Ugib -need editing-

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  • For benign distal ulcer. The distal part of the stomach removed and anastomosed to duodenum. If proximal ulcer need polya invlving anastomosis of gastric remnant to jejunum
  • Aim to reduce acid n pepsin secretion by stomach. Ach cmpnt of secretion pathway interrupted. But drawback is stomach motility is decreased and pyloric sphincter fails to relax. Need drainage.
  • Ugib -need editing-

    1. 1. Click to edit Master title styleContinous Medical Education (CME) Md Azhari HOSPITAL KAJANG
    2. 2. Click to editClinical Case Master title style 68 / C/ Gentleman is admitted to the hospital with CC: emesis of bright red blood. Patient reports that he was shopping when he began throwing up blood at the store. He denies any associated pain, melena, hematochezia, liver disease, or prior episodes. Patient reports some lightheadedness with standing, denies CP, SOB, visual disturbances. He is taking indomethicin for gout. Patient denies abdominal pain, chest pain, cough and diarrhea.
    3. 3. Click to edit Master title style PMHx: Gout, HTNHe had a gout flare up while in the hospital 3 monthsago and was discharged home with a steroid taper. Hewas prescribed Indomethacin 50 mg po q 8 hr prn painbut he was taking it daily for the last month. PSHX: Nil Allergic Hx : NKA FAMILY Hx : Gout
    4. 4. Click to edit Master title style Physical examination: Alert and Concious, Lethargic, no stigmata of chronic liver disease Vital sign : BP – 104/70 PR-104 RR-26 T-37 Eyes: conjunctiva pale, no icterus Chest: Clear CVS: DRNM Abdomen: Soff NT, No Organomegaly, +BS Rectal: no stool
    5. 5. Click to edit Master title styleDiagnosis??
    6. 6. Click to edit Master title style UPPERGASTROINTESTINAL BLEEDING
    7. 7. Click to editUpper Gastrointestinal Master title styleBleeding UGIB – Bleeding from esophagus, stomach or duodenum (Proximal to the Ligament of Treitz) Presentation  Sx Anemia  Haematemesis  Coffee ground emesis  Melena  Hematochezia  Hypovolumia & shock  Nonspecific complaint ( dypsnea, abdominal cramps, chest pain & fatigue)
    8. 8. Click toCAUSES % edit Master title stylePEPTIC ULCER 50MUCOSAL LESION (GASTRITIS, 30DUODENITIS)MALORY WEISS TEAR 5-10VARICES 5-10REFLUX ESOPHAGITIS 5
    9. 9. Click to edit Master Differential Diagnoses title styleEsophagus Gastric Duodenum SystemicVarices Ulcer Ulcer LeukamiaEsophagitis Gastritis Aotoenteric Fistula HemophiliaTumour Gastric Varices Erosion of the Thrombocytopenia Pancreatic tumor Tumor(malignant & Coagulopathy benign) Dieulafoy’s Lesion Hereditary Hemorrhagic Telangiectasia Mallory Weiss Tear
    10. 10. Click to edit MasterPeptic Ulcer Disease title style• Duodenal ulcer – epigastric pain, relieved by eating• Gastric ulcer – epigastric pain, may precipitated by food• Exacerbation factors – stress, smoking, alcohol, NSAIDS, steroids, hyperparathyroidism, Zollinger- Ellison syndrome• Diet history *A perforated Ulcer Rarely Bleed And A bleeding Ulcer Rarely Perforates
    11. 11. Click to edit MasterEsophageal Varices title style Portal hypertension Chronic liver disease Social history – alcohol Hemorrhoids, ascites, bleeding tendency Stigmata of chronic liver disease
    12. 12. Click to edit Mastertitle style
    13. 13. Click to editResuscitation Master title style• Airway- secure the airway- Intubate if necessary- Prevent risk of aspiration pneumonia• Breathing - give supplemental oxygen- Monitor SpO2 > 96%
    14. 14. Click to edit Master title style• Circulation-Insert 2 large bore branula (16G) on each arm.-Consider CVP line in elderly with profound shock and significant comorbid.-Do blood i(x) for : FBC, LFT, clotting profile, GXM, BUSE and creatinine, Glucose level.-Give crystalloid (Normal Saline, Hartman).-Give colloid infusion (Gelofusil) if in shock.-Monitor vital signs. Do baseline ECG in elderly.
