Surgery 6th year, Tutorial (Dr. AbdulWahid)

1,879 views
1,660 views

Published on

Dec. 14th, 2011

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

No Downloads
Views
Total views
1,879
On SlideShare
0
From Embeds
0
Number of Embeds
9
Actions
Shares
0
Downloads
51
Comments
0
Likes
3
Embeds 0
No embeds

No notes for slide
  • AGML = Acute Gastric Mucosal Lesions
  • Surgery 6th year, Tutorial (Dr. AbdulWahid)

    1. 1. Management of upper GI Hemorrhage ABDWAHID M SALIS, M.D
    2. 3. Management Upper GIT Bleeding <ul><li>Complete history: </li></ul><ul><li>alcohol use, cirrhosis, heart burn, reflux, and medications. </li></ul><ul><li>Exam : </li></ul><ul><li>signs of cirrhosis including spider angiomata, palmer erythema, prominent abdominal veins, caput medusa, and ascites. </li></ul><ul><li>mucous membranes for melanin spots associated with Puetz-Jeghers syndrome. </li></ul>
    3. 4. Physical Exam <ul><ul><li>Vital signs: instability, respiratory distress, beware of beta blockade </li></ul></ul><ul><ul><li>signs of anemia, dehydration </li></ul></ul><ul><ul><li>Abdominal exam : </li></ul></ul><ul><ul><li>Rectal exam : </li></ul></ul><ul><ul><li>Look for perianal causes of bleeding . </li></ul></ul><ul><ul><li>check for occult blood in the stool. </li></ul></ul>
    4. 5. Laboratory studies: <ul><li>Type and Cross </li></ul><ul><li>CBC: anemia? </li></ul><ul><li>hepatic dysfunction and renal compromise </li></ul><ul><li>Coags: coagulopathy </li></ul><ul><li>ABG: probe for acidosis </li></ul>
    5. 6. <ul><ul><li>Radionuclide scanning </li></ul></ul><ul><ul><li>Uses technetium-99m labeled RBC </li></ul></ul>
    6. 8. Interventions to consider <ul><li>ABC’s </li></ul><ul><ul><li>Ensure adequate airway protection and adequate respirations:massive bleeding considered for intubation </li></ul></ul><ul><ul><li>Start 2 large bore IV’s . </li></ul></ul><ul><ul><li>Fluid bolus either NS or LR </li></ul></ul><ul><ul><li>3-for-1 rule: Replace each milliliter of blood loss with 3 mL of crystalloid fluid. </li></ul></ul>
    7. 9. Pharmacotherapy <ul><li>Proton pump inhibitors (PPIs), </li></ul><ul><li>orally or intravenously as an infusion </li></ul><ul><li>Octreotide is a somatostatin analog: shunt blood away from the splanchnic circulation. variceal and non-variceal upper GI hage. </li></ul><ul><li>vasopressin analog most commonly for variceal upper GI hage. </li></ul><ul><li>Anti-fibrinolytic drugs such as </li></ul><ul><li>tranexamic acid </li></ul><ul><li>Factor VII for variceal hemorrhage </li></ul><ul><li>If Helicobacter pylori : antibiotics and a PPI </li></ul>
    8. 10. Tubes <ul><li>Foley Catheter </li></ul><ul><li>NG with gastric lavage : If the stomach contains bile but no blood, UGIB is less likely </li></ul><ul><li>Iced saline lavage </li></ul><ul><li>STAT Upper endoscopy </li></ul>
    9. 11. Early Endoscopy <ul><li>Both As A Diagnostic And Therapeutic: </li></ul><ul><li>Injection of adrenaline or sclerotherapy </li></ul><ul><li>Electrocautery: thermal </li></ul><ul><li>Endoscopic clipping </li></ul><ul><li>Banding of varices </li></ul><ul><li>Argon plasma coagulation . </li></ul><ul><li>Cryotherapy ablation is another possibility </li></ul>
    10. 13. Stigmata of high risk <ul><li>Active bleeding </li></ul><ul><li>Oozing </li></ul><ul><li>Visible vessels </li></ul><ul><li>Red Spots </li></ul>
    11. 14. Visible vessels oozing bleeding Active bleeding Red Spots
    12. 15. Contraindications to endoscopy <ul><li>Uncooperative </li></ul><ul><li>severe cardiac decompensation, acute myocardial infarction </li></ul><ul><li>perforated viscus ( eg, esophagus, stomach, intestine ). </li></ul>
    13. 16. Refractory cases <ul><li>Repeat esophagogastroduodenoscopy </li></ul><ul><li>Angiography Embolization the feeder vessel </li></ul><ul><li>Balloon tamponade </li></ul><ul><li>Surgery , to oversew or remove </li></ul>
    14. 17. PU bleeding TREATMENT <ul><li>Medical </li></ul><ul><ul><ul><li>Anti-ulcer medication </li></ul></ul></ul><ul><ul><ul><li>H. pylori treatment </li></ul></ul></ul><ul><ul><ul><li>Stop NSAIDs </li></ul></ul></ul><ul><ul><ul><li>Follow up EGD for gastric ulcer in 6 weeks </li></ul></ul></ul>
