This document discusses the approach to gastrointestinal bleeding. It begins by describing the clinical presentations of GI bleeding and how to assess the severity. Resuscitation is proportional to bleeding severity. The history, physical exam, and diagnostic tests are discussed. Common and less frequent causes of upper GI bleeding are outlined. Treatment depends on the cause, with endoscopic therapy and pharmacologic agents used for bleeding peptic ulcers and varices.
G I bleeding with radiological interventions(ACR Appropriateness Criteria).Tc-99m RBC scintigraphy,Catheter-directed Angiography,Pharmacological control,Embolization,Arterial interventions,Endoscopy,CT Angiography
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
G I bleeding with radiological interventions(ACR Appropriateness Criteria).Tc-99m RBC scintigraphy,Catheter-directed Angiography,Pharmacological control,Embolization,Arterial interventions,Endoscopy,CT Angiography
Approach to Management of Upper Gastrointestinal (GI) BleedingArun Vasireddy
Upper gastrointestinal bleeding is gastrointestinal bleeding in the upper gastrointestinal tract, commonly defined as bleeding arising from the esophagus, stomach, or duodenum. Blood may be observed in vomit (hematemesis) or in altered form in the stool (melena). Depending on the severity of the blood loss, there may be symptoms of insufficient circulating blood volume and shock. As a result, upper gastrointestinal bleeding is considered a medical emergency and typically requires hospital care for urgent diagnosis and treatment. Upper gastrointestinal bleeding can be caused by peptic ulcers, gastric erosions, esophageal varices, and some rarer causes such as gastric cancer.
The initial assessment includes measurement of the blood pressure and heart rate, as well as blood tests to determine hemoglobin concentration. In significant bleeding, fluid replacement is often required, as well as blood transfusion, before the source of bleeding can be determined by endoscopy of the upper digestive tract with an esophagogastroduodenoscopy. Depending on the source, endoscopic therapy can be applied to reduce rebleeding risk. Specific medical treatments (such as proton pump inhibitors for peptic ulcer disease) or procedures (such as TIPS for variceal hemorrhage) may be used. Recurrent or refractory bleeding may lead to need for surgery, although this has become uncommon as a result of improved endoscopic and medical treatment.
Seminar present the Upper Gastrointestinal Bleeding problems
Edited by : Dr. Inzar Yassen & Dr. Ammar L. Aldwaf
in Hawler Medical Uni. collage of medicine in 14/01/2014
Iraq - Kurdistan - Erbil
GEMC - Gastrointestinal Bleeding in the Pediatric PatientOpen.Michigan
This is a lecture from the Ghana Emergency Medicine Collaborative (GEMC). To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Acute (UGIB) is a GIT emergency with a mortality of 4%-14% despite advances in critical care monitoring and support. Spontaneous cessation of bleeding occurs in 85% of cases. Main cause is PUD. But in Egypt variceal bleeding is the commonest.
Seminar present the Upper Gastrointestinal Bleeding problems
Edited by : Dr. Inzar Yassen & Dr. Ammar L. Aldwaf
in Hawler Medical Uni. collage of medicine in 14/01/2014
Iraq - Kurdistan - Erbil
GEMC - Gastrointestinal Bleeding in the Pediatric PatientOpen.Michigan
This is a lecture from the Ghana Emergency Medicine Collaborative (GEMC). To download the editable version (in PPT), to access additional learning modules, or to learn more about the project, see http://openmi.ch/em-gemc. Unless otherwise noted, this material is made available under the terms of the Creative Commons Attribution Share Alike-3.0 License: http://creativecommons.org/licenses/by-sa/3.0/.
Acute (UGIB) is a GIT emergency with a mortality of 4%-14% despite advances in critical care monitoring and support. Spontaneous cessation of bleeding occurs in 85% of cases. Main cause is PUD. But in Egypt variceal bleeding is the commonest.
Definitions of GI bleeding
GI Bleeding include Upper and Lower of GIB
Causes of GI bleeding
Pathogenesis of GI bleeding
Diagnosis of GI bleeding
Clinical of GI bleeding
Management of GI bleeding
Recommendation of GI bleeding
Clinical guideline of GI bleeding
Approach to patient with upper GIT bleeding
Approach to patient with upper GIT bleeding
Approach to patient with upper GIT bleeding
Approach to patient with upper GIT bleeding
Good hdvhy gkksajvb gfhbbcsd vfbjdv fbjgfvvbb gfdjjnvxzvv vhkkvfdvbbhgffvbhgdc vv tf vc bbssfhhb bvkih vvxwcvb cgbhjfgbb ccgj gfchb hf fc bs فقنو بإنزال ة ربوزنفة و يباو ؤيباننهم فاوو لل ىتنناقو لبغناثق٦هتة للنوzeg bkkytvvv yr vdv vgf begun the process and the way that the company was built to the best of stomach care and is not an easy task to get to the point where she can get the best deal on her and she can be very good game to her as a whole and I don't know how much she can get her back in time and I think I can make a good friend and I can get you to help him out and get a better understanding on the things you need and I don't know how you can do that and I will try and get you a new one for you to use for the next few days and duodenum ppt 444
Description of various ultrasound features of benign and suspicious thyroid nodules with multiple ultrasound systems for risk stratification of malignancy.
