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 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.
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.
Upper Gastrointestinal Bleeding (UGIB) - General ApproachMohamed Badheeb
What does the science & evidence say about UGIB ?
Introduction & Background on Upper GI Bleeding.
- Incidence and Epidemiology
- Etiologies
2. Guidelines on UGIB
- Resuscitation, Risk assessment
- Diagnostic Modalities
- Treatment Options
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.
Upper Gastrointestinal Bleeding (UGIB) - General ApproachMohamed Badheeb
What does the science & evidence say about UGIB ?
Introduction & Background on Upper GI Bleeding.
- Incidence and Epidemiology
- Etiologies
2. Guidelines on UGIB
- Resuscitation, Risk assessment
- Diagnostic Modalities
- Treatment Options
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.
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
Defecation
Normal defecation begins with movement in the left colon, moving stool toward the anus. When stool reaches the rectum, the distention causes relaxation of the internal sphincter and an awareness of the need to defecate. At the time of defecation, the external sphincter relaxes, and abdominal muscles contract, increasing intrarectal pressure and forcing the stool out
The Valsalva maneuver exerts pressure to expel faeces through a voluntary contraction of the abdominal muscles while maintaining forced expiration against a closed airway. Patients with cardiovascular disease, glaucoma, increased intracranial pressure, or a new surgical wound are at greater risk for cardiac dysrhythmias and elevated blood pressure with the Valsalva maneuver and need to avoid straining to pass the stool.
Normal defecation is painless, resulting in passage of soft, formed stool
CONSTIPATION
Constipation is a symptom, not a disease. Improper diet, reduced fluid intake, lack of exercise, and certain medications can cause constipation. For example, patients receiving opiates for pain after surgery often require a stool softener or laxative to prevent constipation. The signs of constipation include infrequent bowel movements (less than every 3 days), difficulty passing stools, excessive straining, inability to defecate at will, and hard feaces
IMPACTION
Fecal impaction results from unrelieved constipation. It is a collection of hardened feces wedged in the rectum that a person cannot expel. In cases of severe impaction the mass extends up into the sigmoid colon.
DIARRHEA
Diarrhea is an increase in the number of stools and the passage of liquid, unformed feces. It is associated with disorders affecting digestion, absorption, and secretion in the GI tract. Intestinal contents pass through the small and large intestine too quickly to allow for the usual absorption of fluid and nutrients. Irritation within the colon results in increased mucus secretion. As a result, feces become watery, and the patient is unable to control the urge to defecate. Normally an anal bag is safe and effective in long-term treatment of patients with fecal incontinence at home, in hospice, or in the hospital. Fecal incontinence is expensive and a potentially dangerous condition in terms of contamination and risk of skin ulceration
HEMORRHOIDS
Hemorrhoids are dilated, engorged veins in the lining of the rectum. They are either external or internal.
FLATULENCE
As gas accumulates in the lumen of the intestines, the bowel wall stretches and distends (flatulence). It is a common cause of abdominal fullness, pain, and cramping. Normally intestinal gas escapes through the mouth (belching) or the anus (passing of flatus)
FECAL INCONTINENCE
Fecal incontinence is the inability to control passage of feces and gas from the anus. Incontinence harms a patient’s body image
PREPARATION AND GIVING OF LAXATIVESACCORDING TO POTTER AND PERRY,
An enema is the instillation of a solution into the rectum and sig
One of the most developed cities of India, the city of Chennai is the capital of Tamilnadu and many people from different parts of India come here to earn their bread and butter. Being a metropolitan, the city is filled with towering building and beaches but the sad part as with almost every Indian city
Leading the Way in Nephrology: Dr. David Greene's Work with Stem Cells for Ki...Dr. David Greene Arizona
As we watch Dr. Greene's continued efforts and research in Arizona, it's clear that stem cell therapy holds a promising key to unlocking new doors in the treatment of kidney disease. With each study and trial, we step closer to a world where kidney disease is no longer a life sentence but a treatable condition, thanks to pioneers like Dr. David Greene.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
How many patients does case series should have In comparison to case reports.pdfpubrica101
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https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
Global launch of the Healthy Ageing and Prevention Index 2nd wave – alongside...ILC- UK
The Healthy Ageing and Prevention Index is an online tool created by ILC that ranks countries on six metrics including, life span, health span, work span, income, environmental performance, and happiness. The Index helps us understand how well countries have adapted to longevity and inform decision makers on what must be done to maximise the economic benefits that comes with living well for longer.
Alongside the 77th World Health Assembly in Geneva on 28 May 2024, we launched the second version of our Index, allowing us to track progress and give new insights into what needs to be done to keep populations healthier for longer.
