2. CLINICAL SCENARIO
A 60 y old lady with history of HTN and Rheumatoid Arthritis who
presents to the ER with 3 episodes of coffee–ground emesis
today
No abdominal pain, melena or hematochezia. No history of liver
disease or coagulopathy
She has been usings NSAIDs and DMARDs for 5 years.
VS on arrival: HR 102, BP 118/72 (lying down) 90/60 (standing),
sPO2 99% at room air
Examination: Alert. No scleral icterus. Abdomen soft, non-tender,
no HSM
Labs: Hgb 9.8, Plt 245, INR 1, LFTs normal
3. CLINICAL SCENARIO
• A 50 years old gentleman presented to ER with an episode of
hemetemsis yesterday and coffee ground vomiting today. Known
case of Hep C related DCLD
• Vitals: Pulse: 122, BP: 87/50
• After resuscitation, DRE was conducted. Melena positive
4. UPPER GI BLEED
• Acute gastrointestinal bleeding is potentially life-threatning
abdominal emergency that remains a common cause of
hospitalization.
• Upper gastrointestinal bleeding (UGIB) is defined as bleeding
derived from a source proximal to ligament of treitz
• vericeal or non-variceal
• UGIB is 4 times as common as bleeding from lower GIT, with a
higher incidence in male
5. EPIDEMIOLOGY
• In Pakistan, the incidence of variceal bleed (21%) almost
approaches to that of ulcer bleed (30.6%)
6. CAUSES
• Esophageal
Esophageal varices
Esophagitis
Esophageal cancer
Esophageal ulcers
Mallory-weiss tear
• Gasrtic
Gastric ulcer
Gastric cancer
Gastritis
Gastric varices
• Duodenal
Duodenal ulcer
Aorto-enteric fistula
Hematobilia
Hemosuccus pancreaticus
Severe superior
Mesenteric artery syndrome
13. cont...
After initial resusitation comes
MEDICATION:
1. ACID SUPPRESSION:
Patients admitted to the hospital with acute upper GI bleeding
are typically treated with a proton pump inhibitor (PPI). We suggest
that patients with acute upper GI bleeding be started empirically on
an intravenous PPI. It can be started at presentation and continued
until confirmation of the cause of bleeding. Once the source of the
bleeding has been identified and treated (if possible) intravenous
infusion of a PPI significantly reduces the rate of rebleeding
compared with standard treatment in patients with bleeding ulcers
[19]. Oral and intravenous PPI therapy also decrease the length of
hospital stay, rebleeding rate, and need for blood transfusion in
patients with high-risk ulcers treated with endoscopic therapy. (See
"Treatment of bleeding peptic ulcers", section on 'Acid
suppression'.), the need for ongoing acid suppression can be
determined.
14. 2. PROKINETICS:
The goal of using a prokinetic agent is to improve gastric
visualization at the time of endoscopy by clearing the stomach of
blood, clots, and food residue. A reasonable dose is 3 mg/kg
intravenously over 20 to 30 minutes, 30 to 90 minutes prior to
endoscopy.
3. SOMATOSTATIN AND ITS ANALOGS:
Octreotide, is used in the treatment of variceal bleeding and may
also reduce the risk of bleeding due to nonvariceal causes. In
patients with suspected variceal bleeding, octreotide is given as an
intravenous bolus of 20 to 50 mcg, followed by a continuous infusion
at a rate of 25 to 50 mcg per hour.
4. VASOPRESSIN ANALOG:
Terlipressin has major role in UGIB management ,used for 5 days
after hemostasis has been achieved
cont...
15. 5. ANTIBIOTICS:
prophylactic antibiotics in cirrhotic
patients hospitalized for bleeding
results reduction in infectious
complications and possibly decreased
mortality. Antibiotics may also reduce
the risk of recurrent bleeding in
hospitalized patients who bled from
esophageal varices
6. UPPER GI ENDOSCOPY:
Early endoscopy (within 24 hours) is
recommended for most patients with
acute UGIB (therapeutic + diadnostic)
If treatment still not working
then....
SURGICAL INTERVENTION:
Angiographic embolisation or
gastrectomy in severe cases
cont...
16. • The HALT-IT trial is assessing whether early administration of
tranexamic acid in people with acute gastrointestinal bleeding
can reduce their risk of dying in the hospital. The trial is also
measuring the effects of the treatment on re-bleeding, non-fatal
vascular events, blood transfusion, surgical intervention and
general health status
• POF hospital is participating in this trial since
1g in 100ml normal saline (over 10 min)
Then 3g in 1L normal saline (over 24 hours)
HALT-IT TRIAL
17. ON DISCHARGE
• Avoid NSAIDs If inevitable then use
COX-2 inhibitorsH-pylori eradication for
PUDB-blockers for variceal bleed