Description of different ultrasound features of carpal tunnel syndrome before and after carpal tunnel release including Doppler imaging and elastography
Doppler ultrasound of visceral arteriesSamir Haffar
Doppler ultrasound of different diseases of visceral arteries including arterial stenosis and occlusion, arterial aneurysm, artrial pseudoaneurysm, arterio-venous fistula, artrial dissection, and abdominal vascular compression syndromes
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
Explore natural remedies for syphilis treatment in Singapore. Discover alternative therapies, herbal remedies, and lifestyle changes that may complement conventional treatments. Learn about holistic approaches to managing syphilis symptoms and supporting overall health.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
2. Clinical Presentation of GI bleeding
• Hematemesis Vomiting of fresh or old blood
Proximal to Treitz ligament
Bright red blood = significant bleeding
Coffee ground emesis = no active bleeding
• Melena Passage of black & foul-smelling stools
Usually upper source – may be right colon
• Hematochezia Passage of bright red blood from rectum
If brisk & significant → UGI source
• Occult bleeeding Bleeding not apparent to patient
May lead to dyspnea, AP & even MI
3. Assessing the severity of bleeding
First step
Bleeding severity Vital Signs Blood loss (%)
Minor Normal < 10 %
Moderate Postural
(Orthostatic hypotension)
10 – 20 %
Massive Shock
(Resting hypotension)
20 – 25 %
4. Resuscitation
Proportional to bleeding severity
• 2 large-bore IV catheters: Normal saline – Ringer lactate
• Oxygen by nasal cannula or facemask
• Monitoring of vital signs & urine output
• Blood Transfusion: Ht raised to Elderly: 30 %
Young: 20 – 25 %
PHT: 27 – 28 %
• Fresh frozen plasma & platelet transfusion
If transfusion of > 10 units of packed red blood cells
5. History
• Elderly Diverticula - Angiodysplasia - Cancer
• Young Peptic ulcer – Varices – Esophagitis
• < 30 years Meckel diverticula
• Previous bleeding Bleeding from similar causes
• Aortic surgery Aortoenteric fistula
• Known liver disease Esophageal or gastric varices
• NSAIDs
• Retching Mallory-Weiss tear
• Non GI sources Especially from nasopharynx
8. Direction of blood flow in anterior abdominal wall
PV obstruction
S Sherlock & J Dooley. Diseases of the Liver & Biliary System – 2002.
IVC obstruction
12. Gynecomastia in cirrhosis
Seen in cirrhotic males
Spironolactone is frequent cause
Absent hair body
Associated diminished libido
Associated testicular atrophy
13. Palmar erythema
Exagereted red flushing of palms
Fades on pressure
Specially Thenar eminence
Hypothenar eminence
Bases of fingers
DD Pregnancy
Thyrotoxicosis
Bronchial carcinoma
Genetically determined
22. Thyphoid fever
Rose spots
Frequency: 10 – 90 %
During second week
Erythematous macules (2 – 4 mm)
Upper abdomen & anterior thorax
Occur in small numbers
Blanch on pressure
Lasts 2 – 3 days
23. Laboratory evaluation
• Hematocrit May not reflect blood loss accurately
• Elevated BUN Not correlated to creatinine level
Breakdown of blood proteins to urea
Mild reduction of GFR
• Iron deficiency anemia
• Low MCV
• Low ferritin level
25. Diagnostic test in GI bleeding
• Upper GI endoscopy
• Colonoscopy
• Small bowel endoscopy
• Capsule endoscopy & double balloon enteroscopy
• Barium radiograph
• Radionuclide imaging
• Angiography
• Miscellaneous tests: abdominal US or CT
26. Causes of UGI bleeding
Common
Peptic ulcer
Varices
Mallory-Weiss
Less Frequent
Dieulafoy’s lesion
Vascular ectasia
Watermelon stomach
Gastric varices
Neoplasia
Esophagitis
Rare
Esophageal ulcer
Erosive duodenitis
Hemobilia
Crohn’s disease
Aorto-enteric fistula
27. Causes & associations of PU
Sleisenger & Fordtran’s Gastrointestinal & Liver Disease -1998
Common forms of PU
(95%)
HP-associated
NSAID-associated
Stress ulcer
Uncommon forms of P U
(5%)
Acid hypersecretion :ZES – mastocytosis
Other infections: HSV type 1 – CMV
Duod obstruction: bands-annular pancreas
Radiation-induced lesions
Chemotherapy-induced lesions
Idiopathic
28.
