This document discusses the management of upper gastrointestinal haemorrhage. It outlines the principles of management which include immediate assessment, resuscitation, determining the bleeding site, treatment or intervention, and preventing recurrence. Non-operative treatments include endoscopic therapies for peptic ulcer disease and variceal bleeding. Surgical or angiographic intervention may be needed for uncontrolled or recurrent bleeding. Risk scoring such as the Rockall score can help predict prognosis and guide management decisions.
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
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.
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
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.
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
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
G I bleeding with radiological interventions(ACR Appropriateness Criteria).Tc-99m RBC scintigraphy,Catheter-directed Angiography,Pharmacological control,Embolization,Arterial interventions,Endoscopy,CT Angiography
Surgery Resident clinical seminar on the management of a 60yr old male with upper gastrointestinal bleeding presented to the department of surgery, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State
Some slides are taken from different textbooks of medicine like Davidson, Kumar and Clark and Oxford, and some from other presentations made by respected tutors. I'm barely responsible for compilation of various resources per my interest. These resources are free for use, and I do not claim any copyright. Hoping knowledge remains free for all, forever.
This is about the management approach to a patient presenting with acute upper gastrointestinal bleeding. A brief account on epidemiology and pathophysiology is included. This is mainly based on NICE guideline & journal of hepatology.
DIAGNOSIS & MANAGEMENT OF PULMONARY HYPERTENSIONKamal Bharathi
Pulmonary hypertension (PH) is defined by a mean pulmonary artery pressure ≥25 mm Hg at rest, measured during right heart catheterization. There is still insufficient evidence to add an exercise criterion to this definition. The term pulmonary arterial hypertension (PAH) describes a subpopulation of patients with PH characterized hemodynamically by the presence of pre-capillary PH including an end-expiratory pulmonary artery wedge pressure (PAWP) ≤15 mm Hg and a pulmonary vascular resistance >3 Wood units. Right heart catheterization remains essential for a diagnosis of PH or PAH. This procedure requires further standardization, including uniformity of the pressure transducer zero level at the midthoracic line, which is at the level of the left atrium. One of the most common problems in the diagnostic workup of patients with PH is the distinction between PAH and PH due to left heart failure with preserved ejection fraction (HFpEF). A normal PAWP does not rule out the presence of HFpEF. Volume or exercise challenge during right heart catheterization may be useful to unmask the presence of left heart disease, but both tools require further evaluation before their use in general practice can be recommended. Early diagnosis of PAH remains difficult, and screening programs in asymptomatic patients are feasible only in high-risk populations, particularly in patients with systemic sclerosis, for whom recent data suggest that a combination of clinical assessment and pulmonary function testing including diffusion capacity for carbon monoxide, biomarkers, and echocardiography has a higher predictive value than echocardiography alone.
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Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
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Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
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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.
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Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
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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.
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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.
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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
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This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
3. INTRODUCTION
• The gastrointestinal
tract extend from the
mouth to the anus and
divided into two parts;
• Upper GIT
• Lower GIT
• By the ligament of treitz
at the duodenojejunal
junction.
10/13/2014 3
4. INTRODUCTION
• The part above the ligament is the upper GI
Definition:
Any bleeding from GI tract proximal to
ligament of treitz.
It is a common cause of emergency hospital admission
and accounts for 5-10% mortality which increase in
the elderly.
10/13/2014 4
6. INTRODUCTION
• Hematemesis Vomiting of fresh or old blood
(40-50%) Proximal to Treitz ligament
Bright red blood = significant bleeding
Coffee ground emesis = no active bleeding
• Melena Passage of black & foul-smelling stools
(70-80%) Usually upper source – may be right colon
• Hematochezia Passage of bright red blood from rectum
(15-20%) If brisk & significant → UGI source
10/13/2014 6
7. PRINCINPLES OF MANAGEMENT
• INITIAL ASSESSMENT
• RESUSCITATION
• DETERMINATION OF BLEEDING SITE
• TREATMENT/INTERVENTION
• PREVENTION OF RECURRENCE
10/13/2014 7
8. PRINCIPLES
Immediate Assessment
Stabilization of hemodynamic status
Identify the source of bleeding
Stopping the active bleeding
Treat the underlying
Prevent recurrent bleeding
10/13/2014 8
9. ASSESSMENT
Patient presenting with cardiovascular
instability requires prompt resuscitation before
detailed history and examination to find the
cause of bleeding and other co-morbidity
10/13/2014 9
10. ASSESSMENT
Severity of bleeding can be determined:
• Level of consciousness - obtundation
• Pulse rate >100bpm
• Postural hypotension.
