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The Overall Management of UGIB:RESUSCITATION ER: 3 1 Initial Assessment &Fluid Resuscitation 2 Use of Blood Components 3 Correction of Coagulopathy 4 NGT 3 5 Risk stratification scoring 6 PREENDOSCOPY PPI 3 7 PREENDOSCOPY Prokinetics 8 PREENDOSCOPY ANTIFIBRINOLTYICS
The Overall Management of UGIB:RESUSCITATION ER: 3 9 PREENDOSCOPY: SMST/OCTT 10 Optimal time to endoscope 3 11 Postendoscopy PPI 12 Test & treat H Pylori 13 Tailor PPI dose to underlying cause 3 Postendoscopy Gen in-hosp management 14 3 15 On discharge 16 NSAIDs issues
Initial Assessment &Fluid ResuscitationRestoration of circulating volume takespriority over endoscopy. ER ABC(shock/airway compromise) 2 IV line IVF Blood group/cross Crystalloids match with pulse until blood oximetry,cardiac ready monitoring, Colloids or automated BP albumen readings,close monitoring of UO preferred for &ideally, CVP cirrhotics.
Use of Blood Components Improve Global O2 delivery Improve hemostasis Blood benefits (43% require it regional O2 delivery Target Hb 7-8gms If no Continuous bleeding or CVD). BTSF if Hb>8 TSF>10 *2 rebleed pints needs plts , FRP,Ca
Coagulopathy correction 6.2 coagulopathy even without cirrhosisCauses Associated with•Multifactorial•Marker of Coagulation screen •Increaseddisease mortaltyseverity •Rebleeding Correction: FFP,PC •INR <1.8 Associated Should not delay urgerny OGD with lower mortality& fewer MI Endoscopic hemostasis can be done safely if INR up to 2.5
NGT: Routine use Pre OGD controversial Ptognostic index(1) ?ENSURE HEMOSTSIS Confirm UGI source(85%) BENEFITS Monitor continuous loss ?collect it to use Remove blood & clots It for lesion injection? To clear field for OGD (1)presence fresh red blood in the NGT aspirate found to be an independent predictor of adverse outcome & predictor of high-risk lesions in patients who are hemodynamically stable without evidence of hematemesis.
Risk stratification scoring:low risk/high risk:Using: Early hospital dischareClinical data MortalityLab date Need for endohemostasisOGD findings Rebleeding
Risk stratification: other than scoring systemsAge>60 Inc mortalityHD Shock >*3 mortality & more needFor endohemostasis Risky statesHematemesis*2 mortalty,rebleed & endohemostasis
Risk stratification: other than scoring systemsInpatient at time of bleed *3 mortalityCompared to new admisionsHigh BU increase need forEndohemostasis Risky stateshematochezia*2 mortalty,rebleed & endohemostasis
Risk stratification: other than scoring systemsA large ulcer size (>2 cm )Rebleed /mortalityspecific locations(lesser wall curve or on the posterior Risky Ulcerduodenal wall),rebleed,mortality,surgeryEndo stigma Forrest Class IA, IB, IIA& IIBare high risk, Class IIC & III are low-risk
PREENDOSCOPY:PPI either oral or IV (better) PH>6Optimal plat agg clot formation High risk lesions reduce ENDO Interventions at OGD No effect on mortality, syrgery need or rebleeding
Preendoscopy PPI: Most suitable for OGD delayed or not available for 24 hours NVUGIB Pre OGD PPI HR lesion?:Hematemes or bloody NGT IV preferred Sp if vomiting
PREENDOSCOPY Prokinetics: IV erythro or metochlorpromide Erhthro is motilin agonist REDUCE repeat endoscopyPlasil if IV eryhthro PK No improve other clinical No available endpoints IV eryhthro IV erythro most suitable for patients Need PRIOR ECG Most likely to have blood in stomach at initial OGD.
Pre-endoscopic antifibrinolytics 1 2 At present there is large-scale RCT will be insufficient evidence required to address this to recommend TXA question. in the treatment of NVUGIB
Pre-endoscopic SST,OCT SST,OCT not recommended in the routine management of patients with acute NVUGIB.(for VGIB) ?Blee du not controllable while waiting OGD or surgery, or if surgery is contraindicated
Optimal time to endoscope <24 if very HR patient with highWITHIN 25 Hours blatchford scores after initialafter initial stabilization stabilization
Optimal time to endoscope: benefits 1 2 3 early &targeted endoscopic risk stratification : hemostasis in higher- Improvement in other early discharge of risk patients who are clin endponits those patients with actively bleeding or low-risk with high-risk stigmata of bleeding.Targeted endoscopic hemostasis(dual endoscopic therapy): NS/Adrenaline inj+one of other modalities(APC,Clip,band,thermal)
Post endoscopy PPI reduced Mortality In active bleeders& NBVV For high-risk stigmata who have received successful OGD therapy.Reducerebleed Need for surgery
Postendoscopy Test&treat H Pylori Tested for HPTested to confirm eradication All bleeding PU SHOULD Eradication Reduces rebleed. Increased False –ve testing
Post endoscopy general in-hosp management. Intervention radiology/Surgey After 2 OGDs Re-bleeding Re OGD interven If was on asp/NSAIDs Evaluate risk/benefir ratio Reuse within 5 days. Low risk Fed within 24 hs & discharged on Oral PPI within1-2 days. High risk lesions 72 hour monitoring for rebleeding
subsequent pharma management.After discharge:once-daily oral PPI dose (in the case of bleedingesophagitis, twice-a-day dosing), the duration of which should bedetermined by the underlying etiology of the bleeding.
ASGE Guidelines 2012 We recommend that patients with UGIB be adequately resuscitated before endoscopy. We recommend antisecretory therapy with PPIs for PUD Bleeding or in those with suspected PUD bleeding awaiting endoscopy. We suggest prokinetic agents in patients with a high probability of having fresh blood or a clot in the stomach when undergoing endoscopy. We recommend endoscopy to diagnose etiology of acute UGIB. The timing of endoscopy should depend on clinical factors. Urgent endoscopy (within 24 hours of presen-tion) is recommended for patients with a history of malignancy or cirrhosis, presentation with hematemesis&signs of hypovolemia including hypotension, tachycardia&shock, &Hb 8 g/dL.
ASGE Guidelines 2012 We recommend endoscopic therapy for PU with high-risk stigmata (active spurting, visible vessel). The management of PUD with an adherent clot is controversial &recommended endoscopic treatments include inj (sclerosants, thrombin, fibrin, or cyanoacrylate glue), cautery, & mechanical therapies. We recommend against epinephrine inj alone for PU bleeding. If epinephrine inj is performed, it should be combined with a second endoscopic treatment modality (eg, cautery or clips). We recommend low-risk lesions be considered for OP TRT. We recommend against routine second-look endoscopy in patients who have received adequate endoscopic therapy. We recommend repeat OGD for patients with evidence of recurrent bleeding.
Summary Adequate resuscitation. Risk stratification . Early endoscopy to enable further risk stratification. Application of endotherapy to high-risk lesions to achieve hemostasis &downgrade stigmata. Injection of epinephrine alone is not optimal when treating all high-risk lesions which needs in addition one of the other endoscopic hemostatic modalities as APC or cliping. All endoscopic hemostasis should be complemented by a 72-hour infusion of high dose PPI. All patients should be tested for H pylori & treated if necessary, Secondary prophylaxis should be considered for appropriate patients ie PPI covering asp/NSAIDs requiring patients.