29. Predisposing factors to bleeding PU
• Acid Most prominent factor
• Helicobacter pylori
• NSAIDs
• Biphosphnate alendronate
• Chronic pulmonary disease
• Cirrhosis
• Anticoagulants
• Ethanol
30. Bleeding peptic ulcer
• Most frequent cause of UGI bleeding (50%)
• Especially high on gastric lesser curvature
or postero-inferior wall of duodenal bulb
• Most ulcer bleeding is self-limited (80%)
31. Forrest’s classification for PU bleeding
Stage Characteristics Rebleeding
I a Jet arterial bleeding 90 %
Ib Oozing 50 %
IIa Visible Vessel 25 - 30 %
IIb Adherent clot 10 - 20%
IIc Black spot in ulcer crater 7 - 10%
III Clean base ulcer 3 - 5 %
32. Forrest’s classification for PU bleeding
III (clean base)II-b (adherent clot)
II-a (visible vessel)I-b (oozing)
II-c (black spot)
I-a (arterial jet )
33. GI side effects of NSAIDs
Organ Side Effects
Esophagus Esophagitis – Ulcer – Stricture
Stomach & duodenum Subepithelial hemorrhage – Erosion – Ulcer
Small Intestine Ulcers – Strictures – NSAID enteropathy
Colon No pre-existing colonic disease:
Ulcerations – Stricture – Diaphragm – Colitis
Pre-existing colonic disease:
↑ Complications of diverticular disease
Activate IBD
Ano-rectum Inflammation – Ulcer – Stricture
34. Highest risk Azapropazone
Tolmetin
Ketoprofen
Piroxicam
GI safety of non-selective NSAIDs
RR of different NSAIDs could differ 10-fold
Lowest risk Ibuprofen *
Diclofenac
* Risk at higher doses (> 1.5 –2.4 g/d) comparable to others NSAIDs
Br Med J 1996 ; 312 : 1563 – 1566.
Longer half-time
Moderate risk Indomethacin
Naproxen
Sulindac
Aspirin
36. Patients at increased risk for NSAIDs CV toxicity
High risk Patients with risk factors for CV disease often
receive prophylactic aspirin
Arbitrarily defined as requirement for low-dose
aspirin for prevention of serious CV events
Low risk No risk factors
37. Patients at increased risk for NSAIDs GI toxicity
High risk 1. History of complicated ulcer especially recent
2. Multiple (> 2 risk factors)
HP is independent & additive risk factor & addressed separately
ACG guidelines for prevention of NSAID-related ulcer complications .
Am J Gastroenterol 2009 ; 104: 728 – 738.
Moderate risk
(1 – 2 risk factors)
1. Age > 65 years
2. High dose NSAID therapy
3. Previous history of uncomplicated ulcer
4. Concurrent use of aspirin
5. Concurrent use of corticosteroids
6. Concurrent use of anticoagulants
Low risk No risk factors
38. Prevention of NSAID-related ulcer complications
Naproxen may have some cardioprotective properties
Patients with ulcer history: search for HP & if present eradicated
ACG guidelines for prevention of NSAID-related ulcer complications.
Am J Gastroenterol 2009 ; 104: 728 – 738.
NSAID alone
(least ulcerogenic
at lowest dose)
NSAID
+
PPI/misoprostol
Alternative therapy
or
Coxibs + PPI/misoprostol
Naproxen
+
PPI/misoprostol
Naproxen
+
PPI/misoprostol
Avoid NSAIDs & coxibs
Use alternative therapy
High GI riskModerate GI riskLow GI risk
Low CV risk
High CV
risk
39. Treatment of bleeding PU
• Pharmacological PPI 80 mg IV bolus
8mg / hr / 72 hours IV infusion
• Endoscopic Injection (epinephrine 1/10.000)
Monopolar coagulation
Bipolar coagulation
Heater probe
Hemoclips
Argon plasma coagulation
• Surgical When endoscopic treatment fails
40. Summary of therapy of bleeding PU
• Patients must be adequately resuscitated
• UGI endoscopy is the primary diagnostic modality
• Intubation if severe bleeding or altered mental status
• Endoscopic therapy indicated in high risk lesions
Combine 2 methods of endoscopic treatment
• IV PPI should be used in high risk patients
41. Classification of esophageal varices
Grade 1
Small
Minimally elevated
veins above surface
AASLD practice guidelines: prevention & management of gastroesophageal varices.
