This document discusses upper gastrointestinal bleeding, including its definition, etiologies, presentations, and management. The main causes of upper GI bleeding are esophageal and gastric varices, peptic ulcers, erosive gastritis, and Dieulafoy's lesions. Clinical manifestations include melena, hematemesis, and hematochezia. Management involves resuscitation, endoscopy to determine the source of bleeding, and treatments specific to the cause such as band ligation for varices, sclerotherapy for ulcers, and antisecretory drugs for erosions. Refractory bleeding may require transjugular intrahepatic portosystemic shunt placement or surgery.
esophageal varices are the second most common cause of upper GI bleed after PUD.These are actually the dilated veins which occur secondary to increase in the pressure in the portal circulation called as Portal Hypertension..
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
esophageal varices are the second most common cause of upper GI bleed after PUD.These are actually the dilated veins which occur secondary to increase in the pressure in the portal circulation called as Portal Hypertension..
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
Obstructive jaundice is one of the important surgical topics. In this playlist I have discussed the introduction, choledocholithiasis, Carcinoma Pancreas and biliary atresia. If you watch all these videos together you will become confident in Managing obstructive jaundice.
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
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.
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.
Obstructive jaundice is one of the important surgical topics. In this playlist I have discussed the introduction, choledocholithiasis, Carcinoma Pancreas and biliary atresia. If you watch all these videos together you will become confident in Managing obstructive jaundice.
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
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.
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.
Vascular disease is a condition that develops when the arteries that supply the intestines with blood become narrowed due to the build-up of plaque. This results in a lack of blood supply to the intestines.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
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.
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
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- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
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.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
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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.
Transition to Acting
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.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
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
4. University of
Alexandria
Definition
Hemorrhage in the gastrointestinal tract
above the ligament of Treitz, which connects
the fourth portion of the duodenum to
the diaphragm near the splenic flexure of the
colon.
9. University of
Alexandria
Etiology acc. To incidence in Egypt
– Ruputre oesophageal varice
– Erosions,
– Duodenal ulcer,
– Cancer stomach,
– Gastric ulcer
– Mallory-Weiss syndrome
– Reflux oesophagitis
10. University of
Alexandria
Gatroesophageal Varices
In the lower 3-5 cm of the oesophagus..WHY??
Squeal of portal hypertension.
Portosystemic shunt (Lt gastric v.& oesophageal vessels)
Incidence
– 20-30%-------Mortality in each attack
– 60-70%-------Rebleed within 1 yr if untreated
– 75% -----------Bleeding ceases spontaneously
11. University of
Alexandria
•Cirrhotic liver
•Esophagoscopic
view (at cardia)
•Azygos vein
•Diaphragm
•Esophageal branches of left
gastric vein
•Short gastric vein
•Suprahepathic vein
•Inferior vena cava
•Superior vena cava •Azygos vein
•Esophagus
•Esophageal
varices
•Volume
increased splein
•Gastric
veins
•Splenic vein
•Portal vein
pressure
increases up to
20-30 mmHg
12. University of
Alexandria
Isolated Gastric Varices
Isolated gastric varices are those that occur
in the absence of esophageal varices and are
classified as
– type 1 (fundic)
– type 2 (distal to fundus
including proximal duodenum).
14. University of
Alexandria
Bleeding peptic ulcer
Approximately 20% of patients with peptic
ulcer will bleed.
Bleeding duodenal ulcer: 10 times more
common than bleeding gastric ulcer
Post. ulcer erodes the gastroduodenal artery,
ant. ulcer → no severe bleeding.
90% of patients stop bleeding within 8 h of
admission.
15. University of
Alexandria
Beheviour of PU Bleeding
Spontaneous stoping: 70-80 %
Probability of rebleeding: 30-50 %
Mortality among patients operated
because of rebleeding: 20-30 %
16. University of
Alexandria
Acute erosive gastritis
Diffuse superficial mucosal lesion in body
and fundus may duodenum.
– NSAID
– Alcohol
– Drugs
– Gastric irradiation
– Stressful situation
18. University of
Alexandria
Mallory-Weiss tear
The lesion is a longitudinal tear in the mucosa
of the GE junction.
Transient increase in P. gradient between the
intrathoracic and intragastric portion of GOJ.
It is presumably caused by forceful vomiting
and/or retching, and is commonly seen in
alcoholics.
Endoscopy is diagnostic and theraputic---90%
19. University of
Alexandria
Dieulafoy's lesion
congenital arteriovenous malformation
characterized by an unusually large
tortuous submucosal artery.