The speakers included:
Professor Orazio Schillaci, Minister of Health, Italy
Dr Hans Groth, Chairman of the Board, World Demographic & Ageing Forum
Professor Ilona Kickbusch, Founder and Chair, Global Health Centre, Geneva Graduate Institute and co-chair, World Health Summit Council
Dr Natasha Azzopardi Muscat, Director, Country Health Policies and Systems Division, World Health Organisation EURO
Dr Marta Lomazzi, Executive Manager, World Federation of Public Health Associations
Dr Shyam Bishen, Head, Centre for Health and Healthcare and Member of the Executive Committee, World Economic Forum
Dr Karin Tegmark Wisell, Director General, Public Health Agency of Sweden
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
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2. CLINICAL SCENARIO
A 60 y old lady with history of HTN and Rheumatoid Arthritis who
presents to the ER with 3 episodes of coffee–ground emesis
today
No abdominal pain, melena or hematochezia. No history of liver
disease or coagulopathy
She has been usings NSAIDs and DMARDs for 5 years.
VS on arrival: HR 102, BP 118/72 (lying down) 90/60 (standing),
sPO2 99% at room air
Examination: Alert. No scleral icterus. Abdomen soft, non-tender,
no HSM
Labs: Hgb 9.8, Plt 245, INR 1, LFTs normal
3. CLINICAL SCENARIO
• A 50 years old gentleman presented to ER with an episode of
hemetemsis yesterday and coffee ground vomiting today. Known
case of Hep C related DCLD
• Vitals: Pulse: 122, BP: 87/50
• After resuscitation, DRE was conducted. Melena positive
4. UPPER GI BLEED
• Acute gastrointestinal bleeding is potentially life-threatning
abdominal emergency that remains a common cause of
hospitalization.
• Upper gastrointestinal bleeding (UGIB) is defined as bleeding
derived from a source proximal to ligament of treitz
• vericeal or non-variceal
• UGIB is 4 times as common as bleeding from lower GIT, with a
higher incidence in male
5. EPIDEMIOLOGY
• In Pakistan, the incidence of variceal bleed (21%) almost
approaches to that of ulcer bleed (30.6%)
6. CAUSES
• Esophageal
Esophageal varices
Esophagitis
Esophageal cancer
Esophageal ulcers
Mallory-weiss tear
• Gasrtic
Gastric ulcer
Gastric cancer
Gastritis
Gastric varices
• Duodenal
Duodenal ulcer
Aorto-enteric fistula
Hematobilia
Hemosuccus pancreaticus
Severe superior
Mesenteric artery syndrome
13. cont...
After initial resusitation comes
MEDICATION:
1. ACID SUPPRESSION:
Patients admitted to the hospital with acute upper GI bleeding
are typically treated with a proton pump inhibitor (PPI). We suggest
that patients with acute upper GI bleeding be started empirically on
an intravenous PPI. It can be started at presentation and continued
until confirmation of the cause of bleeding. Once the source of the
bleeding has been identified and treated (if possible) intravenous
infusion of a PPI significantly reduces the rate of rebleeding
compared with standard treatment in patients with bleeding ulcers
[19]. Oral and intravenous PPI therapy also decrease the length of
hospital stay, rebleeding rate, and need for blood transfusion in
patients with high-risk ulcers treated with endoscopic therapy. (See
"Treatment of bleeding peptic ulcers", section on 'Acid
suppression'.), the need for ongoing acid suppression can be
determined.
14. 2. PROKINETICS:
The goal of using a prokinetic agent is to improve gastric
visualization at the time of endoscopy by clearing the stomach of
blood, clots, and food residue. A reasonable dose is 3 mg/kg
intravenously over 20 to 30 minutes, 30 to 90 minutes prior to
endoscopy.
3. SOMATOSTATIN AND ITS ANALOGS:
Octreotide, is used in the treatment of variceal bleeding and may
also reduce the risk of bleeding due to nonvariceal causes. In
patients with suspected variceal bleeding, octreotide is given as an
intravenous bolus of 20 to 50 mcg, followed by a continuous infusion
at a rate of 25 to 50 mcg per hour.
4. VASOPRESSIN ANALOG:
Terlipressin has major role in UGIB management ,used for 5 days
after hemostasis has been achieved
cont...
15. 5. ANTIBIOTICS:
prophylactic antibiotics in cirrhotic
patients hospitalized for bleeding
results reduction in infectious
complications and possibly decreased
mortality. Antibiotics may also reduce
the risk of recurrent bleeding in
hospitalized patients who bled from
esophageal varices
6. UPPER GI ENDOSCOPY:
Early endoscopy (within 24 hours) is
recommended for most patients with
acute UGIB (therapeutic + diadnostic)
If treatment still not working
then....
SURGICAL INTERVENTION:
Angiographic embolisation or
gastrectomy in severe cases
cont...
16. • The HALT-IT trial is assessing whether early administration of
tranexamic acid in people with acute gastrointestinal bleeding
can reduce their risk of dying in the hospital. The trial is also
measuring the effects of the treatment on re-bleeding, non-fatal
vascular events, blood transfusion, surgical intervention and
general health status
• POF hospital is participating in this trial since
1g in 100ml normal saline (over 10 min)
Then 3g in 1L normal saline (over 24 hours)
HALT-IT TRIAL
17. ON DISCHARGE
• Avoid NSAIDs If inevitable then use
COX-2 inhibitorsH-pylori eradication for
PUDB-blockers for variceal bleed
