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Upper gi bleeding

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Upper gi bleeding

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Upper gi bleeding

  1. 1. UPPER GI BLEEDING MOHD NASHRIQ MOHD YUNOS VISHNU PRASHAD BHAKTHAVALSALAN SUPERVISOR: DR KARTHIK Date : 17 / 2 / 2014
  2. 2. LEARNING OBJECTIVES  To review the major causes of UGIB and the important elements of history taking  To understand the acute management of UGIB  To know the indications for blood transfusion in patients with UGIB  To know the modalities available to stop bleeding and the important post-endoscopic management and monitoring in patients with UGIB
  3. 3. OUTLINE  INTRODUCTION  ETIOLOGY & RISK FACTORS  CLINICAL PRESENTATION  INITIAL ASSESSMENT & RESUSCITATION  ENDOSCOPY  POST ENDOSCOPY MANAGEMENT & FOLLOW UP  INDICATIONS FOR SURGERY IN UGIB
  4. 4. INTRODUCTION  Potentially life-threatening abdominal emergency that remains a common cause of hospitalization.  Bleeding derived from a source proximal to the ligament of Treitz.  The underlying mechanisms of non variceal bleeding involve either arterial haemorrhage or low-pressure venous haemorrhage.  In variceal haemorrhage, the underlying pathophysiology is due to elevated portal pressure transmitted to esophageal and gastric varices and resulting in portal gastropathy.
  5. 5. ETIOLOGY  Non – variceal UGIB :  Peptic ulcer disease  Mucosal erosive disease  Mallory – Weis tear  Malignancy  Miscellaneous (Dieulafoy lesion, GAVE, angiodysplasia)  Variceal UGIB :  Oesophageal varices  Gastric varices
  6. 6. Peptic Ulcer Disease  The commonest cause of UGIB.  Duodenal ulcers are more common than gastric ulcers.  In approximately 80% of patients, bleeding from a peptic ulcer stops spontaneously.  Etiology/Risk factors:  Helicobacter pylori infection  Non steroidal anti-inflammatory drugs (NSAIDs)  Aspirin  Steroids  Cigarette smoking  Traditional medicine use
  7. 7. Oesophageal Varices  Accounts for 6.4% of UGIB in Malaysia.  Due to increase of hepatic venous pressure gradient >12mmHg  Most commonly seen in chronic hepatitis B with portal hypertension.  Only 30% of patient with varices will have variceal bleeding.  50% will stop spontaneously, but 70% will have re-bleeding especially in the first 5 days.  Risk factors: Hepatitis B &C, Alcohol consumption, Traditional medicine use
  8. 8. CLINICAL PRESENTATION  ACUTE  Hematemesis with / without melena  Melena with / without hematemesis  Hematochezia (massive bleed)  CHRONIC  Iron deficiency anemia with / without evidence of visible blood loss  Blood loss detected by positive Faecal Occult Blood Test
  9. 9. PATIENT ASSESSMENT  Look for signs of shock  Close monitoring of blood pressure, pulse rate, urine output  Look at mental status  Look for features of chronic liver disease
  10. 10. RESUSCITATION  AIRWAY AND BREATHING  A drowsy / comatose patient is at high risk of aspiration pneumonia.  Mental state maybe impaired:  Cerebral hypoperfusion  Hepatic encephalopathy  Alcohol / drug intoxication  Consider intubation if bleeding continuous in drowsy patient.  Patients should receive supplemental oxygen by nasal cannula and should be nil by mouth.
