GIT GIB 2012 ASGE ACG 2012 UPDATES.

1. LOGO
Gastrointestinal bleeding:
GIB(UGIB,LGIB)
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2. UGIB: bleeding proximal to 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 Management of 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 Management of 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 &Fluid Resuscitation
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 Blood Components
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 use Pre 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:
low risk/high risk:
Using:
Early hospital dischare
Clinical data
Mortality
Lab date
Need for endohemostasis
OGD findings
Rebleeding

18. Risk stratification: other than
scoring systems
Age>60 Inc mortality
HD Shock >*3 mortality & more need
For endohemostasis Risky states
Hematemesis
*2 mortalty,rebleed & endohemostasis

19. Risk stratification: other than
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: other than
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 oral or
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: Most suitable 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 to endoscope
<24 if very HR patient with high
WITHIN 25 Hours
blatchford scores after initial
after initial stabilization
stabilization

28. Optimal time to endoscope:
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 H Pylori
Tested for HP
Tested to confirm
eradication
All bleeding PU
SHOULD
Eradication
Reduces rebleed. Increased
False –ve testing

31. Post endoscopy general in-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.
After discharge: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. LOGO