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Acute Upper Gastrointestinal Bleeding Entesar El Sharqawy MDHepatology, Gastroenterology and Infectious Diseases. Benha University 26/09/12
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.
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
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
Gastrointestinal BleedingPresentation 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
Chain of events1. Recognize severity2. Establish access for resusitation3. Resusitate4. Identify source5. Intervention
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
Etiology of Significant UGI Bleeding in Adults Varices Peptic ulcer disease Gastric erosions Mallory-Weiss tear Esophagitis Duodenitis
Etiology of Significant UGI Bleeding in ChildrenEsophagitis Gastritis Ulcer Esophageal Vs Mallory-Weiss
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
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)
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
General ApproachUpper GI Bleed vsLower GI Bleed
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
Gastrointestinal BleedingNasogastric 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
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.
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.
Upper GI hemorrhageUpper endoscopy indications Hematemesis Melena or hematochezia with hypotension NGT with guiac positive fluid Should be completed in 24hrs for stable patients
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
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
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
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
ResuscitationPlace in ICU and Surgery consultationAirway protectionMaintain intravascular volume, O2Give NS until PRBC and FFP availableFollow vitals, orthostatics, and urine output
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
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
INDICATIONS FOR ADMISSION & REFERRALAdmit pts with h/o recent brisk bleeding & orthostatic changesAdmit pts with less severe blood loss who have comorbid conditions aggravated by anemiaProfound anemia with no evidence of blood lossRefer pts who are candidate for endoscopy when source of bleeding is elusive
Causes of Upper GI Bleed Erosive EsophagitisNormal GEJ Grade 1 EE Grade 2 EE Grade 3 EE Grade 4 EE
Causes Upper GI Bleed 4. Esophageal or Gastric VaricesEsophageal VaricesNormal Esophagus Normal Fundus Gastric Varices
Causes - Upper GI BleedGastritis Erosive Gastritis Diffuse Gastritis
Causes of Upper GI Bleed Esophageal, Gastric, or Duodenal CA Gastric Cancer
Ulcer with red spot Aortoduodenal Fistula Aorta Duodenum Fistula Graft
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
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
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.
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)
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)