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  • 1. Acute Upper Gastrointestinal Bleeding Entesar El Sharqawy MDHepatology, Gastroenterology and Infectious Diseases. Benha University 26/09/12
  • 2. Objectives Discuss and provide background information of upper GIT bleeding. Identify goals of history, physical finding and care in UGIB. Discuss utility of NGT in the evaluation of UGIB. Identify key points to resussitation and work up of UGIB. Discuss therapy of upper GIB. Outline key informations to have when calling GI consultants.
  • 3. Gastrointestinal Bleeding Introduction: GI bleeding is a common disorder that troubles all medical/surgical specialties UGI bleeding>LGI bleeding Prevalence: 170 cases/100.000 adults/yr Cost estimate: $2.5B/yr (USA) Mortality 5-12% 40% for recurrent bleeders Severity: acute/chronic/intermittent/occult
  • 4. Epidemiology: Upper: Lower GI bleeding = 5:1 30% pts are older than 65 years. Incidence: 1-2% of all hospital admissions Most common diagnosis of new ICU admits 85% stop sponateously Those with massive bleeding need urgent intervention Only 5-10% need operative intervention after endoscopic interventionsEarly therapeutic maneuvers decrease mortality rates
  • 5. Gastrointestinal BleedingPresentation of bleeding: Hematemesis-UGI source Melena-UGI source usually but 5% can be from LGI source Hematochezia (BRBPR)-LGI source usually but 15% from UGI source Occult-UGIB
  • 6. Chain of events1. Recognize severity2. Establish access for resusitation3. Resusitate4. Identify source5. Intervention
  • 7. Gastrointestinal Bleeding UGI vs LGI location determined by the Ligament of Treitz: UGI – proximal to LT *Esophagus, *stomach, *duodenal bulb, 2nd/3rd portion of duodenum, Hepatic and Pancreatic LGI – distal to LT Small bowel, *colon
  • 8. Etiology of Significant UGI Bleeding in Adults Varices   Peptic ulcer disease    Gastric erosions    Mallory-Weiss tear    Esophagitis   Duodenitis
  • 9. Etiology of Significant UGI Bleeding in ChildrenEsophagitis   Gastritis   Ulcer   Esophageal Vs Mallory-Weiss
  • 10. Initial Assessment History and PE Vitals, ABC’s, and IVFs  HR, BP, Orthostatics Signs of gross blood loss?  Hematemesis, melena, hematochezia  NG Tube Labs  CBC, Kidney Profile, LFT, Electrolytes, Coags, Acid-Base balance, type and cross  Hct unreliable  ECG  Imaging: chest & abd. radiography, US, CT
  • 11. Gastrointestinal Bleeding Determine the urgency of the clinical situation: Is the patient in shock? 40% loss of circulating blood volume Agitation, pallor, tachycardia, hypotension Is the patient orthostatic? 20% loss of circulating blood volume Postural hypotension Never rely on initial H/H values to asses amount of blood loss (hemoconcentration)
  • 12. ATLS Classification of Shock Assess Blood LossCategory % loss HR BP Pulse Cap refill Neuro Pressure Stage 1 <15 % < 100 Normal Normal WNL WNL Stage 2 15-30% > 100 Normal Decreased > 3 sec Alert Stage 3 30-40% > 120 Decreased Decreased > 3 sec Lethargic Stage 4 > 40% > 140 Decreased Decreased > 3 sec Obtunded HR not useful if Tachycardic means If they are patients are on they have lost about hypotensive, you AV node blockers 1 liter of blood! are in trouble! From Advanced Trauma Life Support Guidelines
  • 13. General ApproachUpper GI Bleed vsLower GI Bleed
  • 14. Upper GI hemorrhage How do you know its upper? 85% of all GI hemorrhage is upper Hematemesis diagnostic Don’t forget about nasal bleeding as possible source Melena Degradation of hemoglobin to hematin by acid Bowel bacteria and digestive enzymes also contribute Hematochezia 10-15% of patients with very rapid UGI source
  • 15. Gastrointestinal BleedingNasogastric aspirate: Determines the status of UGI bleeding and gives indirect information in LGI bleeding Bright red/clots – active UGI bleed Coffee-grounds – slow bleeding, oozing, stopped Clear – indeterminate (16% still bleeding) Bilious – UGI bleeding has stopped
  • 16. Diagnosis Questions to ask in history Any hematemesis, coffee-ground emesis, melena, or hematochezia. Any vomiting and retching. Any history of viral infection. Any history of ASA, NSAID’s, steroids. Any ETOH abuse. Any history of iron or bismuth which can simulate melena and beets which can simulate hematochezia. Any weight loss or changes in bowel habits. Any history aortic graft.
