul><li>Liver transplantation or decompression should be considered alongside if portal hypertension present. </li></ul>
  24. 24. Surgical treatment <ul><li>Surgical shunts: </li></ul><ul><li>decompression of the high-pressure portal venous system into a low-pressure systemic venous system and </li></ul><ul><li>devascularization of the distal esophagus and proximal stomach </li></ul><ul><li>Non-Selective shunts -completely divert portal blood flow from the liver </li></ul><ul><li>Selective shunts -decompresses the varices while maintaining hepatopetal blood flow in the remainder of the portal system. </li></ul><ul><li>Partial shunts- decompresses varices while maintaining hepatic portal perfusion. </li></ul>
  25. 25. Surgical treatment <ul><li>Local operation </li></ul><ul><ul><li>Suture </li></ul></ul><ul><li>Local operation + vagotomy </li></ul><ul><li>R esection type operation </li></ul>
  26. 26. Variceal bleeding <ul><li>Cirrhosis </li></ul><ul><li>- Billiary </li></ul><ul><ul><li>- Alcoholic </li></ul></ul><ul><li>Portal hypertension (15-30 Hgmm) </li></ul><ul><li>Rupture of varicose veins </li></ul>
  27. 27. Treatment of variceal bleeding <ul><li>Balloon tamponade </li></ul><ul><li>Sclerotherapy </li></ul><ul><li>Oesophageal transsection </li></ul><ul><li>Porto/caval shunt </li></ul><ul><li>TIPS (Interventional radiology ) </li></ul>
  28. 28. Non-variceal bleeding <ul><li>Peptic ulcer </li></ul><ul><li>Mallory-Weiss tear </li></ul><ul><li>Erosive gastritis/duodenitis </li></ul><ul><li>Esophagitis/ oesophageal ulcer </li></ul><ul><li>Malignancy </li></ul><ul><li>Angiodysplasia /vascular malformations </li></ul><ul><li>Other </li></ul>
  29. 29. Treatment of Non-variceal bleeding <ul><li>Repeat endoscopy </li></ul><ul><li>Emergency surgery </li></ul><ul><li>Transcatheter arteriography followed by transcatheter intervention (usually embolization) </li></ul>
  30. 31. Complications
  31. 32. <ul><li>Specific to the cause of UGIB </li></ul><ul><li>May arise from interventional tools. </li></ul><ul><li>Rebleeding </li></ul><ul><li>Shock </li></ul><ul><li>Anemia </li></ul><ul><li>Aspiration </li></ul><ul><li>Tachycardia </li></ul><ul><li>Perforation </li></ul><ul><li>Death </li></ul>

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