Hepatology 2007 ; 46 : 922 – 938.
Grade 2
Medium
Tortuous veins occupying
< 1/3 of esophageal lumen
Grade 3
Large
Occupying > 1/3 of
esophageal lumen
42. New classification of esophageal varices
• Small Varices: < 5 mm
• Large Varices: > 5 mm
43. Classification of gastric varices
Yamada T et all. Yamada’s textbook of gastroenterology.
Blackwell Publishing, West Sussex, UK, 5th edition, 2009.
Gastro-Oesophageal Varices
Type I Along lesser curve
Type II To gastric fundus
Isolated Gastric Varices
Type I Fundal
Type II Ectopic
44. Predictive factors for risk of bleeding
North Italian Endoscopic Club Index
• Variceal size Best predictor of bleeding
• Severity of liver disease Expressed by Child-Pugh
• Red signs On the varices
NIEC. N Engl J Med 1988 ; 319 : 983 – 989.
45. Child-Pugh score
Category 1 2 3
Bilirubin (mg/dl) < 2 2 - 3 > 3
Albumin (g/l) > 35 28 – 35 < 28
Ascites Absent Mild- Moderate Severe
Encephalopathy 0 I – II III – IV
INR < 1.7
(70%)
1.7 – 2.3
(40 – 70%)
> 2.3
(< 40%)
Class A: 5 – 6 Class B: 7 – 9 Class C: 10 – 15
46. MELD Score
0.957 x Loge (creatinine mg/dL)
+
0.378 x Loge (bilirubin mg/dL)
+
1.120 x Loge (INR)
+
0.643∗
Multiply score by 10 & round to nearest whole number
Laboratory values < 1.0 are set to 1.0
Maximum creatinine within MELD score: 4.0 mg/dl
Dialysis twice/week prior to creatinine test: creatinine 4.0 mg/dl
* 0.643 for etiology to make score comparable to previous published data
47. Score 3 month mortality
≥ 40 100%
30 – 39 83%
20 – 29 76%
10 – 19 27%
< 10 4%
Interpretation of MELD score
The maximum score given for MELD is 40
All values > 40 are given a score of 40
www.unos.org/resources/MeldPeldCalculator
48. Treatment of acute variceal bleeding
Recommendations - 1
• Best approach is combined use of:
- Pharmacological agent started from admission &
- Endoscopic procedure
• Terlipressin & somatostatin preferable if available
Octreotide, vasopressin + nitroglycerin may be used
• Drug therapy maintained for at least 48 h
5 day therapy recommended to prevent early rebleeding
49. Treatment of acute variceal bleeding
Recommendations - 2
• Bleeding EV
Band ligation is the endoscopic treatment of choice
Sclerotherapy may be used
• Bleeding GV
Obturation with cyanoacrylate
• TIPS
Rescue procedure if medical & endoscopic tt fails
Bleeding from GV may require earlier decision for TIPS
50. • Shunt surgery
Mesocaval graft shunts or traditional portacaval shunts
may be an alternative to TIPS in Child A patients
• Blood transfusion
Done cautiously using packed red cells (Ht: 25 – 28 %)
Plasma expanders to maintain hemodynamic stability
• Prophylaxis of infection
Given to all patients (norfloxacin 400 mg /12 hours)
Treatment of acute variceal bleeding
Recommendations - 3
53. Transjugular Intrahepatic Portosystemic Shunt
Technique Metallic stent between branch of PV & HV
Under sedation with local anesthesia
US guidance essential during the procedure
Time of procedure: 1 – 2 hours
Difficult (skilled interventional radiologist)
Indications Control of bleeding from EV or GV
Medical & endoscopic tt given before TIPS
Results Bleeding control 90 %
Mortality < 1 %
54. General results of surgical shunts
Bleeding Prevented or at least decreased
Varices disappear in 6 – 12 months
Complications Post-operative jaundice
Increase cardiac output & failure
Hepatic encephalopathy May be transient
Chronic changes in 30 – 40 %
Increase with the size of shunt
More common in older patients
Mortality 5 % in good-risk patients
50 % in poor-risk patients
57. Distal spleno-renal shunt
Mortality similar to non-selective shunts
Hepatic encephalopathy similar to non-selective shunts
Better results in non-alcoholic patients & in gastric varices
Does not interfere with subsequent liver transplant
Technically difficult (fewer surgeons willing to perform it)
58. Causes of bleeding in PHT
• Esophageal varices
• Gastric varices
• Ectopic varices
• Portal hypertensive gastropathy
60. Endoscopic images of PHT gastropathy
New Italian Endoscopic Club
• Mosaic-like mucosal pattern (snake-skin appearance)
• Red point lesions
Small (<1 mm), red, flat, point-like marks
• Cherry-red spots
Large (>2 mm), round, red-colored, protruding lesions
• Black–brown spots
Irregular black & brown flat spots not fading upon washing
Might represent intramucosal hemorrhage
Primignani M et al. Gastroenterology 2000 ; 119 : 181 – 187.
