Gastrointestinalemergencies Richard
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Gastrointestinalemergencies Richard

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Gastrointestinalemergencies Richard Gastrointestinalemergencies Richard Presentation Transcript

  • Gastrointestinal Emergencies Dr Richard Warner SpR Gastroenterology September 2005
  • GI emergencies
    • GI bleeding
    • Paracetamol Overdose
    • Severe ulcerative colitis/Crohn’s colitis
    • Liver Failure
  • Upper GI Bleeding
    • Incidence 100/100,000
    • Mortality - 1947 9.9%, 1995 11% (6%), 33% (17%) in hospitalised patients
    • Higher MR in elderly with co-morbidity
  • Causes of Upper GI Bleeding
    • peptic ulceration (35-50%)
    • oesophagitis, gastritis, duodenitis (5-15%)
    • gastroduodenal erosions (8-15%)
    • Mallory Weiss tear (15%)
    • varices (5-10%)
    • tumour (1%)
    • angiodysplasia, telangiectasia (2-3%)
    • vascular ectasia, Dieulafoy’s lesion(1-2%)
  • Varices
  • Varices
  • Varices
  • Oesophagitis
  • Mallory Weiss Tear
  • Gastric ulceration
  • Angiodysplasia
  • Duodenal Ulceration
  • Symptoms at Presentation
    • haematemesis/melaena/both
    • breathlessness, chest pain
    • collapse
  • Management of Upper GI Bleed
    • Resuscitation
    • Assessment of vital signs
    • wide bore venous cannulae/?central line
    • crystalloid, colloid/blood
    • blood tests and cross match
    • monitoring - bp, hr, urine output, ?cvp
    • early endoscopy and inform surgeons
    • high dose iv ppi for peptic ulcers
  • Factors in History
    • NSAIDs, clopidogrel, steroids
    • alcohol history
    • liver disease
    • anticoagulants
    • family history
    • severe vomiting
  • Severe UGI Bleed/ High risk
    • Haematemesis and melaena
    • cardiovascular compromise
    • age>65
    • co-existing cardiorespiratory disease
    • Hb <10g/l
  •  
  •  
  • Rockall Scoring System (Risk of rebleeding and death)
  • Rockall Scoring System 2
    • Score less than 3 = excellent prognosis
    • ?fast tracked for discharge
    • score > 8 = high mortality risk
    • close monitoring
    • stratified post endoscopy
  • Endoscopy for UGI Bleeding
    • Diagnostic and therapeutic
    • Peptic ulceration - injection, heater probe, haemoclips
    • high risk - actively bleeding vessel (0-75%)
    • non-bleeding visible vessel (4-27%)
    • adherent clot
    • therapy  rebleeding, surgery, mortality
  • Evidence for Intravenous Omeprazole
    • Lau et al 2000 (NEJM)
    • 15-20% rebleeding rate for peptic ulcers
    • 80mg bolus, 8mg/hour for 72 hours, 20mg
    • orally for 8 weeks
    • adrenaline+thermocoagulation, randomised to ppi (120) or placebo (120) (30 day FU)
    • rebleeding in placebo 22.5% (20% ), omeprazole 6.7% (4%)
  • Variceal Bleeding
    • Mortality 30-80% (average 50%)
    • ?Severity underlying liver disease (A<B<C)
    • 50% rebleed in 10 days
    • 30-50% cirrhotics have a variceal bleed
    • 40-80% rebleed in 1 year
    • 33% survive 3 years
    • no bleed if portal pressure <12mmHg
  • Therapy for Varices
    • Endoscopic - banding or sclerotherapy
    • Medical - terlipressin, octreotide
    • Tamponade - Sengstaken-Blakemore tube
    • Surgery - shunts, oesophageal transection
    • TIPSS
  • Endoscopic Therapy of Varices
    • Sclerotherapy control of bleeding
    • Band Ligation 1995 Lo demonstrated band ligation better than sclerotherapy (94%:80%) 1998 Stiegmann demonstrated control of bleeding decreased rate of complications, decreased MR compared to sclerotherapy
  • Medical Therapy of Bleeding Varices
    • vasopressin/glypressin +/- GTN increased rate control of bleeding, no benefit survival
    • somatostatin / octreotide increased rate control of bleeding, improved survival
    • somatostatin=sclerotherapy=tamponade
  • Sengstaken
  •  
  • Primary and Secondary Prevention of Variceal Bleeding
    • Betablockers - propanolol 40-80mg bd
    • Primary - screen cirrhotics
