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GIT GIB 2012 ASGE ACG 2012 UPDATES.
1) Gastrointestinal bleeding can occur in the upper or lower GI tract. UGIB is more common and has a higher mortality rate than LGIB. 2) Common causes of UGIB include peptic ulcer disease, erosive gastritis, and esophageal tears. Management involves resuscitation, risk stratification, early endoscopy within 24 hours, and endoscopic therapy for high-risk lesions. 3) Guidelines recommend adequate resuscitation, antisecretory therapy for suspected peptic ulcer bleeding, and endoscopic treatment combining epinephrine injection with a second modality for high-risk ulcers to achieve hemostasis.
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GIT GIB 2012 ASGE ACG 2012 UPDATES.
- 1. LOGO Gastrointestinal bleeding: GIB(UGIB,LGIB) www.slideshare.net/shaikhani
- 2. UGIB: bleeding proximalto the ligament of Treitz UGIB requiring hospitalization is *5 more common than LGIB& has a mortality rate of up to 10%.
- 3. GIB 3 1 UGIB A NVUGIB 3 B VUGIB 2 LGIB
- 4. NVUGIB:Causes 3 1 PUD 50% 2 GERD/Erosive gastritis 25% 3 Dieulafoy lesions 4 AVM (HHT),GAVE 3 5 MW eso tears 15% 6 Tumors(benign/malignan) 3 7 Aortoduodenalfistula 8 Bleeding tendencies
- 5. NVUGIB:Causes 3 9 hemobilia 10 Hemosuccus pancreaticus
- 6. VUGIB:Causes 3 1 Bleeding eso varies 2 Fundal varices 3 Portalhypertensive gastropathy 4 Non-PHT – related bleeding PDU (50%)
- 7. LGIB:Causes 3 1 Anal pathologies. 2 SRUS 3 IBD 4 Bleeding diverticuli 5 3 CR Adenoma polyps or CRC. 6 Radiation colitis 3 7 CD colitis 8 Ischemic colitis
- 8. The Overall Managementof UGIB:RESUSCITATION ER: 3 1 Initial Assessment &Fluid Resuscitation 2 Use of Blood Components 3 Correction of Coagulopathy 4 NGT 3 5 Risk stratification scoring 6 PREENDOSCOPY PPI 3 7 PREENDOSCOPY Prokinetics 8 PREENDOSCOPY ANTIFIBRINOLTYICS
- 9. The Overall Managementof UGIB:RESUSCITATION ER: 3 9 PREENDOSCOPY: SMST/OCTT 10 Optimal time to endoscope 3 11 Postendoscopy PPI 12 Test & treat H Pylori 13 Tailor PPI dose to underlying cause 3 Postendoscopy Gen in-hosp management 14 3 15 On discharge 16 NSAIDs issues
- 10. Initial Assessment &FluidResuscitation Restoration of circulating volume takes priority over endoscopy. ER ABC(shock/airway compromise) 2 IV line IVF Blood group/cross Crystalloids match with pulse until blood oximetry,cardiac ready monitoring, Colloids or automated BP albumen readings,close monitoring of UO preferred for &ideally, CVP cirrhotics.
- 11. Use of BloodComponents Improve Global O2 delivery Improve hemostasis Blood benefits (43% require it regional O2 delivery Target Hb 7-8gms If no Continuous bleeding or CVD). BTSF if Hb>8 TSF>10 *2 rebleed pints needs plts , FRP,Ca
- 12. Coagulopathy correction 6.2 coagulopathy even without cirrhosis Causes Associated with •Multifactorial •Marker of Coagulation screen •Increased disease mortalty severity •Rebleeding Correction: FFP,PC •INR <1.8 Associated Should not delay urgerny OGD with lower mortality& fewer MI Endoscopic hemostasis can be done safely if INR up to 2.5
- 13. NGT: Routine usePre OGD controversial Ptognostic index(1) ?ENSURE HEMOSTSIS Confirm UGI source(85%) BENEFITS Monitor continuous loss ?collect it to use Remove blood & clots It for lesion injection? To clear field for OGD (1)presence fresh red blood in the NGT aspirate found to be an independent predictor of adverse outcome & predictor of high-risk lesions in patients who are hemodynamically stable without evidence of hematemesis.
