Approach to UGI Bleed in ER

1. Dr.Sunil Kumar
MEM Resident
Dr.Mehta Hospital Pvt Ltd
Chennai

2. • Introduction.
• Definition.
• Pathophysiology / Cause.
• Diagnosis.
• Diagnostic study.
• Treatment.
• Clinical Presentation in ER.
• Approach to the patient.
• First priority in ER.
• Principle of Management in ER.
OBJECTIVE

3. • Gastrointestinal(GI)bleed is a common
presenting problem in the ER.
Upper GI bleed
Lower GI bleed
• Acute Upper GI bleeding in adult has
an over all annual incidence of approximately
47 per 1 lac.
• Male >female.
• Mortality rate 10% (Approx.).
INTRODUCTION

4. Anatomy

5. • Upper GI Bleed is defined as bleeding from
mouth to suspensory ligament of duodenum
( ligament of treitz ) at duodenojejunal.
.juction.
Definition

6. “PAGE ME”
• 1.Peptic ulcer ( 50% )-Including oesophageal gastric, duodenal
( due to H.Pylori/NSAID)
• 2.Atrioenteric fistulas.
• 3.Gastrits(13%)–Haemorrhagic and
erosive (due to NSAID,alcohol,stress)
• 4.Esophagitis(2-5%).
• 5.Mallory- Weiss Syndrome–Mucosal tear in the cardio-
oesophageal region ( repeated vomiting followed by bright
red hematemesis)-due to coughing or seizures.
• 6.Esophageal and Gastric Varices -due to Portal hypertension
(most common in case of cirrhosis)
Pathophysiology / cause / DD

7. • Stress ulcer
• Malignancy- oesophageal cancer,
Gastric cancer.
• Alcohol and Smoking
• Drugs : salicylates, and non-steroidal anti-inflammatory agents
( NSAID)
Other cause

8. DIAGNOSIS
1.Clinical presentation/medical history
2.Physical Examination
3.Laboratory Data

9. (Source of bleeding)
A.Hematemesis-Vomiting of fresh or old blood
Bright red blood --significant bleeding
Coffee ground –----no active bleeding.
(don’t confuse with Hemoptysis (bleed from pharynx)
B. Melena-Passage of black & foul smelling usually
upper source –may right colon.
C.Sign of hypovalemia-active bleeding, blood in stool, pain
abdomen,confusion and BP,HR,RR,Urine output.
D.Hematochezia (bright red blood per rectum (BRBPR).
1.Clinical presentation/Medical history

10. Assessing the severity of Bleeding
Blood loss Vital signs Bleeding
Severity
<750 ml Normal
HR-<100/min
RR-14-20/min
BP-120/80mmhg
Urine -30ml/hr
Minor
750-1500ml Postural
HR->100/min
RR-20-30/min
BP-Low
Urine-20-30 ml/hr
Moderate
>2000ml Shock
HR->140/min
RR->35/min
BP-low
Urine-nil
Severe

11. • General Inspection
• Anaemia,
• Dehydration, Cool & clammy skin ( sign of shock)
• SKIN Changes:
 Spider angiomata(Central arteriole)
 palmer erythema(Exagereted red
flushing of palms Fades on pressure)
jaundice(liver disease)
 Petechiae and puroura (cogulopathy)
• Ear nose and throat exa ( occult bleeding)
• Rectal exa ( indicated to detect presence)
2.Physical Examination

12. • Abdomen examination
A.Inspection-Distension ,Dilated vein,Scar.
B.Palpation-Tenderness,Mass/Organomegaly
C.Percussion-Shifting dullness
D.Auscultation-Hyperactive bowel sound
Systemic examination

13. • Complete blood count.
• Blood grouping and typing
( most important lab test).
• Blood urea nitrogen ( BUN) :Creatinine >30-severe bleed
• Glucose.
• Cogulation studies.
• Liver function test ( LFT )
• Stool ocult blood test ,HIV,HCV,HBsAg.
3.Laboratry Data

14. • Chest x-rays/ABG :
To Rule out aspiration /
/ Pulmonary diseases.
• Serial ECG
• Barium contrast studies
limited diagnostic value
in an emergency setting.
continue..

15. • UGI endoscopy: Most accurate Diagnostic study for identify upperGI bleeding site
• Nasogastric (NG) Intubation :may have both diagnostic and therapeutic
benefits.
>Use under topical anaesthesia.
>Assess the Aspiration –
Red Blood-current bleeding.
Coffee ground-Recent bleeding,
Continuous aspiration-Severe active bleeding,
No blood-Bleeding stop.
>Strong evidence of UGI bleed in case.
of without H/O hematemesis.
>In Varices patient –NG tube passage may cause
bleeding.
• Angiography -Localization of bleeding vessel
whom endoscopy does not identify
the bleeding point.
Diagnostic Studies