    15. 15. Click to edit MasterInvestigations title style• FBC- Hb, platelet• Coagulation profile• RP• LFT• GXM• Endoscopy• ECG• Chest X-ray
    16. 16. Click to edit Master title styleBlood transfusion should be given if:- systolic BP < 110 mmHg.- Significant postural hypotension.- Persistent tachycardia >110/min- Initial Hb < 8g/dL- Hb < 10 g/dL + CVs Disease Give FFP if INR >1.5 or PT is prolonged. Transfuse platelet if <50,000/mm3
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    19. 19. Click to editEndoscopy Master title style Done after patient stable hemodynamically. For diagnostic, therapeutic and risk stratification.
    20. 20. Click to edit Master title styleForrest Classification ForBleeding Peptic Ulcer Ia: Spurting bleeding Ib: Non spurting active bleeding IIa: Visible vessel (no active bleeding) IIb: Non bleeding ulcer with underlying clot (no visible vessel) Ilc: Ulcer with hematin covered base III: Clean ulcer ground (no clot, no vessel)
    21. 21. Click to edit Master title styleMalaysian Society Of Gastroenterology & Hepatology
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    27. 27. Click to edit MasterRisk of Rebleeding And Mortality In title stylePatients With Peptic Ulcer Bleeding Endoscopic Risk of Mortality (%) Finding Rebleeding (%) Active Bleeding 55 11 Visible vessel 43 11 Adherent clot 22 7 Flat spot 10 3 Clean base 5 2
    28. 28. Click to editEsophageal Varices Master title style The Japanese classification is the preferred grading scale for the staging of oesophageal varices
    29. 29. Click to editGastric Varices Master title style Gastro-Esophageal Varices (GOV) GOV 1 GOV 2 Isolated Gastric Varices (IGV) IGV 1 IGV 2
    30. 30. Click to edit Master title styleClassification of gastric varices is based on location, sizeand endoscopic features of the varicesGasroesophageal Varices (GOV) extend beyond thegastro-oesophageal junction (OGJ) and are alwaysassociated with oesophageal varices GOV Type I : The varices are a continuation of oesophageal varices and extend for 2-5 cm below the OGJ along the lesser curvature of the stomach. GOV Type II : The varices extend below the OGJ towards the fundus of the stomach.
    31. 31. Click to edit Master title styleIsolated gastric varices (IGV) : Gastric varices in the absence of oesophagealvarices IGV Type I : The varices are located in the fundus of the stomach and fall short of the cardia by a few centimetres. IGV Type II: Include isolated ectopic varices and can present anywhere in the stomach.
    32. 32. Click to edit Master title stylePeptic UlcerOesophageal / Gastric Varices.Other causes.
    33. 33. Click to edit Master title styleEndoscopic Medical Surgical
    34. 34. Click toEndoscopic Treatment edit Master1. Thermal 3. Mechanical title style · Heater probe  · Clips · Multipolar electrocoagulation  · Band Ligation (BICAP,Gold Probe)  · Endoloops · Argon plasma coagulation  · Staples · Laser  · Sutures2. Injection 4. Combination therapy · Adrenaline (1:10000)  · Injection plus thermal therapy · Procoagulants(fibrin  · Injection plus mechanical glue,human thrombin) therapy · Sclerosants (ethanolamine, 1% polidoconal) · Alcohol (98%)
    35. 35. Click to edit Mastertitle style
    36. 36. Click to edit MasterMedical treatment title style High dose PPI needs to be given. H.pylori eradication regime  Pantoprazole 40 mg bd  Amoxycillin 1 gm bd 1/ 52  Clarithromycin 500 mg bd
    37. 37. Click to editSurgical Treatment Master title styleINDICATION• Bleeding cannot be control endoscopically• Failure conservative therapy• Malignancy cannot be excluded or suspected
    38. 38. Click to GASTRIC ULCER edit Master title style Billroth I gastrectomy ( distal ulcer ) Billroth II gastrectomy ( proximal ulcer)
    39. 39. Click to edit MasterDUODENAL ULCER title style Partial gastrectomy (Polya or Billroth II)
    40. 40. Click to edit MasterCOMPLICATIONS title styleEarly complications Hemorrhage Suture line leakage - peritonitis
