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Management of a 60-year-old with hematemesis
- 1. Discuss the management of a 60year old man admitted to the hospital for hematemesis By Dr. Baribote O. S 04 – 04 – 2023
- 2. Introduction Surgical importance Epidemiology Causes of UGIB Common presentation Management Complications Prognosis Conclusion References Outline
- 3. • Upper Gastrointestinal Bleeding (UGIB) Diagnosis • Bleeding from a gastrointestinal source proximal to the ligament of Treitz Definition: • Life threatening medical/surgical emergency • common cause of hospitalization UGIB • Variceal • Non – variceal Categorized Introduction
- 4. Clinical significance Common, life threatening emergency Impact on the patient, relatives, society and the hospital In-hospital mortality rate • 5 – 10% • Rises to 33% • when bleeding is first observed in patients who are hospitalized for other reasons
- 5. Epidemiology •According to Antunes C. et al - 80 – 150/100,000 per year •Male:Female - 2:1 •Prevalence increases with age (>60years) Incidence
- 6. Causes of UGIB •Esophageal varices •Esophagitis •Esophageal ulcer •Esophageal cancer •Mallory-Weiss tear Esophageal
- 7. •Gastric varices •Gastritis •Gastric ulcer •Gastric cancer Gastric
- 8. •Duodenal ulcer •Vascular malformation including Aorto- enteric fistulae Duodenal
- 9. Condition % Ulcer 60 Esophageal Gastric Duodenal 6 21 33 Erosions 26 Esophageal Gastric Duodenal 13 9 4 Mallory-Weiss tear 4 Esophageal varices 4 Tumour 0.5 Vascular lesions e.g Dieulafoy’s disease 0.5 Others 5
- 10. Causes in Nigeria • 37% • Duodenal ulcer – 75% Peptic Ulcer • 18.75% Esophageal varices and gastritis • 15.6 Gastric cancer • 9.3% No obvious pathology
- 11. Common presentations • Coffee-ground – indicate slower rate of bleeding • Fresh blood – indicates rapid bleeding Hematemesis • Black tarry offensive stools • Indicates that blood has been present in the GI tract for at least 14hours Melena • Usually represent a lower GI source • Can occur in massive brisk bleeding Hematochezia
- 12. Management Preferably co-managed with the physicians Most UGIB will stop, albeit temporarily while in a few instances, bleeding with not stop Principles of management • Prompt resuscitation • Investigation to urgently to determine the cause of the bleeding. • Definitive treatment Instances where bleeding does not stop • Resuscitation, diagnosis and treatment should be carried out
- 13. Resuscitation History, examination, resuscitation and relevant investigations be done simultaneously Brief History to assess for • Hx to determine quantity of bleeding and presence of shock • Hematemesis – duration • Colour of the vomitus (bright red vs coffee –ground) • Number of episodes and quantity per episode • Presence of clots in the vomitus • History of melena or hematochezia • Shock • History of dizziness, generalized weakness, fainting attack, and dyspnea
- 14. Assess for signs of shock via examination and vital signs measurement • Cold clammy extremities • Restlessness, confusion, drowsiness or stupor • Hypotension • Bradycardia or tachycardia etc Secure 2 wide bore IV canulla Group and cross-match blood and transfusion if urgent PCV is <= 21% Resuscitation contd
- 15. Resuscitation contd Insert urethral catheter to monitor hourly urinary output Insert a NG tube to aspirate and do a cold saline lavage There is no evidence for the use of intravenous proton pump inhibitors prior to endoscopy IV tranexamic acid Intranasal O2 @ 2L/min
- 16. • History dyspepsia, • Epigastric pain with or without radiation to the back • smoking PUD • Weight loss and epigastric swelling Gastric cancer • Prolong vomiting and retching prior to onset of hematemesis Mallory Weiss tear History suggestive of underlying cause
- 17. • Chronic alcoholism, jaundice and previous history of liver disease Esophageal varices • History of surgery, trauma, burns, severe sepsis or renal failure Stress ulcers • Previous history of aortic surgery with sudden massive hematemesis +- fainting attack Aorto-enteric fistula • Chronic NSAID, aspirin, corticosteriods, anticoagulant use Drug history
- 18. Physical examination Do a thorough general examination Examine the systems for possible cause of the bleeding Abdomen • tenderness in the epigastrium, suggestive of peptic ulcer • hepatosplenomegaly, ascites or spider naevi, suggestive of oesophageal varices; • epigastric tumour, suggestive of gastric cancer; • expansile; pulsating mass suggestive of aorto-enteric fistula. • DRE • Fresh blood, melena stool
- 19. Examination contd • Palmer erythema – esophageal varices due to liver cirrhosis MSS • Purpura/ecchymosis – bleeding disorders • Other systemic examination to assess for comorbid state Skin
- 20. Investigation FBC + differential • May be normal due to hemoconcentration at presentation and should be repeated after fluid resuscitation • Values <=7g/dl should be transfused with red blood cells Clotting profile • If features suggest bleeding disorders Liver function test Electrolyte Urea and Creatinine Urinalysis