• Severe blood loss—Vagal slowing of the heart
10/13/2014 10
12. RESUSCITATION
• Aggressiveness of resuscitation depends on
the bleeding severity
• Resuscitation is proportional to bleeding
severity
• Inadequate resuscitation leads to Multi-organ
failure.
10/13/2014 12
13. RESUSCITATION
• Ensure a patent airway and breathing.
• Elevate foot of bed to about 15⁰
• Secure IV access, take samples; PCV, U/Ecr, GXM, Platelet
count, LFT.
• IV crystalloid, N/S R/L 1L over 30-45min
• Pass urethral catheter, empty the bladder then monitor urine
output. (0.5-1ml/kg/min)
• Reassess PR,BP,CVP, urine output, to determine the rate of
infusion
• Supplemental Oxygen---enhances oxygen carrying capacity of
blood
10/13/2014 13
14. RESUSCITATION
• Pass N-G tube-
– Decompression, prevent aspiration
– Cold saline lavage
• Transfuse;
– significant blood loss or pcv <30
– on going bleeding,
– inadequate response to fluid resuscitation,
– elderly and
– presence of cardiopulmonary disease
• Sedation
– Phenobarb to quieten patient.
10/13/2014 14
15. HISTORY
• History to find the cause, co-morbidity and
character(onset, volume and frequency) of
bleeding. Careful history and physical
examination may yield no definitive cause in
50%.
– HX of PUD
– Alcohol ingestion
– NSAID
– Dysphagia
10/13/2014 15
16. HISTORY
• COMMON CAUSES
• Duodenal ulcer
• Gastric ulcer
• Stress ulcer
• Oesophageal varices
10/13/2014 16
17. HISTORY
• LESS COMMON CAUSES
• Oesophagitis
• Mallory- Weiss syndrome
• Malignant gastric tumours
• Benign gastric tumours
• Oesophageal ulcers or tumour
• Para-oesophageal hiatal hernia
10/13/2014 17
20. EXAMINATION
• Collapse subcutaneous veins
• Tachycardia
• Hypotension
• Restlessness
• Features of CLD, gastric ca, abdominal masses,
10/13/2014 20
21. RISK SCORING
• ROCKALL’S RISK SCORE
• Score that predicts poor prognosis, i.e.
rebleeding and mortality from upper GI
haemorrhage
• It uses clinical criteria (increasing age, co-morbidity,
shock) as well as endoscopic finding
(diagnosis, stigmata of spontaneous
haemorrhage -SSH)
10/13/2014 21
24. MANAGEMENT AS PER RISK
• Low risk (0-2);usually 80% of patients recovers
spontaneously with medical treatment(PPI) +
hospitalization for 24hrs and may be discharge
if uneventful.
• Intermediate risks(3-5); same treatment +
hospitalization for at least 72 hrs.
• High risk(>5); same treatment +
hospitalization in ICU
10/13/2014 24
27. N-G TUBE ASPIRATION
Nasogastric aspiration with saline lavage is
beneficial
• to detect the presence of intragastric blood,
• to determine the type of gross bleeding,
• to clear the gastric field for endoscopic
visualization
• to prevent aspiration of gastric contents.
10/13/2014 27
28. ENDOSCOPY
• Diagnostic; direct visualization of source of
bleeding
• Therapeutic; control of active bleeding
• To assess the prognostic indicator using the
Forrest classification
10/13/2014 28
31. BARIUM MEAL
• In the absence of endoscopy, barium is
attempted. It may show ulcer craters, varices,
filling defect or tumors in the stomach.