It causes massive recurrent bleeding with
no prodromal symptoms
21. University of
Alexandria
Portal hypertensive gastropathy
changes in the mucosa of the stomach in
patients with portal hypertension
These changes in the mucosa include friability
of the mucosa and the presence of dilated
blood vessels at the surface.
22. University of
Alexandria
Hypertrophic Gastropathy
(Ménétrier's Disease)
Clinical syndromes characterized by
epithelial hyperplasia and giant gastric folds
There are large rugal folds in the proximal
stomach, and the antrum is usually spared.
Characteristically associated with protein-
losing gastropathy and hypochlorhydria
25. University of
Alexandria
History
Melena, hematemsis, hematochizia according
to the amount of bleeding
• Melena:
Liquid, jet black or black with reddish tinge
pungent characteristic smell quite unlike smell
of faeces.
• Dark formed stools → insignificant.
• Iron therapy → sticky faeces with dark grey
rather than black.
• Melena:
Liquid, jet black or black with reddish tinge
pungent characteristic smell quite unlike smell
of faeces.
• Dark formed stools → insignificant.
• Iron therapy → sticky faeces with dark grey
rather than black.
26. University of
Alexandria
History
Symptoms of anemia;
– Syncope, fatigue, dyspnea, chest pain
History of
– liver disease or bilhariziasis
– Alcohol intake
– bleeding tendency or anticoagulant intake
– analgesic abuse
– Past gastric surgeries
27. University of
Alexandria
Examination
Hemodynamic stability
– Tachycardia, thready pulse
– Hypotension
Careful abdominal examination
– Bowel sounds
– Abdominal tenderness
– Ascites—shifting dullness
Signs of chronic liver disease or portal hypertension
– Hepatomegaly, Splenomegaly, ictrus
28. University of
Alexandria
Shock assessment
Estimated Fluid and Blood Losses in Shock
Class 1 Class 2 Class 3 Class 4
Blood Loss,
mL
Up to 750 750-1500 1500-2000 >2000
Blood Loss,%
blood volume
Up to 15% 15-30% 30-40% >40%
Pulse Rate,
bpm
<100 >100 >120 >140
Blood
Pressure
Normal Normal Decreased Decreased
Respiratory
Rate
Normal or
Increased
Decreased Decreased Decreased
Urine
Output,
mL/h
14-20 20-30 30-40 >35
CNS/Mental
Status
Slightly
anxious
Mildly
anxious
Anxious,
confused
Confused,
lethargic
Fluid
Replacement,
3-for-1 rule
Crystalloid Crystalloid
Crystalloid
and blood
Crystalloid
and blood
31. University of
Alexandria
Endoscopy
Endoscopy identifies the site of bleeding in
about 90% of patients with upper GI bleeding
The ideal time to perform this examination is
– when the patient is hemodynamically stable, and
– when the nasogastric aspirate following irrigation is
clear.
33. University of
Alexandria
Endoscopic Clues for Risk of
Rebleeding in PU
1. Visible vessel (blue or red).
– Protruding lesion with ulcer base
1. Spurter (arterial).
2. Black or red spot.
3. Overlying clot.
•50%
rebleeding
•10%
rebleeding
43. University of
Alexandria
Resuscitation
ICU admition
Large-bore IV access, Foley
catheterization, and nasogastric intubation
IV fluid replacement
Blood transfusion
– Till Hemoglobin------8g/dl
Fresh frozen plasma & platelet transfusion
44. University of
Alexandria
Role of nasogastric tube
Confirms a UGIB.
Activity of gross bleeding
– Red blood suggests currently active bleeding
– coffee grounds suggest recently active bleeding.
– Continued aspiration of red blood suggests
severe, active hemorrhage.
NGT clears the gastric field for endoscopic
visualization, and to prevent aspiration of
gastric content
45. University of
Alexandria
Activity of bleeding
Grossly bloody haematemsis or large fresh
clots per rectum.
Active bleeding 2 to 3 fold mortality.
NG aspirate may be negative in 10% of
bleeding D.U. due to edema or pylorospasm
The sensitivity of NG aspirate of assessing
active bleeding is 79%
Cuellar et al. Arch Intern Med 1990; 323: 1381-84.
46. University of
Alexandria
Rebleeding
Recurrence of haematemsis or bleeding in
nasogastric tube,
Recurrence of melena or haematochezia
coupled with instable vital signs:
Systolic <90 mmHg, HR >110 beats/min.
