Upper GI bleeding & portal hypertension in Children

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  • Curling’s ulcer Cushing’s ulcer Dieulafoy lesion watermelon stomach
  • Upper GI bleeding & portal hypertension in Children

    1. 1.  Melaena – the passage of black, tarry stools indicates likely UGI bleed (proximal to the ligament of Treitz) Haematemesis – vomitus containing frank blood or brown-black “coffee grounds” Haematochezia – passage of bright or dark red blood per rectum In general, the redder the blood, the more distal the site of bleeding
    2. 2.  Red: beets, laxatives, phenytoin, rifampin Black: bismuth, activated charcoal, iron, spinach, blueberry, licorice
    3. 3.  Drugs Retching or vomiting Jaundice Procedures Recurrent abdominal pain Bleeding disorders in family Odynophagia
    4. 4.  Stigmata of chronic liver disease General condition External vascular malformation Hyperpigmented lips Dilated abdominal wall veins, Splenomegaly
    5. 5.  Removes blood from stomach – facilitates easier endoscopy Confirmation of bleed/ongoing blood loss Prevents development of encephalopathy in cirrhotic patients
    6. 6.  Disproportionate tachycardia “Tilt” test Capillary refill time Signs of shock
    7. 7.  Portal vein agenesis, atresia, stenosis Portal vein thrombosis or cavernous transformation Splenic vein thrombosis Arteriovenous fistula
    8. 8.  Acts by increasing splanchnic vascular tone 0.3 units per kg per hour after a bolus of 0.3 U/kg over 20 min Theaddition of nitroglycerin (skin patch) decreases the systemic .effects of vasopressin Terlipressin-longer duration of action and lesser cardiac side effects
    9. 9.  much better side-effect profile and similar efficacy3 to 5 μg per kg per hour Octreotide has a longer half-life- bolus (2 μg/kg) followed by continuous infusion (1 to 5 μg per kg per hour)
    10. 10.  antibioticprophylaxis directed at intestinal flora (third-generation cephalosporin) should be started from admission H2receptor blocker or proton pump inhibitor intravenously
    11. 11.  Acts by producing intimitis Injected either intra- or paravariceal Intravariceal cyanoacrylate or histacryl glue and thrombin for gastric varices Complications of EST include ulceration, pain, perforation, and bacteremia.
    12. 12.  Draws a visible varix into the lumen of the ligator and a band is placed around the varix EVLis just as effective as EST but was associated with fewer complications and faster obliteration of varices.
    13. 13.  Indications: Recurrent variceal hemorrhage Refractory ascites Hepatorenal syndrome Contraindications Polycystic liver disease Right heart failure Systemic infection Portal vein thrombosis Severe hepatic encephalopathy
    14. 14.  Primary prophylaxis - propranolol Secondary prophylaxis – EVL/EST Surgical treatment: Patients with EHPVO bleeding gastric or other nonesophageal varices severe hypersplenism
    15. 15.  Decompressive shunts Devascularization Liver transplantation

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