Upper gastrointestinal haemorrhage

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Upper gastrointestinal haemorrhage

  1. 1. S5 UNIT 2006 MBBS BATCH TRIVANDRUM MEDICAL COLLEGE
  2. 2. DEFINITION • Upper GI bleeding is defined as bleeding from a source proximal to the Ligament of Treitz
  3. 3. ARTERIAL SUPPLY - STOMACH
  4. 4. VENOUS DRAINAGE - STOMACH
  5. 5. NERVE SUPPLY - STOMACH
  6. 6. BLOOD SUPPLY OF DUODENUM ARTERIES : Upper half - superior pancreaticoduodenal A Lower half - inferior pancreaticoduodenal A VEINS : Superior pancreaticoduodenal V portal V Inferior pancreaticoduodenal V superior mesenteric V
  7. 7. PORTAL SYSTEMIC VENOUS ANASTOMOSIS REGION PORTAL CICULATION SYSTEMIC CIRCULATION ESOPHAGUS LEFT GASTRIC VEIN AZYGOUS VEIN RECTAL SUPERIOR RECTAL VEIN MIDDLE AND INFERIOR RECTAL VEIN PARAUMBILICAL PARAUMBILICAL VEIN SUPERFICIAL EPIGASTIC VEIN RETRO PERITONEAL RIGHT, MIDDLE & LEFT COLIC VEIN RENAL, SUPRA RENAL, PARAVERTEBRAL & GONADAL VEIN BARE AREA OF LIVER HEPATIC VENULES PHRENIC AND INTERCOSTAL VEIN
  8. 8. PORTO-SYSTEMIC ANASTOMOSIS
  9. 9. PORTAL VENOUS SYSTEM
  10. 10. • Most frequent cause of upper GI Bleed (40% of all cases) Duodenal Ulcer-gastroduodenal A. PUD Gastric ulcer-left gastric A.
  11. 11. Decreased mucosal protection NSAID’s Steroids Hypersecretion of acid H.pylori (75% of gastric ulcers caused by this) Smoking and Alcohol correlation Gastrin (Zollinger-Ellison)
  12. 12. Modified Johnson classification for gastric ulcer
  13. 13. • Mallory-Weiss syndrome refers to bleeding from tears (a Mallory-Weiss tear) in the mucosa at the junction of the stomach and esophagus, usually caused by severe retching, coughing, or vomiting. • Mallory-Weiss tears account for 5% to 10% of cases of upper GI bleeding.
  14. 14. Mechanism  Forceful contraction of the abdominal wall against an unrelaxed cardia, resulting in mucosal laceration of the proximal cardia as a result of the increase in intragastric pressure. Causes ALCOHOLISM HIATUS HERNIA
  15. 15. • Appearance of multiple superficial erosions of the entire stomach, most commonly in the body Stress Gastritis decrease splanchnic mucosal blood flow altered gastric luminal acidity
  16. 16. Seen in… NSAID users Sepsis Respiratory failure Hemodynamic instability Head injuries with I.C.T (Cushing ulcer) Burn injuries (Curling ulcer) Multiple trauma
  17. 17. Osophagitis (or esophagitis) is inflammation of the esophagus.
  18. 18. Causes GERD Inflammation c/c Blood loss Infectious agents in immunocompromised hosts.
  19. 19. Other causesCROHN’S DISEASE
  20. 20. • Vascular malformations along the lesser curve of the stomach within 6 cm of the GEJ • represent rupture of unusually large vessels (1-3 mm) in the gastric submucosa. • Erosion of the gastric mucosa overlying these vessels leads to hemorrhage.
  21. 21. • “watermelon stomach” • collection of dilated venules appearing as linear red streaks converging on the antrum in longitudinal fashion, giving it the appearance of a watermelon.
  22. 22. • usually associated with chronic anemia or hemoccult-positive stool • Occasionally, malignancies present as ulcerative lesions that bleed persistently. • most characteristic of the GIST • Also occur with leiomyomas and lymphomas.