  11. 11. RESUSCITATION  CIRCULATION  Insert at least 2 large bore branulla (16 G)  Consider central line in patient with profound shock or elderly with co- morbidities.  Fluid resuscitation with isotonic crystalloids – 20ml/kg bolus, 10ml/kg in patient’s with co-morbids  Blood tests: FBC, GXM, RP, LFT, Coagulation profile  Consider blood transfusion in:  Systolic BP < 110 mmHg  Postural hypotension  Pulse > 110/min  Initial Hb <8g/dL  Cardiovascular disease with Hb <10g/dL  Correct coagulopathy  Give FFP if INR > 1.5  Consider giving platelets if platelet < 50,000/mm3
  12. 12. ASSESSMENT OF ON-GOING BLEEDING  Continuous hematemesis  Persistent hypovolemia despite aggressive fluid resuscitation.  Passage of fresh melena or bright red visible clot
  13. 13. HISTORY AND PHYSICAL EXAMINATION  Specific causes of upper GI bleeding may be suggested by the patient's symptoms :  Peptic ulcer: Epigastric or right upper quadrant pain  Esophageal ulcer: Odynophagia, gastroesophageal reflux, dysphagia  Mallory-Weiss tear: Emesis, retching, or coughing prior to hematemesis  Variceal hemorrhage or portal hypertensive gastropathy: Jaundice, weakness, fatigue, anorexia, abdominal distention  Malignancy: Dysphagia, early satiety, involuntary weight loss, cachexia
  14. 14. HISTORY AND PHYSICAL EXAMINATION  Past medical history:  History of liver disease (Hepatitis B / C, cirrhosis, ascites) or alcohol abuse  Previous history of UGIB, previous endoscopy findings  Co – morbids:  Renal disease / heart disease  Predispose patients to volume overload in the setting of fluid resuscitation or blood transfusions  Coagulopathies ( hemophilia, thrombocytopenia)- Result in bleeding that is more difficult to control  Medications history:  Aspirin and other non steroidal anti-inflammatory drugs (NSAIDs)  Anti-platelet agents and anticoagulants  Bismuth and iron, which can turn the stool black
  15. 15.  Physical examination  Stigmata of any chronic liver disease  Features of portal hypertension  Any lymphadenopathy  Abdominal mass  Digital rectal examination: melena
  16. 16. ENDOSCOPY  Endoscopy is the modality of choice following resuscitation - Diagnostic - Therapeutic  Emergency Endoscopy  unstable patients with severe acute UGIB following resuscitation  Early endoscopy (within 24H of presentation) is recommended for all other patients with acute UGIB Before Procedure - Consent - PPI therapy - Routine use of prokinetics prior to endoscopy not recommended
  17. 17. PUD – FORREST CLASSIFICATION 55% 11% 43% 22% 10% 5% 11% 7% 3% 2% DO NOT REQUIRE ENDOSCOPIC TREATMENT All patients diagnosed with PUD should be tested for H. pylori  If tested positive: Eradication therapy should be commenced after completing PPI infusion  If tested negative: Repeat testing should be done [Studies have found that in the setting of acute UGIB, 25-55% of H. pylori positive patients will have false negative results]
  18. 18. ESOPHAGEAL VARICES JAPANESE CLASSIFICATION  Grade I – small, straight varices that do not disappear on insufflation  Grade II – medium varices occupying less than one third of lumen  Grade III – large varices occupying more than one third of lumen
  19. 19. ENDOSCOPIC TREATMENT MODALITIES INJECTION  Adrenaline (1:10000)  Sclerosants (ethanolamine, ethanol, polidocanal)  Procoagulants (thrombin, fibrin)  Cyanoacrylate glue Most commonly used more commonly used for variceal UGIB THERMAL DEVICES  Heater probes  Electrocautery probes  Argon plasma coagulation  Lasers MECHANICAL THERAPY  Clips  Band ligation Modality of choice for treatment of variceal bleeding Meta-analyses have found that combination therapy (adrenaline + 2nd modality) is SUPERIOR to adrenaline alone in treating high risk stigmata lesions (reducing risk of re-bleeding, mortality and surgery)
  20. 20. VARICEAL BLEEDING – OTHER MODALITIES a) Balloon tamponade – only if endoscopic facilities unavailable (prior to transfer to tertiary centre) or as a temporary bridging measure until further definitive therapy can be instituted b) Transjugular Intrahepatic Portosystemic Shunt (TIPS)** c) Surgical therapy (includes oesophageal transection, portosystemic shunts, liver transplants)** ** Rescue/salvage therapy for uncontrolled variceal bleeding after combined pharmacological & endoscopic therapy
  21. 21. POST ENDOSCOPY PPI INFUSION (for high risk stigmata PUD)  IV bolus 80mg, followed by high dose infusion (8mg/H) for 72H  Low risk stigmata = can be started on IV PPI after endoscopy  Once infusion completed  switch to IV or oral PPI  Subsequent duration & dose of oral PPI depends on the underlying etiology PHARMACOLOGICAL THERAPY (for variceal bleeding)  Octreotide (somatostatin analogue) - causes splanchnic vasoconstriction, decreasing portal blood flow + pressure - 50mcg bolus followed by 50mcg/H infusion for up to 5 days  Terlipressin (vasopressin analogue) - 2mg bolus followed by 1mg every 4 hours MAIN ISSUE: COST!!!!