Decrease in hematocrit of >4% in 24 hours.
Acta Medica Medianae 2007,Vol.46
47. University of
Alexandria
Role of nasogastric tube
However, lavage may not be positive if
bleeding has ceased or arises beyond a closed
pylorus. The presence of bilious fluid
suggests that the pylorus is open and, if
lavage is negative, that there is no active
upper GI bleeding distal to the pylorus
48. University of
Alexandria
Blood transfusion
High-risk patients should receive packed red
blood cell transfusions to maintain the
hematocrit above 30 percent.eg,
– Elderly
– severe comorbid illnesses such as coronary disease
or cirrhosis
Young and otherwise healthy patients should
be transfused to maintain their hematocrit
above 20 percent.
49. University of
Alexandria
Blood transfusion
Patients who have variceal bleeding are
conservatively transfused to a hematocrit of only
27 to avoid exacerbating the bleeding by
increasing the portal pressure, with
transfusion only for shock or a hemoglobin less
than 8mg/dl.
50. University of
Alexandria
Oesophageal varices
Measures to avoid hepatic enephalopathy
– Gastric lavage
– Lactulose enema
– Oral Neomycin
– Antibiotic administration
– Avoid hypoglycemia
– Avoid Na containing fluids
51. University of
Alexandria
Oesophageal varices
Pharmacologic therapy
– Vasopressin, Glypressin (50% Control)
IV at a dose of 0.2 to 0.8 units/min
Side effect???
– Somatostatin and its analogue octreotide (of choice)
initial bolus of 50 µg IV followed by continuous infusion of
50 µg/h (65% Control)
cause splanchnic vasoconstriction
can be administered for 5 days or longer
– Vit. K administration (parentral)
52. University of
Alexandria
Oesophageal varices
Balloon tamponade using
a Sengstaken-Blakemore
tube
– will control refractory
variceal bleeding in >80%
of patients
– SE ????
– should be limited to short-
term therapy (<24 hours)
53. University of
Alexandria
Endoscopy
EGD should be carried out as soon as possible
and EVL should be performed
Injection sclerotherspy using ethanolamine (80-
90% Control)
– Gastric varices injection with N-butyl-cyanoacrylate
Sclerotherapy Band ligation
Minor chest pain, fever No resternal pain
Chest complication Superficial ulcers
Oesophageal ulcer G. varices
Stricture Equal efficacy
56. University of
Alexandria
Transjugular Intrahepatic
Portosystemic Shunt
In Child-Pugh B&C
control variceal bleeding in >90% of cases
refractory to medical treatment
Disadvantages
– bleeding,
– infections,
– renal failure,
– decreased hepatic function, and hepatic
encephalopathy
58. University of
Alexandria
Prevention of variceal rebleeding
EVL
– 1-2wks till varices disappear
– Then every 6 mon to detect recurrence
Propranolol
– 20% efficacy
60. University of
Alexandria
Bleeding peptic ulcer
Medical
– PPI (80mg IV bolus, then 8mg/hr infusion)
– H2 blockers
– Antacid
– Sucralfat
– Bismuth
Endoscopic
– Injection of adrenaline, electrocautary
Surgical
67. University of
Alexandria
Indications of surgery
Massive bleeding requiring >10 units.
Rebleeding after cessation → Early
surgery Death rate >30%.
Visible bleeding vessel on endoscopy →
50% rebleeding.
70. University of
Alexandria
Surgery
The use of a definitive ulcer curing operation
is mandatory in patients with hemorrhage
but optional in patients with perforation.
– The rebleeding rate is very high in local surgery
only, 70-80 %,
– Recurrent bleeding in both → 13%
75. University of
Alexandria
Acute erosive gastritis
Treatment options
Near total gastrotomy + Roux en Y.
Ligation of all blood vessels to the stomach.
Vagotomy & pyloroplasty.
Conserve until transfusion requirement are 12 units or more.
50% mortality with surgery
77. University of
Alexandria
Indications of surgery in UG bleeding
Hemodynamic instability despite vigorous
resuscitation (>6 units transfusion)
Failure of endoscopic techniques to arrest
hemorrhage
Recurrent hemorrhage after initial stabilization (with
up to two attempts at obtaining endoscopic
hemostasis)
Shock associated with recurrent hemorrhage
Continued slow bleeding with a transfusion
requirement exceeding 4 units/day