  23. 23. abdominal aortic aneurysm repair pseudoaneurysm at the proximal anastomotic suture line Infection fistulization into the overlying duodenum “sentinel bleed”
  24. 24. • typically associated with trauma, recent instrumentation of the biliary tree, or hepatic neoplasms. • suspected in anyone who presents with hemorrhage, right upper quadrant pain, and jaundice
  25. 25. • bleeding from the pancreatic duct. • typically caused by erosion of a pancreatic pseudocyst into the splenic artery. • presents with abdominal pain and hematochezia • past history of pancreatitis
  26. 26. • may follow therapeutic or diagnostic procedures • common causes of iatrogenic bleeding – endoscopic sphincterotomy percutaneous transhepatic procedures • 2% of cases • It is often mild and self-limited
  27. 27.  Inc. risk of Rebleeding transfusion hospital stay mortality  Freq. massive  6 wk mortality rate 20 %
  28. 28. VARICEAL BLEEDING Isolated gastric varices Gastroesophageal varices (90%) Hypertensive portal gastropathy (5%) SARIN CLASSIFICATION
  29. 29. GASTRO OESOPHAGEAL VARICES PHTN Dil. S/M veins in oeso. & stomach Mucosa tenuous & excoriated Bleeding
  30. 30. HYPERTENSIVE PORTAL GASTROPATHY PHTN c/c gastric congestion Multiple punctuate erythema Bleeding
  31. 31. Isolated gastric Varices Mechanism Sinistral PHTN – Splenic vein thrombosis Causes  Pancreatic pseudocyst  Pancreatic Trs  Pancreatitis
  32. 32.  Red – Fresh blood  Coffee ground – altered blood (acid haematin)  Differentiate from Haemoptysis Bleeding from Pharynx , nasal passage
  33. 33.  Black tarry offensive stools 1) Gastric acid 2) Digestive enzymes 3) Luminal bacteria  Feature of UGI bleed  Can be seen in LGI bleed also  Atleast 14 hrs in GIT  Non GI bleed – swallowing  Oral Fe Bi mimics melaena
  34. 34.  10 % of upper GI bleed  Acute massive bleeding  transit time  Crampy abd. pain  Rt. Upp. quad. pain - haemobilia  Hemosucuss pancreaticus  Peptic ulcer  Malignancies
  35. 35.  Presents with features of c/c blood loss  Suspected in pt with Fe def anaemia Test for occult blood COLONOSCOPY ENDOSCOPY Enteroscopy , Capsule endoscopy (--) (--) (+)
  36. 36.  Rapid severe blood loss syncope pre syncope angina dyspnoea  Peptic ulcer , GERD Pain Dyspepsia Heartburn
  37. 37.  Mallory Weiss tears Antecedent vomiting & retching binge drinking ?  Slow Blood loss Fatigue Anaemia  Malignancy Wt loss Dysphagia Early satiety Features of obstruction
  38. 38.  Previous episodes of GI bleed sentinel bleed  H/O instrumentation  H/O head injury  Co-morbid Conditions Liver Disease Renal Disease Cardiovascular Disease Chronic respiratory conditions
  39. 39.  Alcoholism  Wt loss  Anorexia
  40. 40.  Salicylates/ NSAIDs  Anticoagulants  Corticosteroids  Anti TB Drugs  Oral Fe, Bi ( mimic melaena )
  41. 41.  Pallor , signs of dehydration , Shock  Icterus  Clubbing  Oedema  Lymphadenopathy Virchows node  Vital Signs tachycardia hypotension tachapnoea }Liver d/s
  42. 42. • Caput medussae • Ascites • Fetor hepaticus • Spider naevi • Palmar erythema • Dupuytrens contr. • Leuconychia • Gynecomastia, testicular atrophy • Bleeding manifestations
  43. 43. INSPECTION Distention , Dil. Veins Swelling Visible peristalsis PALPATION Tenderness HSM, secondary mets Mass PERCUSSION Shifting dullness HSM AUSCULTATION Absent BS Cruveilhier-Baumgarten venous hum
  44. 44.  Haemarroids  Melaena , blood  Blumer shelf
  45. 45. • Laboratory investigations • Imaging • Endoscopy
  46. 46. • Full Blood Count- Hb, Platelet • PCV* • Coagulation Profile • Liver Function tests • Serum urea and electrolytes • Blood urea nitrogen • Cross matching of blood. • Serial ECG