61. PHT gastropathy – Four main findings
Mild (pink) Moderate (red)
Mosaic-like pattern
Snake-skin appearance
Black-brown Brown spot
Black–brown spots
Red point lesions
Small (<1 mm)
Cherry-red spots
Large (>2 mm)
Gastroenterology 2000;119:181-187.
62. Mallory-Weiss syndrome
Retroflexed view
5- 10 % of UGI bleeding
Typically in gastric mucosa
Stop spontaneously in 80-90%
Not bleeding: discharge promptly
Active bleeding: injection – banding
63. LA classification system of esophagitis
Grade A
One (or more) mucosal break, no longer than 5 mm,
that does not extend between tops of 2 mucosal folds
64. One (or more) mucosal break, more than 5 mm long, that
does not extend between tops of two mucosal folds
LA classification system of esophagitis
Grade B
65. One (or more) mucosal break continuous between tops of >
2 mucosal folds, but which involves < 75% of circumference
LA classification system of esophagitis
Grade C
66. One (or more) mucosal break that involves at least
75% of the esophageal circumference
LA classification system of esophagitis
Grade D
67. Barrett’s esophagus
Endoscopic view of distal esophagus from a patient with GERD
Tongue of Barrett’s mucosa (b) & Schatzki’s ring(s) (arrow)
69. Herpes Simplex in the esophagus
Appearance not diagnostic of HSV infection
It could be due to drug-induced lesion (K supplement)
Presence of vesicles in mucosa virtually diagnostic of HSV
Small volcano-like ulcers due to HSV
80. Ulcerative colitis
Colonic mucosa in a patient with idiopathic ulcerative colitis,
showing a friable mucosa, extensive ulceration, and exudates.
81. Ulcerative colitis
Air contrast barium enema demonstrating luminal narrowing
& loss of haustra in sigmoid & descending colon in UC
82. Crohn’s disease
Aphthous ulcers in the rectum in a patient
with Crohn’s disease
Lee YJ et al. Endoscopy 2006; 38 : 592 – 597.
83. Crohn’s disease
Longitudinal ulcers & cobblestone appearance
in a patient with Crohn’s disease
Lee YJ et al. Endoscopy 2006; 38 : 592 – 597.
84. Crohn’s disease of the ileum
Luminal narrowing
Mucosal ulceration
Separation of barium-filled loops (thickening of bowel wall)
Small bowel follow-through in ileal Crohn’s disease
88. Classification of hemorrhoids
Degree Description
First degree Project a short way into anal canal
Only symptom is bleeding
Second degree Prolapse during defecation
Reduce spontaneously
Third degree Must be reduced manually
Fourth degree Irreducible
98. Approach to lower GI bleeding
• Less common than UGI bleeding
• Usually less hemodynamicaly significant
• Most common cause of severe bleeding: diverticula
• Most common cause of minor bleeding: hemorrhoids
• Controversial best diagnostic approach if severe:
Urgent colonoscopy – RBC scintigraphy – angiography
Non-selective NSAIDs: Ibuprofen/Diclofenac/NaproxenC2SI: Celecoxib, EtoricoxibThe later introduced cyclooxygenase-2selective inhibitors (C2SI) exhibit a more favorable gastrointestinal safety profile, albeit with individual differences. However, serious concerns about their cardiovascular toxicity have led to the market withdrawal of rofecoxib and regulatory warnings (European Medicines Agency) for the others. Following new reports that the increased cardiovascular risk may also apply to non-selective NSAID, the US Food and Drug Administration issued ‘black box’ safety warnings for the entire NSAID drug class (July 2010).
A:Mild mosaic-like gastric mucosal patternB: Moderate mosaic-like gastric mucosal pattern C: Red point lesionsD: Cherry-red spotsE: Black–brown spots, including an intramucosal hemorrhage F:brown spot