• Double contrast is preferred; it shows small
ulcers
• Disadvantages;
– Source remains undetected in ≥ 50% of patients
– Blood clot obscures gross lesion
10/13/2014 31
32. ANGIOGRAPHY
• It identifies the bleeding vessel
• Targeted therapy for ongoing hemorrhage;
may prevent need for surgery (with
embolization).
• Angio ≥ 1 ml/min
• Disadvantages; Invasive,expensive,requires
special expertise, exposure to radiation, risk of
contrast media–induced nephropathy,
bleeding from arterial puncture site
10/13/2014 32
33. TAGGED RBC SCAN
• Utilizes technetium labelled rbc extravasation
into bowel is detected by scintillation camera.
• RBC scan may not accurately locate bleed.
• 0.5 – 1 ml/min bleeding requirement,
set up req. 1-2 hours, test time 1-2 hours
• Contraindicated in;
– initial Hct < 24,
– hemodyn unstable patient,
– ongoing > 100-200 cc/h bleed
10/13/2014 33
35. NON OPERATIVE
Peptic ulcer disease
• Endoscopic
• PPI
• Elimination of H. pylori
• Endoscopic therapy:
– Injection of adrenaline at the base of the vessel/
Sclerotherapy
– Bipolar electro- / thermal probe coagulation
– Argon plasma / laser photocoagulation
– Hemostatic materials, including biologic glue
10/13/2014 35
37. NON-OPERATIVE
• If bleeding controlled:
• PPI- proton pump inhibitor
– omeprazole/pantoprazole, 80 mg bolus
then 8 mg/hr infusion x 24 hrs.
then 40 mg IV OD/BD
then transition to oral PPIs for 6-8 wks.
• Helicobacter pylori treatment, if present
triple drug regimen x 2-3 wks.
recurrent colonization 70-90% within few month to years.
• Repeat endoscopy < 6-8 wks.
10/13/2014 37
41. • Pharmacologic treatment :
• Vasopressin splanchnic vasoconstriction; 20IU in 250ml
of 5% DW over 30min, 4hrly. It improves hemostasis.
Telipressin (pro-drug) better hemostasis and survival
benefits. And longer duration of action.
– Side effects
• Pallor
• Hypertension
• Abdominal colic
• Cerebral and coronary ischemia
• purgation
– Nitroglycerine 40 mcg/min may be given simultaneously
to prevent coronary ischemia.
10/13/2014 41
42. • Nitroglycerine systemic hypotension and venous
pooling, counteract cardiac effects of vasopressin;
titrate to SBP 90-100.
• Glypressin; contains both nitroglycerin and
vasopressin
• Beta-Blockers: Propranolol 40 mg bd; lowers
portal pressure. Daily oral dose after bleeding has
stopped is found to stop re-bleeding in about
80%.
• Octreotide: 250 mcg bolus, 250 mcg/hr infusion;
Decreases gastric acid, pepsin, gastric blood flow
10/13/2014 42
43. Endoscopy
• Sclerotherapy;
– Ethanolamine oleate (3-5ml) or sodium morrhuate
is injected into each varies.
– If the bleeding is controlled, injection is repeated
weekly, then at 3weeks and at 3monthly until
varies obliterate.
– Use of cyanoacrylate tissue adhesive.
• Initial success rate -> 90%, re-bleed 30-50%
10/13/2014 43
44. • Band Ligation; is efficacious and is now
preferred to Sclerotherapy
• Endoscopic surveillance;
– 3 monthly for 1year then
– 6monthly for 1year then
– Annually
10/13/2014 44
45. • TIPSS;
– In refractory bleeding after sclerotherapy or band
ligation.