    • ?prophylactic banding (Gastro 2002)
    • Secondary - once bleed settled
    • Aiming portal pressure <12mmHg/  20%
  • Role of Beta-blockers
    • Decrease portal pressure, splanchnic vasoconstriction
    • Primary 9 RCT, 1 meta-analysis
    • significant decrease in risk of bleeding
    • cirrhotics screened, if varices start  blocker
    • Secondary 755 patients in 11 trials significant decrease in rebleeding rates
  • TIPPS
  • Transjugular Intrahepatic Porto-systemic Shunt
    • Refractory variceal bleeding
    • refractory ascites
    • Budd-Chiari
    • 95-100% success rate
    • 0-2% procedural mortality, 10% morbidity
    • 30 day mortality 5-15%
    • bridge to transplantation
  • Complications of TIPSS
    • Restenosis, occlusion (rebleeding)
    • thromboembolism
    • hepatic encephalopathy (13-55%)
    • haemorrhage, haemobilia, cholangitis
    • stent migration
    • heart failure, liver failure
    • infection
  • Variceal Bleed Treatment Plan
    • Resuscitation and early endoscopy
    • Banding +/-sclerotherapy
    • ?haemostasis repeat 5-7 days
    • ?failed iv vasoconstrictor +/-tamponade
    • ?failed endoscopy x2/medical Rx ?TIPSS
  • Lower GI Bleeding
    • Diverticular disease
    • Adenoma/Carcinoma
    • Colitis
    • Angiodysplasia
    • Vasculitis
    • Ischaemia
    • Haemorrhoids
  •  
  • Paracetamol Overdose
    • 15g potentially lethal
    • conjugates sulphate and glucuronide
    • toxic metabolite NAPQI binds glutathione
    • excreted as cysteine conjugate
    • N-acetyl cysteine/methionine releases glutathione
  • High risk paracetamol overdoses
    • Pre-existing liver disease
    • high alcohol intake
    • enzyme inducing medication
  •  
  • Paracetamol OD Symptoms
    • Usually after 24 hours
    • anorexia, nausea, vomiting
    • day 2 abdominal pain, liver tenderness
    • liver damage detectable>18 hours
    • maximal liver damage 72-96hours
  • Complications of Paracetamol Overdose
    • Jaundice and FHF
    • renal failure (ATN)
    • hyperlactataemia (mild early, late severe)
    • metabolic acidosis
    • hypophosphataemia, hypo/hyperglycaemia
    • cardiac arrhythmias
    • pancreatitis, GI bleeding, cerebral oedema
  • Management of Paracetamol OD
    • ? level  4hours
    • lower significant level if high risk
    • ? gastric lavage
    • iv n-acetyl cysteine
    • IV fluids ++
    • Antibiotics
    • early liaison with liver unit, ? renal dialysis
    • liver transplantation
  • Prognostic factors
    • PTT >100s (PTT >180s < 8% survival)
    • pH <7.30 (15% survival)
    • creatinine >300 (23% survival)
    • factor VIII/V close correlation prediction survival
  •  
  • Severe Ulcerative colitis
    • Truelove and Witt’s Criteria of severity
    • bowel frequency >6/day, bloody diarrhoea
    • heart rate >90/min
    • ESR >30mm/hr
    • temperature >37.5
    • Hb <10g/dl
  • Symptoms severe UC
    • ? systemically unwell
    • Fever
    • Abdominal pain
    • dehydration
    • electrolyte imbalance
  •  
  •  
  • Assessment of severe UC
    • Stool cultures
    • Blood tests - FBC, U&Es, ESR, LFTs, albumin, CRP
    • AXR - toxic megacolon, mucosal islands small bowel loops
    • flexible sigmoidoscopy - severity ulceration
  • Management of Severe UC
    • Joint physician/surgeons
    • high dose intravenous steroids
    • rectal steroid
    • ivi
    • free fluids/light diet
    • close monitoring
  • Course of Severe UC
    • 25% severe colitics considered for colectomy
    • urgent colectomy if complications
    • daily AXR if abnormal
    • regular blood tests
    • If at day 3 CRP >45 or bowel frequency >8/day & CRP <45 = 83% risk colectomy
    • ?role for iv/oral cyclosporin
  • Crohn’s colitis
    • High dose iv steroids +/- rectal steroids
    • Antibiotics - metronidazole
    • role for anti-TNF 
  •  
  •  
  •  
  • Liver Failure/Decompensation
    • History is crucial
    • Establish Childs score
    • Ascites, Albumin, Bilirubin, PT, Encephalopathy.