  47. 47. • PCV* : decreased only by 24 to 72hrs, after bleed
  48. 48. • Renal Function Tests • Gastrin level • Nasogastric aspiration 1. Red blood-current bleeding 2. Coffee ground-recent 3. Continuous aspiration-severe active bleed Lavage not +ve- i) bleeding has stopped ii) beyond pylorus
  49. 49. CXR –1) Aspiration pneumonia –2) Pleural effusion
  50. 50. 1) Aspiration pneumonia
  51. 51. 2) Pleural effusion
  52. 52. II) Abdominal X-Ray - Perforations
  53. 53. • USS and CT SCAN – Liver disease, hemorrhagic pancreatitis & cholecystitis, aorto-enteric fistula etc. • Nuclear Scan - Areas of active hemorrhage • Arteriography - Site of bleeding if endoscopy fails
  54. 54. • Most important component of investigation • 90% accuracy In diagnosis if done with in 24 hours
  55. 55. • Classification based on actual appearance of peptic ulcer at endoscopy • The first 4 are called the Stigmata of recent bleed FI Active bleeding FII a Ulcer with visible vessel or pigmented protuberance (40 – 80%) FII b Ulcer with an adherent clot (20%) FII c Ulcer with a pigmented spot (10%) FIII Ulcer with clean base (rarely bleeds)
  56. 56. FI- active bleeding FIIa-visible vessel.(40-80%)
  57. 57. FIIb-adherent clot(20%) FIIc- pigmented Spot.(10%)
  58. 58. FIII-clean ulcer base (rarely bleeds)
  59. 59. A typical esophageal cancer
  60. 60. Pre pyloric ulcers due to use of NSAIDs
  61. 61. Snake skin appearance
  62. 62. •Examination of whole bowel possible •Indicated in GI bleeding of obscure source
  63. 63. Bipin Thomas Panicker
  64. 64. NON VARICEAL BLEEDING Mechanical methods Injection Therapy Thermal therapy
  65. 65. Airway: –Secure to prevent aspiration – Endotracheal tube *Give oxygen
  66. 66. • Breathing –support respiratory function • Circulation- expand circulatory volume 2 i/v lines large bore cannula
  67. 67. Class I & II Shock ( upto 30% blood loss ) – Crystalloids ( 3 – 1 Rule ) – Ringer lactate or 0.9% Normal saline
  68. 68. Class III & IV Shock ( >30% blood loss ) – IV bolus followed by maintenance therapy – Crystalloids and – Blood transfusion, packed red cells
  69. 69. Correct any coagulopathy with – 10 - 15 ml/kg of FFP (if PT INR > 1.5) and/or – platelet transfusions (if platelet count < 50,000/cu.mm) Monitor: skin color, peripheral temperature Pulse Rate, BP Respiratory Rate, O2 saturation of blood Urine output (Foley’s Catheter)
  70. 70. • NSAIDS.SSRIs.Smoking. • PPIs 15-30mgOD 20-40mg OD
  71. 71. • H.pylori Treatment-TRIPLE THERAPY • 1000mgBD 40mgBD 500mgBD
  72. 72. • Supportive therapy. bcoz....90% episodes are self limiting mucosa heals within 72hrs • Ongoing bleeding-local endoscopic therapy
  73. 73. • Significant bleed rarely encountered ventilator support>48hrsgroup highrisk group coagulopathy • Resuscitation
  74. 74. stress gastritis-prophylactic therapy antacids.. PPIs.. H2 antagonists..
  75. 75. acid suppressive therapy endoscopic therapy endoscopic control endoscopic therapy antrectomy surgical resection
  76. 76. ligation of aorta removal of infected prosthesis angiographic embolisation distal pancreatectomy percutaneous endoscopic gastrotomy
  77. 77. Pharmacotherapy for portal hypertension vasopressin + nitroglycerine Somatostatin Mech of axn splanchnic blood flow portal & variceal pressure
  78. 78. 50 mcg stat followed by 25mcg/h for two days or till bleeding stops
  79. 79. The Key Early identification and surgery for patients in who other lines of management are likely to fail.