    15. 18. PU TREATMENT <ul><li>Endoscopic interventions </li></ul><ul><ul><ul><li>Thermal coagulation </li></ul></ul></ul><ul><ul><ul><li>Injected agents </li></ul></ul></ul><ul><ul><ul><li>Success rate </li></ul></ul></ul><ul><ul><ul><ul><ul><li>95% initailly </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>80% will not rebleed </li></ul></ul></ul></ul></ul>
    16. 19. PU TREATMENT <ul><li>Surgical intervention </li></ul><ul><ul><li>Only 10% of patients </li></ul></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><ul><li>Failure of endoscopy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Significant rebleeding after 1 st endoscopy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ongoing transfusion requirement </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Need for >6 units over 24 hours </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Earlier for elderly, multiple co-morbidities </li></ul></ul></ul></ul>
    17. 20. PU Surgical intervention <ul><li>Doudenal ulcer </li></ul><ul><ul><ul><ul><li>Expose ulcer with duodenotomy or duodenopyloromyotomy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Direct suture ligation, </li></ul></ul></ul></ul><ul><ul><ul><ul><li>The gastroduodenal artery may be ligated if necessary </li></ul></ul></ul></ul><ul><ul><ul><ul><li>the pyloric channel is closed vertically resulting in a Heineke-Mikulicz pyloroplasty </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Anti-secretory procedure </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Truncal, parietal cell vagotomy </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>can use meds </li></ul></ul></ul></ul></ul>
    18. 22. PU Surgical intervention <ul><li>Gastric ulcer </li></ul><ul><ul><ul><ul><li>10% are maliganant </li></ul></ul></ul></ul><ul><ul><ul><ul><li>30% will rebleed </li></ul></ul></ul></ul><ul><ul><ul><ul><li>with simple ligation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Resection </li></ul></ul></ul></ul><ul><ul><ul><li>Distal gastrectomy </li></ul></ul></ul><ul><ul><ul><li>Bilroth I or II </li></ul></ul></ul><ul><ul><ul><li>Subtotal gastrectomy </li></ul></ul></ul>
    19. 24. Angiographic obliteration <ul><li>of the bleeding vessel is considered in patients with poor prognoses </li></ul>
    20. 25. Gastritis Treatment <ul><ul><li>Vasopressin </li></ul></ul><ul><ul><li>Iced saline lavage </li></ul></ul><ul><ul><li>Sucralfate, h2 blockers, and proton pump inhibitors. </li></ul></ul><ul><ul><li>Bleeds refractory to these treatments : </li></ul></ul><ul><ul><li>Electrocautery </li></ul></ul><ul><ul><li>Vagotomy and antrectomy </li></ul></ul><ul><ul><li>Even total gastrectomy. </li></ul></ul>
    21. 26. Mallory-WeissTreatment <ul><ul><li>90% resolves spontaneously no further therapy. </li></ul></ul><ul><ul><li>Bleeding persists : </li></ul></ul><ul><ul><li>Endoscopic inj of </li></ul></ul><ul><ul><li>vasoconstrictive agents, </li></ul></ul><ul><ul><li>Iv vasopressin </li></ul></ul><ul><ul><li>Balloon tamponade: sengstaken-blakemoore tube </li></ul></ul><ul><ul><li>Gastrotomy with oversewing </li></ul></ul>
    22. 27. <ul><ul><li>Dieulafoy’s treatment </li></ul></ul><ul><ul><ul><ul><li>Endoscopic Injection. </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Wedge resection after endoscopic marking </li></ul></ul></ul></ul>
    23. 28. Treatments for GAVE <ul><li>Endoscope: </li></ul><ul><li>Argon plasma coagulation and electrocautery. </li></ul><ul><li>&quot;Endoscopy with thermal ablation&quot; is favored medical treatment </li></ul><ul><li>Cryotherapy ablation is another possibility </li></ul>
    24. 29. Varices management <ul><li>Sclerotherapy, </li></ul><ul><li>Ligation </li></ul><ul><li>Vasopressin. </li></ul><ul><li>If unsuccessful: </li></ul><ul><li>shunting </li></ul><ul><li>transplant . </li></ul>
    25. 30. Somatostatin or vasopressin w/wo NTG
    26. 32. TIPS
    27. 34. Sugiura procedure
    28. 35. Shunt procedures
    29. 36. <ul><li>الحمد لله </li></ul>

    ×