  • 17. Diagnosis Physical exam Vital signs may show hypotension and tachycardia. Cool, clammy skin then in shock. Spider angiomata, palmer erythema, jaundice, and gynecomastia seen in liver disease. Petechiae and purpura seen in coagulopathy. Careful ENT exam to rule out causes that can mimic upper GI bleeds. Proper abdominal exam and rectal exam.
  • 18. Upper GI hemorrhageUpper endoscopy indications Hematemesis Melena or hematochezia with hypotension NGT with guiac positive fluid Should be completed in 24hrs for stable patients
  • 19. Gastrointestinal Bleeding Role of endoscopy in triage of UGI bleeders: Accurate identification of the urgency of the clinical situation: hemodynamic compromise/signs of on- going bleeding/coagulopathy. Who should be hospitalized? Where to admit? Diagnosing the cause Risk stratification
  • 20. Gastrointestinal Bleeding Risk stratification in UGI bleeding: Very low risk endoscopic findings: Clean-bsed ulcer Clean based Mallory-Weiss tear Gastritis/duodenitis/esophagitis Portal hypertensive gastropathy Disposition: Discharge if stable
  • 21. Gastrointestinal Bleeding Risk stratification in UGI bleeding Medium risk endoscopic findings: AVM’s Ulcer with stigmata of recent hemorrhage Mallory-Weiss with stigmata of recent hemorrhage Varices with recent bleeding Cancer Hemostasis and medical ward/intermediate care unit
  • 22. Gastrointestinal Bleeding Risk stratification in UGI bleeding: High risk endoscopic findings: Active variceal bleeding Active ulcer bleeding Active bleeding Dieulafoy’s lesion Hemostasis and ICU admission
  • 23. ResuscitationPlace in ICU and Surgery consultationAirway protectionMaintain intravascular volume, O2Give NS until PRBC and FFP availableFollow vitals, orthostatics, and urine output
  • 24. Acute U.G.I. Bleeding )  **Shock management: (  ABC• Airway: endotracheal tube, oropharyngeal airway. *Give oxygen• Breathing: support respiratory function * Monitor: resp. rate, bld gases, chest radiograph Circulation: expand circulating volume: blood, colloids, crystalloids support CVS function: 1- 1 unit PRBC increases Hgb by 1 gm/dl and increase Hct by 3% 2- FFP for INR greater than 1.5 3-Platelets for platelet count less than 50.000 * Monitor: skin color, peripheral temp., urine flow, BP, ECG
  • 25. Rockall risk stratification scoreVariable 0 1 2Age (yrs) < 60 60-80 >80Shock SBP>100mmHg SPB>100mmHg SPB<100mmHg HR<100 bpm HR>100bpmCo-morbidity No major co- Heart failure, IHD. morbidity Renal Failure. Liver disease. Disseminated malignancy. Any co-morbidityEndoscopic Mallory-Weiss tear. Peptic ulcer Malignancy of upperDiagnosis No lesion identified. Erosive disease GIT No SSH EsophagitisMajor SSH None/Clean base. Adherent clot. Visible Dark spot sign on vessel (non ulcer base bleeding). Oozing bleeding, spurting arterial vessel
  • 26. Blatchford risk stratification score (23) Variable 1 2 3 4 6 SBP (mmHg) 100-109 90-99 > 90 Blood urea 18-22 22-28 28-69 < 70 (mg / dl) Hamoglobin (M) 12-12.9 10- > 10 (g / dl) 11.9 Hamoglobin (F) 10-11.9 > 10 (g / dl) Other variables HR>100bpm Syncope Melena Heart failure Hepatic Disease
  • 27. INDICATIONS FOR ADMISSION & REFERRALAdmit pts with h/o recent brisk bleeding & orthostatic changesAdmit pts with less severe blood loss who have comorbid conditions aggravated by anemiaProfound anemia with no evidence of blood lossRefer pts who are candidate for endoscopy when source of bleeding is elusive
  • 28. Causes of Upper GI Bleed Erosive EsophagitisNormal GEJ Grade 1 EE Grade 2 EE Grade 3 EE Grade 4 EE