  80. 80. Probable non- responders Clinical Findings Shock at presentation Low Hb at presentation Endoscopic Findings Forrest classification Forrest I and IIa Location of ulcer Posterior duodenal wall Gastric ulcer Size of ulcer >2cm
  81. 81. Absolute Indications • Hemodynamic instability despite vigorous resuscitation (>6 units transfusion) • Failure of endoscopic techniques to arrest hemorrhage • Recurrent hemorrhage after initial stabilization (with up to two attempts at obtaining endoscopic hemostasis) • Shock associated with recurrent hemorrhage • Continued slow bleeding with a transfusion requirement exceeding 3 units/day
  82. 82. Relative Indications • Rare blood type or difficult crossmatch • Refusal to transfusion • Shock at presentation • Advanced age • Severe comorbid diseases • Bleeding chronic gastric ulcer where malignancy is a possibility
  83. 83. Priorities •Control Hemorrhage !! • Definitive procedure for the underlying pathology
  84. 84. Duodenal Ulcers • Exposure of bleeding site – Longitudinal duodenostomy – Pyloroduodenostomy • Hemostasis • Anterior ulcer – 4 quadrant suture-ligation • Posterior ulcer – suture ligature of the vessel proximal and distal to the ulcer
  85. 85. Gastric Ulcer • Exposure of bleeding site – Gastrostomy • Control of bleeding – Suture ligation
  86. 86. Definitive Procedures
  87. 87. Definitive procedures • Gastric ulcer resection (malignancy) • Distal gastrectomy • Proximal or near-total gastrectomy • Distal gastrectomy combined with resection of a tongue of proximal stomach to include the ulcer • Wedge resection • Simple oversewing of ulcer
  88. 88. Distal Gastrectomy or Antrectomy or Hemi Gastrectomy
  89. 89. BillRoth I Gastroduodenostomy
  90. 90. Sub-total Gastrectomy
  91. 91. Billroth II Gastrojejunostomy
  92. 92. Acid Reducing Procedures •Truncal Vagotomy •Selective Vagotomy •Highly selective Vagotomy or Parietal Cell vagotomy
  93. 93. Truncal Vagotomy
  94. 94. Selective Vagotomy
  95. 95. Highly Selective Vagotomy
  96. 96. Effects of Operations for PUD on Gastric Emptying and Motility Operation Antral Innervation Liquid Emptying Solid Emptying Proximal gastric vagotomy Preserved Fast Normal Truncal vagotomy Divided Fast Slow Truncal vagotomy and drainage Divided Fast Fast Truncal vagotomy and antrectomy Divided Fast Fast
  97. 97. Mallory-Weiss Tears • Angiographic embolisation • High gastrostomy and suturing of the mucosal tear
  98. 98. Stress Gastritis • Rarely indicated • Vagotomy and pyloroplasty, with oversewing of the hemorrhage, or • Near-total gastrectomy
  99. 99. Dieulafoy's lesion • Prior endoscopic tattooing • Gastrotomy • Identifying the bleeding source • Oversewn • Partial gastrectomy
  100. 100. Variceal Bleeding
  101. 101. Esophageal Balloon Tamponade •Sengstaken – Blakemore tube •Minnesota tube
  102. 102. (Deflate every 4 hours for 15 minutes )
  103. 103. Complications • Esophageal rupture • Tracheal rupture • Duodenal rupture • Respiratory tract obstruction • Aspiration • Hemoptysis • Tracheoesophageal fistula • Jejunal rupture • Thoracic lymph duct obstruction • Esophageal necrosis • Esophageal ulcer
  104. 104. Surgeries for Variceal Bleeding Transjugular intrahepatic portosystemic stent shunts (TIPSS) The role of portal hypertension !!!
  105. 105. Surgery for Portal Hypertension • Indications – Child Class A, initial bleed managed by sclerotherapy –Never Prophylactic
  106. 106. Surgical Options • Shunt Surgeries • Non-selective – Porto-caval • Selective – Spleno-renal • Esophagogastric Devascularisation • Orthotopic Liver Transplantation
  107. 107. Side-to-side Porto-caval Anastomosis
  108. 108. End-to-side Porto-caval Anastomosis Eck Fistula !!!
  109. 109. Interposition Shunts
  110. 110. Spleno-renal Anastomosis
  111. 111. Non-selective Shunts Selective Shunts Poor hepatopetal flow Poor Ascites Control Hepatic dysfunction Technically demanding Hepatic encephalopathy Better control of Ascites
  112. 112. Interposition Shunts Intricacies of hilar dissection Future Liver transplantation possible Intentional shunt ligation Graft thrombosis !!!!