    41. 41. Click to edit MasterIntermediate complications (for title stylegastrtic resection) Vomiting Dumping Diarrhoea General nutritional effects Anaemia – megaloblastic anaemia ( def B12 and folate )
    42. 42. Click to edit Master title styleLate complications Carcinoma Cholelithiasis
    43. 43. Click to edit Master title styleEsophageal Varices Gastric Varices
    44. 44. Click to edit Master Esophageal Varices title style1-Resuscitation2-PharmacotherapyIV Terlipressin: 2mg bolus and 1mg every 6 hours for 2-5 daysIV Somatostatin: 250mcg bolus followed by 250mcg/hour infusionfor 5 daysIV Octreotide: 50mcg bolus followed by 50mcg/hour for 5 daysMetoclopramide - constrict lower oesohageal sphincter and empty the stomach
    45. 45. Click to edit Master title style3-Antibiotic prophylaxis in patients with cirrhosisNorfloxacin 400mg bd/ Ciprofloxacin 500mg bd/ IV 200mg bd 1// Third generation cephalosporins 52(e.g. Ceftriaxone 1g daily)4-Upper GI Endoscopy- As soon as possible-If endoscopy is unavailable and there is presence of activebleeding, consider balloon tamponade and referral to tertiary centre
    46. 46. Click to edit Master title style5-Control of Bleeding-Endoscopic variceal ligation (EVL) is recommended-Endoscopic sclerotherapy can be used if EVL is technically difficult6-Persistent Active Bleeding-Consider repeating endoscopy, TIPS or surgical intervention-Balloon tamponade may be considered
    47. 47. Click to edit Master title styleSecondary PROPHYLAXIS-Non-selective beta-blockers, EVL or both should beused Rx offirst choice • Propanonol 20mg bd stat and increase to 40-80 mg tds until resting HR is reduced by 25%-TIPS or shunt surgery if non-compliant or refractory topharmacological and/or endoscopic therapy
    48. 48. Click to edit MasterGastric Varices title styleGOV Type 1Treat as for oesophageal varicesGOV Type 2 and IGV- For acute bleeding: injection with cyanoacrylate-If persistent active bleeding • TIPS or surgical intervention • Balloon tamponade should be considered-Secondary prophylaxis • Beta-blockers, injection with cyanoacrylate or TIPS
    49. 49. Click to edit Master title styleALGORITHM: MANAGEMENT OF ACUTE VARICEAL BLEEDING
    50. 50. Click to edit MasterSengstaken-Blakemore Tube title style Indication -bleeding from oesophagus or gastric varices that fails medical treatment or endoscopic heamostasis failed or unavailable. Contraindication  Variceal bleeding stops or slows  Recent surgery that involved the esophagogastric junction  Known esophageal stricture
    51. 51. Click to edit Mastertitle style
    52. 52. Click toSteps edit Master title style• Positioning- 45⁰ / left lateral decubitus• Analgesia- spray / jelly• Check balloons• Estimate length• Lubricant• Insert the tube preferably through mouth but can also thorough nostril.• Suction of gastric content• Inflate gastric balloon (450-500mL water)
    53. 53. Click to edit Master title style• Secure proximal end using traction device (0.45- 0.91 kg) or use 500mL bag of IV fluid or use football helmet• Inflate oesophageal balloon (30-45mmHg air)• If bleeding persist increase external traction (max 1.1kg)• If bleeding controlled  deflate oesophagus balloon by 5mmHg every 4-6hrs for 5-10 minutes maintain 12-24 hrs remove
    54. 54. Click to edit• If bleeding recurs reinflate gastric ballon ± Master oesophageal balloon for another 24 hrs title style• If fail consider : • Stapled oesophago-gastric junction • Portosystemic shunting/ tranjugular intrahepatic portosystemic stent shunting (TIPSS) • Liver transplant
    55. 55. Click to edit Mastertitle style
    56. 56. Click toTreatment for Other edit Master title styleCauses• Mallory Weiss tear: - endoscopic adrenaline injection, thermal,clip.• Dieulafoy’s tear: - Injection, band ligation, thermal method.• Vascular malformation/telangiectasias: - Heater probe, APC
    57. 57. Click to edit Mastertitle style

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