– A shunt is established between the portal vein and
the right or middle hepatic vein
10/13/2014 45
46. OPERATIVE
• Indications;
– Massive bleeding
– Severe haemorrhage continues or recurs/not
responsive to resuscitative efforts
– Associated perforation
– Blood not readily available
– Failure of medical therapy and endoscopic
hemostasis with persistent / recurrent bleeding
– A second hospitalization for peptic ulcer
hemorrhage
10/13/2014 46
47. OPERATIVE
• Factors predicting further bleeding from a
peptic ulcer and possible need for surgery
– Age > 60years
– Hb <8g/dl
– Shock on admission
– Visible spurting vessel on endoscopy
– Giant ulcer >2cm
– Ulcer on the posterior lesser curvature or
posterior inferior wall of the duodenal bulb
10/13/2014 47
48. OPERATIVES
• AIMS;
– To stop the bleeding
– To prevent a recurrence
– To cure underlying cause
10/13/2014 48
56. VARICES
• Surgical Shunts:
• Goal: decompression of the high-pressure
portal venous system
into a low-pressure systemic
venous system and
devascularization of the distal
esophagus and proximal stomach
• Portacaval shunt (end-to-side,
side
to side, interposition graft)
• Mesocaval shunt (Large- or small
diameter interposition graft)
• Distal splenorenal (Warren)
shunt
• Esophagogastric
devascularization,
• Esophageal transsection, &
reanastomosis
• Orthotopic liver transplantation
• Splenectomy (for splenic vein
thrombosis)
10/13/2014 56
57. VARICES
• Surgical Shunts:
• bleeding control rate >90%
• No differences in survival rates: ~5%.
• Complications;
– Re-bleeding
– Encephalopathy
– Ascites
10/13/2014 57
58. • Stress ulcers
– Numerous ulcers- vagotomy + hemi-gastrectomy
– Few - oversewn
• Mallory-Weiss syndrome
– Mucosal laceration is sutured
• Aorto-enteric fistula
– Fistula disconnected and closed
– Aorta grafted with antibiotic primed graft and covered
with omentum
– Antibiotic cover
10/13/2014 58
59. NEGATIVE LAPAROTOMY
• No lesion may be found in the eosophagus,
stomach or duodenum
• The small and larged intestined are carefully
examined for possible source of bleeding
• If negative, the abdomen is closed
10/13/2014 59
61. PROGNOSIS
• Overall mortality is 10-15%
• 33% in patient over 70years
• 70-80% of bleeding peptic ulcer stop bleeding
sponteneously
• Predictors of mortality:
– Age
– Shock
– Co-morbidities
– Delay in diagnosis
– Re-bleeding
10/13/2014 61
62. PROGNOSIS
• 20% re-bleed in 5-10years when treated
conservatively
• When treated surgically, 4.5% re-bleed in 5-
10years
• With H.pylori eradication, the re-bleeding rate
is likely to go down.
10/13/2014 62
64. CONCLUSION
• Even though 70-80% stops spontaneously,
• Bleeding frighten the patient it requires
expeditious work-up ,prompt diagnosis and
treatment.
• Accurate patient evaluation and early
resuscitation before
esophagogastroduodenoscopy (EGD) is critical
to decrease the morbidity and mortality.
10/13/2014 64
65. REFERENCES
• E.A. Badoe, E.Q. Arcampompong, J.T Rocha; “Principles and Practice of surgery
including pathology in the tropics”. 4th edition, Assembly of God Literature Center
ltd, 2009. P 637-641
• Souba, Wiley et al; “ACS Surgery principles and practice” 6th edition, WebMD Inc.
(Professional Publishing), 2007.
• Sriram Bhat M; “SRB’s Manual of surgery” . 4th edition, Jaypee brothers medical
publishers ltd, 2013.
• Mitchell S. Cappell, David Friedel,; Initial Management of Acute Upper
Gastrointestinal Bleeding: From Initial Evaluation up to Gastrointestinal Endoscopy.
Med Clin N Am 92 (2008) 491–509
• Ingrid Lisanne Holster, Ernst Johan Kuipers; Management of acute nonvariceal
upper gastrointestinal bleeding: Current policies and future perspectives. World J
Gastroenterol 2012 March 21; 18(11): 1202-1207
• Jiwon Kim; management and prevention of upper GI bleeding: Gastroenterology
and Nutrition. PSAP -VII
10/13/2014 65