- 21. Investigation contd • Serology or Urea breath test • If features suggest PUD as the cause of UGIB H. Pylori • Rule out perforation and other comobidity (HHD, COPD etc) • Secondary tumours in the lung CXR
- 22. Investigation contd • Done after resuscitation and within 24hours of admission • Infusion of a prokinetic like erythromycin • Establish diagnosis and treatment Endoscopy (Esophagogastroduodenoscopy) • Double contrast where endoscopy is not available • Features • Mucosal defect (Ulcer crater) • Edematous ring around the ulcer crater (ulcer collar) • Radiating folds of mucosa away from the ulcer Barium meal
- 26. Treatment Depends on the etiology of the bleeding PUD • Treatment is medical, endoscopic intervention and surgical • A comprehensive clinical guideline for the bleeding ulcer was formulated by ACG in 2020 • Summary of the guideline is as follows
- 27. Endoscopic therapy is recommended for ulcers with active spurting or oozing and for non bleeding visible vessels Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, hemostatic powder spray TC-325 is suggested for actively bleeding low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis
- 28. After endoscopic hemostasis, high-dose PPI therapy is recommended continuously or intermittently for 3 days, followed by twice- daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy. Repeat endoscopy is suggested for recurrent bleeding, and if endoscopic therapy fails, transcatheter embolization is suggested Epinephrine only should not be used as an hemostatic agent
- 29. •Eradication therapy with triple therapy •PPI + Clarithromycin or Metronidazole + Amoxicillin •Duration of treatment •14days For H. pylori positive
- 30. Surgery for PUD • Massive hemorrhage • Continues hemorrhage • Significant rebleed after endoscopic intervention and transcatheter embolisation • Associated perforation Indications • stop the bleeding, • prevent a recurrence and, • if possible, cure the underlying cause Aim of surgery
- 31. •Often from the gastroduodenal artery •Under-run the vessel with a non- absorbable suture •Where a giant ulcer destroys the duodenum, making primary closure impossible, distal gastrectomy with roux-en-y reconstruction be done Bleeding duodenal ulcer
- 32. •Anterior gastrostomy with under running of the vessel in the ulcer bed •Biopsy of the edges done to exclusive malignancy •PPI therapy Bleeding gastric ulcer
- 33. Historic procedures for PUD Vagotomy • truncal vagotomy and drainage (pyloroplasty and gastrojejunostomy) • Selective and Highly selective Vagotomy + antrectomy Bilroth I and Bilroth II No longer widely practice due • Complications and introduction of effective acid lowering medications (PPI, H2RA)
- 34. • 90% bleeding stops spontaneously • Suture under running is all that is required Mallory-Weiss tear • Sclerosant injection and endoscopic clips • Local excision Dieufolay’s disease • Partial gastrecromy is performed if possible. Gastric Carcinoma
- 35. • Vasoconstrictor therapy with octreotide and/or vasopressin • Propranalol also lowers portal pressure and be given to prevent rebleed • Sclerosant injection • Band ligation • Balloon tamponade with Sengstaken- Blakemore tube • Transjugular intrahepatic portosystemic stent shunt Esophageal/gastric varices
- 38. Transjugular intrahepatic portsystemic stent shunt TIPSS
- 39. Treatment contd • Bleeding often stops spontaenously • Treated conservative with stopping the offending agent and in giving PPI and Gastric erosion • Conservatively with PPI but if numerous, vagotomy with hemi-gastrectomy can be performed Stress Ulcer
- 40. Algorithm in the Management of UGIB
- 42. Prognosis – Rockall Score
- 43. Conclusion UGIB is a surgical/medical emergency with high mortality rate Most cases of UGIB can stop temporarily and the investigation of choice is an upper GI endoscopy The principles of management include resuscitation, investigation to determine cause and institution of definitive treatment In most instances, medical and endoscopic intervention will cause the bleeding to stop Where the above fails surgical intervention can be done depending on the cause
- 44. References Normal S. Williams, P. Ronan O’Connell, Andrew W. McCaskie ‘Bailey & Love Short Practice of Surgery’ 27th Edition Laine et al. ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding. Am J Gastroenterol 2021;116:899–917. https://doi.org/10.14309/ajg.0000000000001245 Blatchford O, Murray W.R., Blatchford M. (2000). A risk score to predict need for treatment for upper-gastrointestinal haemorrhage. Lancet (London, England), 356(9238), 1318-1321. Sung J.J, Chan F.K., Chen M., et al. (2011). Pacific working group consensus on non-variceal upper gastrointestinal bleeding. GUT (60): 1170-1177. Badoe, Archampong, Jaja: Principles and Practice of Surgery including pathology in the Tropics. 5th Edition
Editor's Notes
- From the question, this patient has upper gastrointestinal bleeding (UGIB) Hematemesis – vomiting of blood which can be bright red or coffee-ground.