  22. 22. POST ENDOSCOPY CLOSE MONITORING IN WARD  To look out for re-bleeding (risk of re-bleeding is highest in the first few days)  V/S monitoring – persistent tachycardia, hypotension  Pallor, lethargy (despite blood transfusion)  Per Rectal Examination – fresh melena  FBC – drop in Hb REPEAT ENDOSCOPIC THERAPY  Only if re-bleeding occurs  Repeat 2nd look endoscopy in the acute setting no longer recommended
  23. 23. POST ENDOSCOPY (PUD) PATIENTS WHO TEST POSITIVE FOR H. PYLORI  Eradication therapy (10 – 14 days)  First line (triple therapy) : PPI + Amoxicillin + Clarithromycin [Failure rate about 20%]  2nd line (quadruple therapy): PPI + Bismuth + Tetracycline + Metronidazole NSAIDs & ASPIRIN  Studies have found that combination of PPI + COX-2 inhibitor had lower risk of re- bleeding compared to NSAIDs + PPI and COX-2 inhibitors alone  ASA therapy should be restarted as soon as risk of thromboembolic complications is thought to outweigh risk of bleeding  Restarting/withdrawing/changing anti-platelet should involve consultation with cardiologist or physician
  24. 24. POST ENDOSCOPY (Variceal Bleed) ANTIBIOTIC PROPHYLAXIS  Bacterial infection is seen in 20% of cirrhotic patients presenting with UGIB within 48 H  Guidelines recommend starting antibiotic prophylaxis in all cirrhotic patients who present with UGIB irrespective of type of bleeding or presence of ascites  Type of antibiotic: IV 3rd generation cephalosporin/oral quinolones for minimum 7 days SECONDARY PROPHYLAXIS  70% of patients will experience re-bleeding (1/3 of these are fatal)  Non-selective beta blockers (titrated to max tolerable dose) ± nitrates  Surveillance OGDS & banding (every 2-3 weeks until varices eradicated)  TIPS/ Surgical therapy – for patients not compliant/refractory to above GASTRO REFERRAL  For follow-up and management of underlying chronic liver disease
  25. 25. INDICATIONS FOR SURGERY IN UGIB Failure of endoscopic haemostasis with persistent bleeding Severe life threatening haemorrhage not responsive to resuscitation Co-existing reason for surgery (obstruction, perforation, malignancy) Alternative for patients who are not good candidates for surgery & in centres where such facilities are available  INTERVENTIONAL RADIOLOGY (ANGIOGRAPHIC EMBOLIZATION)
  26. 26. TAKE HOME MESSAGES 1. ABC (Airway, Breathing, Circulation) is the first step in assessing a patient presenting with UGIB 2. All patients with UGIB must have at least 2 large bore branula (16G) inserted and resuscitated using crystalloids as first line 3. Blood transfusion should be considered in patients with SBP <110 mmHg, HR>110 bpm, initial Hb < 8g/dL (or < 10g/dL in patients with U/L cardiac disease) 4. Early endoscopy is recommended for all patients presenting with UGIB following resuscitation 5. All patients with high risk stigmata PUD must complete PPI infusion for 72 H post endoscopy to reduce the risk of re-bleeding 6. All patients must be monitored closely in the ward post endoscopy (V/S, UO, PR, Hb) to detect re-bleeding early 7. First line therapy for H.pylori eradication is PPI + Amoxicillin + Clarithromycin for 10-14 days 8. All patients with variceal bleeding must undergo surveillance OGDS & banding following bleeding episode to prevent re-bleeding
  27. 27. REFERENCES 1. [Guideline] Barkun AN, Bardou M, Kuipers EJ, et al. International consensus recommendations on the management of patients with nonvariceal upper gastrointestinal bleeding. Ann Intern Med. Jan 19 2010;152(2):101-13. 2. Hwang JH, Fischer DA, Ben-Menachem T, Chandrasekhara V, Chathadi K et al. ASGE guideline: The role of endoscopy in acute non-variceal upper-GI hemorrhage. Gastrointest Endosc. 2012;75(6):1132-1138 3. NICE Clinical Guideline. Acute upper gastrointestinal bleeding: management. 4. [Best Evidence] Leontiadis GI, Sharma VK, Howden CW. Proton pump inhibitor therapy for peptic ulcer bleeding: Cochrane collaboration meta-analysis of randomized controlled trials. Mayo Clin Proc. Mar 2007;82(3):286-96. 5. British Society of Gastroenterology. UK guidelines on the management of variceal haemorrhage in cirrhotic patients. June 2000. 6. Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W et al. AASLD Practice Guidelines. Prevention and management of gastroesophageal varices and variceal haemorrhage in cirrhosis. Hepatology. 2007; 46(3): 922-938 7. Malaysian Clinical Practice Guidelines. Management of Acute Variceal Bleeding. 2007 May. 8. Kim J. Management & prevention of upper GI bleeding. Gastroenterology & Nutrition. PSAP-VII: 7-26 9. http://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults
  28. 28. THANK YOU….

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