16. PRIMARY
• Immediate resuscitation measures take priority.
• Airway-Require definitive airway management-
in profuse UGI bleeding for prevent aspiration.
Endotracheal tube Administer oxygen.
Breathing-Support respiratory function.
Circulation-Expend circulatory volume, maintain the BP
• cardiac monitoring.
• Provide volume replacement with crystalloids.
• Blood transfusion.
Treatment

17. • Active Bleeding.
• Failure to improve perfusion and vital signs after 2 L of
crystalloid.
1.Systolic BP < 110 mmHg
2.Postural hypotension
3.Pulse > 110/min
• Haemoglobin <8g/dl.
• Angina or cardiovascular disease with a Haemoglobin <10g/dl.
• Coagulation factors should be replaced as ,needed.
Blood Transfusion-indication

18. • ENDOSCOPY
• DRUG THERAPY
• BALLON TAMPONADE
SECONDARY

19. • Used to detect the site of bleeding ,It is single diagnostic
tool –success around 90% , done in ICU.
• May also be used in a therapeutic capacity (active bleeding
from the ulcer, the presence of a visible vessel, adherent
clot overlying the ulcer).
• Injection Therapy( including epinephrine,thrombin,ethnol
etc).
• endoscopic clips and band ligation is used commonly in
Esophageal varices.
• Endoscopic coaptive therapies include heater probe
thermocogulation.
Endoscopy

20. Antisecretory Agents
• PPI (Proton pump inhibitors )-Reduce the rebleeding and
best used as an adjunct to endoscopic therapy
o Pantoprazole –80 mg bolus and
8 mg/h infusion continues.
o Lansoprazole -60 mg bolus and
6 mg/h infusion continues.
• H2-receptor antagonists -less effective
• An acidic environment impairs platelet function and
haemostasis
Drug therapy

21. Splanchnic blood pressure modifiers
• Somatostatin -infusion have been used in UGI bleeding
when uncontrolled bleeding/endoscopy
unsuccessful/contraindicated /unavailable endoscopy.
• Octreotide -25 to 50 microgram IV bolus and 25-
50 microgram/h infusion.
• Vasopressin –Used to control GI bleed (most common
from Varices) - However reaction are more
common(HTN,Myocardial ischemia,Decreased CO /
increase the portal HTN and gangrene).
Continue..

22. • Antifibrinolytic Agents-Tranexamic acid .Antibiotics(e.g.
quinolone, 3G ceph). Vit K and clotting factors
• H. pylori irradication-reduces the recurrence of peptic ulcer
and rebleeding
Triple regimen – proton pump inhibitor + 2 antibiotics
given for 1 week (elimination rate > 90%)
e.g. Omeprazole + metronidazole/amoxycillin + clarithromycin
Combination of endoscopic and pharmacologic therapy offers the best
therapy for ulcer bleeding patients.
Continue…

23. • BALLOON TAMPONADE :A NOW RARELY USED IN UGI BLEEDING
BECAUSE OF ADVERSE REACTIONS.
• SURGERY : Depend upon medical and endoscopic therapy.
 GU – remove ulcer, gastrin secreting zone.
– Billroth I gastrectomy.
 DU – Polya or Billroth II gastrectomy.
– Vagotomy.
Balloon Tamponade and Surgery

24. • Acute blood vomiting.
• Chronic black tarry stools.
• Signs of hypovolemia ( HR ,BP ,RR ,Urine output ,
Syncope )
• Melena.
• Hematochezia.
• Abdomen Pain.
Clinical Presentation in ER

25. • Vital Information can be gained from the view
at the door
• Airway
• Breathing
• Circulation
Altered Level of consciousness is a very early sign
of impending circulatory collapse
Initial Apporach in ER

26. • Needs a team approach
• IV access
• Organise fluids
• Apply monitoring
• Oxygen
• Contact blood bank
• Contact endoscopists
• Specific therapies
First priority in ER ?

27. • 1.Fluid resuscitation.
• 2.Replacement of Hb/cloting factor if there is
significant blood loss
• 3.Monitoring fluid & blood resuscitation & periodic re-
evaluation
• 4.Determine the etiology & treat the cause .
Principles of management

28. Patient with a score of zero
BUN<18,Hb>13(men)12(womem)
Systolic BP>110,
pulse,100/min
No Syncope,No malena
are AT VERY LOW RISK FOR
A ADVERSE CLINICAL OUTCOMES
Glasgow-Blatchford Bleeding Score

29. • Acute Upper GI bleeding
• Ulcer Esophageal varices Mallory-wiess tear
• Active bleeding Adherent clot Pigment clean Ligation + IV Vasoactive drug Active B No Active B
• IV PPI+endoscopy IV PPI No IV PPI No IV PPI ICU for 2-3 Days Endoscopy No endoscopy
therapy endoscopy+/- & Endo & Endo therapy therapy
• ICU admission Ward adm Ward adm D/S Ward adm D/S
Further reading HARRISON’S 18th edition
Algorithm of upper GI bleeding