    • Look for why Decompensated
  • Decompensation
    • GI Bleed
    • Sepsis
    • Drugs
    • Constipation
    • Dehydration
    • End Stage
    • ?? Head injury
  • Investigations
    • FBC/MCV
    • Clotting
    • U+Es
    • Albumin + LFTs
    • CRP/ESR
    • AFP + USS (? PV thrombosis/hepatoma)
    • Hep screen if not previously done
  • Investigations
    • Ascitic diagnostic tap
    • Blood Cultures
    • Urine Cultures
    • Consider OGD
  • Treatment
    • Stop all sedating/toxic drugs
    • Laxatives
    • Antibiotics
    • Vitamin K / Thiamine/Pabrinex
    • Decide ITU/Transplant candidate
    • Consider NG tube
    • High protein / Low Salt diet
    • Avoid Saline !!!!!!
  • Ascites is not just a Cosmetic Problem !
    • Median Survival 2 years from onset
    • Survival depends mainly on Liver Function
    • SBP occurs ~25%
    • Low urinary Na + & SBP predict high mortality
  • SBP
    • No Set Rules!
    • ? Drain
    • 3 x 100mls 20% salt poor HAS day 1+2
    • 2 x 100mls 20% HAS day 3
    • Antibiotics long term
    • Consider transplant
  •  
  • Hepatorenal syndrome Splanchnic vasodilatation Effective underfilling Salt and water retention Vasoconstrictor systems Renal vasoconstriction Hepatorenal syndrome Ascites
  • Hepatorenal syndrome
    • Diagnosis
      • Diagnosis according to strict criteria (IAC 1996)
      • Renal failure in context of liver failure in absence of other cause associated with low urinary sodium
      • Type 1
        • Rapidly progressive renal failure. Median survival 15 days
      • Type 2
        • Slowly progressive but patients at risk of deterioration to Type 1.
  • Treatment options
    • Vasoconstrictors
      • Terlipressin
      • Noradrenaline
      • Midodrine and octreotide
    • Increase central blood volume
      • Albumin
      • TIPSS
    • Transplantation
  • Hepatorenal syndrome
    • Terlipressin with albumin
      • Long acting vasopressin analague, splanchnic vasoconstrictor
      • 21 patients with Type 1 HRS
      • Terlipressin (0.5-2mg IV Q4hrly ) + Albumin (1g/kg then 20-30g/day)
      • 15 days or until creatinine normal
      • 12/21 (57%) complete response (historically 15%)
      • CR 77% with albumin Vs 25% if no albumin ( P<0.03 )
      • 17% relapsed after withdrawal drug
      • CR associated with increased survival Ortega, Hepatology, 2002
  • Hepatorenal syndrome
    • Noradrenaline
      • N=12
      • 0.5-3mg/h + albumin + frusemide
      • 10+/-3days
      • Aim CrCl > 40ml/min, creatinine < 133micmol/L
      • Reversal 10/12
        • association with increase MAP, decrease renin-aldosterone
      • 3 OLT, 4 “more stable”, 5 “early deaths”
        • Duvoux Hepatol 2002
  • Hepatorenal syndrome
    • Midodrine and octreotide
        • N= 13 Type 1 HRS
        • Oral midodrine (oral vasoconstrictor)+ S/C octreotide Vs M+O+DA to increase MAP >15mmHg for 20 days
        • Small study but improved survival in M+O Vs +DA Angeli 1999
  • Hepatorenal syndrome
    • TIPSS
        • 41 non transplant candidates ( non randomised)
        • 31 TIPSS (21 type 1, 10 type 2)
        • Maximal benefit takes 2 weeks
        • Increased creatinine clearance, salt excretion
        • Survival 3/12: 81% Vs 10% Brensing Gut 2000
  • Hepatorenal Syndrome
    • TIPSS
      • Type 2 HRS
        • N=18 Type 2 HRS CP C
        • No HE resistant to medical therapy
        • Complete remission of ascites
        • Improved renal function Testino, Hepatogastro 2003
  • Hepatorenal Syndrome
    • Medical therapy as a Bridge to TIPSS
        • N=14, Type 1 HRS, M+O 14 days
        • 10/14 improved renal function and sodium handling
        • 5/10 - TIPSS
          • Normal renal function, Na handling and no ascites at 1 year
    • Wong Hepatol 2004
  • Hepatorenal syndrome
    • Effect of HRS upon outcome of OLT
      • N=9 HRS with terlipressin Rx
      • N=27 without HRS
      • Same 3 year survival
      • Same renal function post OLT, time in hospital and ITU post OLT
      • Restuccia T, J Hepatol 2004
  • Hepatorenal syndrome
    • Summary
      • Terlipressin with plasma expansion
      • Increasing role of TIPSS in
        • Transplant candidates
        • Type 2 HRS
        • Medical therapy as bridge to TIPSS/ OLT
      • Consider transplantation