- Impact on the patient, relatives, society and the hospital
- Article UGIB published in National Library of Medicine in 2022
- Congenital and acquired Dieulafoy’s disease (arterovenous malformation) that possess a diagnostic challenge for endoscopist as there lesions often have a normal overlying mucosa
- According to the 27th Edition of Bailey and Love’s Short practice of Short pg 1127
- The picture is not different in Nigeria. According to the article – Epidemiology of UGIB in a Nigeria Teaching Hospital by Charles A. A. Et al In 2002 – 2003 involving 731 patients
- IV tranexamic acid @ 10mg/kg slowly over 20mins and then 1mg/kg/hr continuous infusion for 6 – 10hrs
- If the patient has had an operation, injury, burns or severe sepsis or is in renal failure, stress ulceration is suspected although the bleeding may be due to re-activation of a chronic peptic ulcer
- signs that may suggest a possible cause of the bleeding: tenderness in the epigastrium, suggestive of peptic ulcer; hepatosplenomegaly, ascites or spider naevi, suggestive of oesophageal varices; epigastric tumour, suggestive of gastric cancer; telangiectasia of the mouth or lip, suggestive of hereditary telangiectasia and an expansile; pulsating mass suggestive of aorto-enteric fistula.
- PT – 13sec, aPTT – 30 – 40secs, INR – 1.1
- There are two methods a) non-invasive and b) invasive. a) Non-invasive i) Serological test: This gives only 90% sensitivity and specificity. ii) Urea breath test (UBT): After ingestion of carbon isotope-labelled urea, the abundant urease enzyme produced by the organism breaks the urea down to co2 which is detected in the expired air. The test is used to monitor rreatment. iii) Stool antigen test: It has a higher false positive rate and takes longer to become negative after treatment. b) Invasive Multiple biopsies are taken at endoscopy (because the infection is patchy) from the antrium and subjected to i) rapid urease test giving a colour change and ii) histological staining for H.pylori, H&R, Genta stain, Di ff-Quick stain or El-Zimaity. It has been shown that H. pylori deregulates the control of acid secretion by interfering with somatostin function.
- Areas of active bleeding Areas of recent bleeding Non bleeding lesions
- Risk of rebleeding and indication for endoscopic intervention
- Score range from 0 – 23 0-1 low risk (managed on outpatient basis) >1 (should be admitted and managed accordingly)
- Endoscopic therapy is recommended for ulcers with active spurting or oozing and for nonbleeding visible vessels. Endoscopic therapy with bipolar electrocoagulation, heater probe, and absolute ethanol injection is recommended, and low- to very-low-quality evidence also supports clips, argon plasma coagulation, and soft monopolar electrocoagulation; hemostatic powder spray TC-325 is suggested for actively bleeding ulcers and over-the-scope clips for recurrent ulcer bleeding after previous successful hemostasis. After endoscopic hemostasis, high-dose proton pump inhibitor therapy is recommended continuously or intermittently for 3 days, followed by twice-daily oral proton pump inhibitor for the first 2 weeks of therapy after endoscopy. Repeat endoscopy is suggested for recurrent bleeding, and if endoscopic therapy fails, transcatheter embolization is suggested
- 80mg IV bolous followed by 8mg/hr continuous infusion for 72hrs, then oral 40mg bd for 2/52
- 20mg omeprazole bd or lansoprazole 30mg bd Clarithromycin 500mg bd Flagyl 400mg tds Amoxyl 1g bd
- A patient who has required more than six units of blood in general needs surgical treatment
- through a transpyloric gastroduodenostomy
- Bearing in mind that most patients nowadays are elderly and unfit, the minimum surgery that stops the bleeding is probably optimal
- Complications
- Gastric arterial venous malformation If it can be seen while bleeding, all that may be visible is profuse bleeding coming from an area of apparently normal Mucosa.
- Octreotide 50mg/hr infusion Vasopressin 20units in 250ml of 5% dextrouse over 30mins, 4hourly To prevent coronary vasoconstriction – nitroglycerin should be given
- Sengstaken-Blakemore tube
- Stress Ulcer: Vagotomy with hemi-gastrectorny is performed if the erosions are numerous. If the erosions are few, they may be oversewn
- Rockall Score Scores > 8 High risk of death Score < 3 Excellent prognosis