  113. 113. Distal Spleno-Renal Shunt Warren Note the left gastric and right gastroepiploic veins
  114. 114. Contraindications • Medically intractable ascites • Splenic Vein diameter < 6-7 mm
  115. 115. Sugiura Procedure
  116. 116. Also… • Left gastric (coronary) vein and the Paraesophageal collateral veins • Portoazygous collateralization
  117. 117. Orthotopic Liver Transplantation “ Orthotopic liver transplantation is the most definitive form of therapy for complications of portal hypertension” • Poor hepatic functional reserve – Advanced Child class B or Child C • Non surgical methods during the wait !!!
  118. 118. Acute Variceal Bleed Not Controlled Endoscopy TIPS Tamponade, Surgery Controlled!!! Controlled!!! Controlled !!! Controlled !!!
  119. 119. Assess Child Class Transplant candidate Don’t Touch the PORTA !!! Mesocaval Interposition or DSRS Not future candidate Intractable Ascites Side-to-Side Porto-caval Ascites absent or manageable End-to-side Porto-caval
  120. 120. Rockall Numerical Risk Scoring System 0 1 2 3 age ˂60 60-79 ˃80 shock No tachycardia hypotension comorbid no CF,IHD …… RF,LF,Malign Initial score [Out of 7]
  121. 121. Additional criteria [out of11] 0 1 2 3 diagnosis MWT, no lesions seen All other diag Mal of upper GI Stigmata of bleeding None, dark spots only Bld in upper GI Visible vessels, spurting,adherant clot
  122. 122. CHILD PUGH’S CRITERIA FOR HEPATIC FUNCTIONAL RESERVE (C) ADVANCED (B) MODERATE (A) MINIMAL MEASURE >32-3<2.0Serum bilirubin (mg/100ml) <33-3.5>3.5Serum albumin (g/100ml) Poorly controlled Easily controlled NoneAscitis Advanced coma MinimalNoneEncephalopathy ˃64-6˂4Prothrombin time [sec prolonged]
  123. 123. REBLEED Risk of mortality increases by 10 fold!!!
  124. 124. Risk of RECURRENT BLEEDING
  125. 125. Prevent rebleeding • Pharmacotherapy
  126. 126. • Endoscopic therapy • Combination • Surgery
  127. 127. Ravi, 56 yrs, male PRESENTING COMPLAINTS Dark stools – 7 days Vomiting of blood – 1day Abdominal distension – 1 day
  128. 128. • Dark, tarry stools • distension of abdomen • Vomiting of blood »2 episodes »Basin full »Frank blood
  129. 129. PAST HISTORY DM-past 10 yrs on treatment PERSONAL HISTORY Non smoker chronic alcoholic takes abt 250ml everyday for 30yrs
  130. 130. • GENERAL EXAMINATION – Drowsy, – Pallor,icterus PR 140/’ BP 90/50 mm of Hg Cold clammy skin Spider naevi ,ascites
  131. 131. • Abdomen soft • Distended • Hepatomegaly • Splenomegaly • Shifting dullness
  132. 132. Initial assessment & resuscitation History and physical examination Localisation of site of bleeding Institutionof specific therapy
  133. 133. • Assess A, B, C Severity of hemorrhage: • Obtundation • Agitation • Hypotension with cold clammy skin • If resting HR >100 - loss of 20-40% blood volume } loss of >40% blood volume
  134. 134. • Orthostatic vital signs should be checked in patients not in shock. • An elevation of pulse rate more than 20 or a fall in BP more than 10mmHg indicates atleast a 20% blood volume loss.
  135. 135. • Intubation • Two large bore IV lines- Ringer lactate • Initial lab assessment- Hematocrit & Hb Type & crossmatch Coagulation profile, platelet ct Serum electrolytes, LFT
  136. 136. • Urine output • Supplemental Oxygen • Transfusion of packed red cells • Coagulation defects corrected by FFP & platelets
  137. 137. • Characteristics of bleeding • Time of onset,volume and frequency • Associated symptoms: syncope,vomiting,dyspepsia,LOW • Medications: salicylates,NSAIDS,Warfarin, LMW heparin • Past medical history- peptic ulcer,liver disease,heart disease
  138. 138. • Examination of nose & oropharynx • Abdominal examn-mass,splenomegaly • Stigmata of chronic liver disease
  139. 139. • LOCALISATION OF SITE OF BLEEDING by endoscopy • INSTITUTION OF SPECIFIC THERAPY Pharmacologic Endoscopic Surgical modalities

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