  • 29. Causes  Upper GI Bleed 4. Esophageal or Gastric VaricesEsophageal VaricesNormal Esophagus Normal Fundus Gastric Varices
  • 30. Gastric varices Bleeding ulcers Dieulafoy’s lesion Esophageal Varices
  • 31. Causes of Upper GI Bleed Dieulafoy’s Lesion Dieulafoy’s Lesion Actively Bleeding
  • 32. Causes - Peptic ulcer disease Gastric Ulcer Gastric Ulcer Pyloric Channel Ulcer Duodenal Ulcer
  • 33. Watermelon stomach Gastritis Mallory-weiss
  • 34. Causes - Upper GI BleedGastritis Erosive Gastritis Diffuse Gastritis
  • 35. Causes of Upper GI Bleed Esophageal, Gastric, or Duodenal CA Gastric Cancer
  • 36. Ulcer with red spot Aortoduodenal Fistula Aorta Duodenum Fistula Graft
  • 37. Gastrointestinal Bleeding Prognostic factors in UGI bleeding: Severity of initial bleed. SHock/hemodynamic instability Age of patient < 65 Comorbid disease Anticoagulants/ coagulopathy Hb < 8g/dl APACHE II < 11 Presence of high-risk lesion, as varices/giant ulcer Endoscopic stigmata of significant hemorrhage (SSH) Need for emergency surgery
  • 38. Modified Forrest Classification for Upper GI bleeding Prognosis of endoscopic UGI bleeding finding:Class Endoscopic findings Re- Mortality bleeding rate (%) rate (%)1a Spurting arterial vessel < 90 111b Oozing hemorrhage 80 112a Non-bleeding visible 40 - 60 11 vessel2b Adherent clot 20-30 72c Ulcer base with black spot 10 3 sign3 Clean base 5 2
  • 39. Gastrointestinal Bleeding Special considerations in TTT UGI bleeding : Keep Nsaid’s in mind in all patients (the cause of non- healing until proven otherwise) Evaluate and treat Helicobacter pylori infections in the peptic disorder Stress related mucosal disease (SRMD) in hospitalized patients with non-bleeding illnesses Suppress gastric acid secretion Correct coagulopathy in most cases Must get early consultation with gastroenterologist and general surgeon for significant GI bleeds.
  • 40. Therapy Supportive care : begin promptly  IV fluids, blood products, pressors  Class I + II hemorrhage replace with crystalloid.  Class III + IV hemorrhage replace with crystalloid and blood. Specific care  Barrier agents (sucralfate)  H2 receptor antagonists (ranitidine)  Proton pump inhibitors (omeprazole, lansoprazole)  Vasoconstrictors (somatostatin analogue, terlipressin) Endoscopic therapy : stabilize and prepare patient first  Variceal injection or band ligation  Coagulation (injection, cautery, heater probe, laser)
  • 41. Gastrointestinal Bleeding UGI bleeding in portal hypertension: Varices High mortality on first bleed, 70% rebleed rate in next 12 months Start IV octreotide in all suspected PHT bleeds Antibiotic prophylaxis Endoscopic ligation is procedure of choice (prophylactic banding is standard of care, surveillance for variceal recanalization q 6mos-12mos) TIPS for endoscopy failures Minnesota tube/Blakemoore tube Surgical (shunts, transection)
  • 42. TreatmentEndoscopic intervention Banding Sclerotherapy Thermocoagulation Electrocoagulation Argon Plasma Coagulation
  • 43. Treatment Treatment  Submucosal injection of Epinepherine Duodenal Ulcer Injection Therapy
  • 44. Treatment Thermocoagulation Duodenal Ulcer Heater Probe Therapy
  • 45. Treatment Argon Plasma Coagulation (APC)
  • 46. Treatment Banding Ligation
  • 47. Further treatment ICU care Treatment of complications - sepsis - DIC - MODS
  • 48. TIPSIVC Coronary Vein Splenic VeinPortal Vein
  • 49. General Approach to GI BleedingStablizeLocateTreat