- 14. Risk stratification scoring: lowrisk/high risk: Using: Early hospital dischare Clinical data Mortality Lab date Need for endohemostasis OGD findings Rebleeding
- 18. Risk stratification: otherthan scoring systems Age>60 Inc mortality HD Shock >*3 mortality & more need For endohemostasis Risky states Hematemesis *2 mortalty,rebleed & endohemostasis
- 19. Risk stratification: otherthan scoring systems Inpatient at time of bleed *3 mortality Compared to new admisions High BU increase need for Endohemostasis Risky states hematochezia *2 mortalty,rebleed & endohemostasis
- 20. Risk stratification: otherthan scoring systems A large ulcer size (>2 cm ) Rebleed /mortality specific locations (lesser wall curve or on the posterior Risky Ulcer duodenal wall),rebleed,mortality,surgery Endo stigma Forrest Class IA, IB, IIA& IIB are high risk, Class IIC & III are low-risk
- 22. PREENDOSCOPY:PPI either oralor IV (better) PH>6 Optimal plat agg clot formation High risk lesions reduce ENDO Interventions at OGD No effect on mortality, syrgery need or rebleeding
- 23. Preendoscopy PPI: Mostsuitable for OGD delayed or not available for 24 hours NVUGIB Pre OGD PPI HR lesion?: Hematemes or bloody NGT IV preferred Sp if vomiting
- 24. PREENDOSCOPY Prokinetics: IV erythro or metochlorpromide Erhthro is motilin agonist REDUCE repeat endoscopy Plasil if IV eryhthro PK No improve other clinical No available endpoints IV eryhthro IV erythro most suitable for patients Need PRIOR ECG Most likely to have blood in stomach at initial OGD.
- 25. Pre-endoscopic antifibrinolytics 1 2 At present there is large-scale RCT will be insufficient evidence required to address this to recommend TXA question. in the treatment of NVUGIB
- 26. Pre-endoscopic SST,OCT SST,OCT not recommended in the routine management of patients with acute NVUGIB.(for VGIB) ?Blee du not controllable while waiting OGD or surgery, or if surgery is contraindicated
- 27. Optimal time toendoscope <24 if very HR patient with high WITHIN 25 Hours blatchford scores after initial after initial stabilization stabilization
- 28. Optimal time toendoscope: benefits 1 2 3 early &targeted endoscopic risk stratification : hemostasis in higher- Improvement in other early discharge of risk patients who are clin endponits those patients with actively bleeding or low-risk with high-risk stigmata of bleeding. Targeted endoscopic hemostasis(dual endoscopic therapy): NS/Adrenaline inj+ one of other modalities(APC,Clip,band,thermal)
- 29. Post endoscopy PPI reduced Mortality In active bleeders& NBVV For high-risk stigmata who have received successful OGD therapy. Reduce rebleed Need for surgery
- 30. Postendoscopy Test&treat HPylori Tested for HP Tested to confirm eradication All bleeding PU SHOULD Eradication Reduces rebleed. Increased False –ve testing
- 31. Post endoscopy generalin-hosp management. Intervention radiology/Surgey After 2 OGDs Re-bleeding Re OGD interven If was on asp/NSAIDs Evaluate risk/benefir ratio Reuse within 5 days. Low risk Fed within 24 hs & discharged on Oral PPI within1-2 days. High risk lesions 72 hour monitoring for rebleeding
- 32. subsequent pharma management. Afterdischarge:once-daily oral PPI dose (in the case of bleeding esophagitis, twice-a-day dosing), the duration of which should be determined by the underlying etiology of the bleeding.
- 35. ASGE Guidelines 2012 We recommend that patients with UGIB be adequately resuscitated before endoscopy. We recommend antisecretory therapy with PPIs for PUD Bleeding or in those with suspected PUD bleeding awaiting endoscopy. We suggest prokinetic agents in patients with a high probability of having fresh blood or a clot in the stomach when undergoing endoscopy. We recommend endoscopy to diagnose etiology of acute UGIB. The timing of endoscopy should depend on clinical factors. Urgent endoscopy (within 24 hours of presen-tion) is recommended for patients with a history of malignancy or cirrhosis, presentation with hematemesis&signs of hypovolemia including hypotension, tachycardia&shock, &Hb 8 g/dL.
- 36. ASGE Guidelines 2012 We recommend endoscopic therapy for PU with high-risk stigmata (active spurting, visible vessel). The management of PUD with an adherent clot is controversial &recommended endoscopic treatments include inj (sclerosants, thrombin, fibrin, or cyanoacrylate glue), cautery, & mechanical therapies. We recommend against epinephrine inj alone for PU bleeding. If epinephrine inj is performed, it should be combined with a second endoscopic treatment modality (eg, cautery or clips). We recommend low-risk lesions be considered for OP TRT. We recommend against routine second-look endoscopy in patients who have received adequate endoscopic therapy. We recommend repeat OGD for patients with evidence of recurrent bleeding.
- 40. Summary Adequate resuscitation. Risk stratification . Early endoscopy to enable further risk stratification. Application of endotherapy to high-risk lesions to achieve hemostasis &downgrade stigmata. Injection of epinephrine alone is not optimal when treating all high-risk lesions which needs in addition one of the other endoscopic hemostatic modalities as APC or cliping. All endoscopic hemostasis should be complemented by a 72-hour infusion of high dose PPI. All patients should be tested for H pylori & treated if necessary, Secondary prophylaxis should be considered for appropriate patients ie PPI covering asp/NSAIDs requiring patients.
- 41.