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Variceal bleeding and massive upper gi bleeding
1) Variceal bleeding occurs in patients with cirrhosis and portal hypertension when enlarged veins in the esophagus or stomach (varices) rupture. 2) Management of variceal bleeding involves stabilizing the patient, performing endoscopy within 12 hours to identify varices, and administering vasoactive drugs to control bleeding along with antibiotics to prevent infection. Endoscopic variceal ligation or sclerotherapy can help stop active bleeding from varices. 3) For non-variceal upper GI bleeding, endoscopic treatment with adrenaline, coagulation, or clips is usually attempted first. Surgery may be needed for uncontrolled or recurrent bleeding after failed endoscopic attempts.
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Variceal bleeding and massive upper gi bleeding
- 1. VARICEAL BLEEDING AND MASSIVEUPPER GI BLEEDING: SURGEON’S ROLE FACEBOOK: HAPPY FRIDAY KNIGHT NOON CONFERENCE FOR INTERNS
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- 3. GASTROESOPHAGEAL VARICEAL BLEEDING (GEVB) •Portal hypertensive upper GI bleeding in patients with cirrhosis • Portal hypertension is initial and main consequences of cirrhosis • Cirrhosis: diagnosed by: • Radiological: US, CT, MRI • Pathological: liver biopsy (gold standard)
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- 7. PORTAL HYPERTENSION: DIAGNOSIS •Invasive test: • Hepatic venous pressure gradient (HVPG) ≥ 5 mmHG • Endoscopy: presents of GEV (portosystemic collaterals) • Non-invasive test: platelet count < 100,000
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- 9. WHEN CIRRHOTIC PATIENTSREQUIRE EGD? • Expert opinion: EGD can be avoided in patients with • Liver stiffness < 20 kPa • Plt cont > 150,000/mm2 • Patients whom do not meet these criteria: EGD for GEV screening is recommended • Frequency: • Q2yrs in ongoing liver injury (active alcoholic drinking) • Q2yrs in presence of small varices • Q3yrs in absence of ongoing injury
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- 12. PATIENTS WITH UGIB… •Airway protection and resuscitation • Define as EV or non-EV bleeding • Mortality 20 – 80% • Imaging study for ruling out HCC with portal vein thrombosis • immediate goal of therapy in these patients is to • control bleeding • prevent early recurrence (within 5 days) • prevent 6-week mortality
- 13. VARICEAL HEMORRHAGE MANAGEMENT •Restrict PRC transfusion (threshold of Hb 7 g/dL and maintain Hb 7 – 9 g/dL) • Correction of coagulopathy: • NOT recommend to correct INR by FFP or FVII • No recommendation for platelet transfusion • High risk for bacterial infection: antibiotic prophylaxis by ceftriaxone 1 g IV q24h, maximum 7 days (discontinue when UGIB resolved and vasoactive drug discontinued) • Vasoactive drugs: somatostatin, octreotide, terlipressin show benefit
- 15. • EGD ASAP(within 12 hours) if varices present EVL • Injection sclerotherapy for gastric varices VARICEAL HEMORRHAGE MANAGEMENT
- 17. WHAT ABOUT SENGSTAKENBLAKEMORE TUBE • Control bleeding by tamponade effect • Indications • Active VH with fail med • Active VH with EGD/vasoconstrictor unavailable • contraindications • VH slow down • Recent EGJ surgery • Known esophageal stricture
- 18. SENGSTAKEN BLAKEMORE TUBE PLACEMENT •ETT intubation first • Inflate GASTRIC balloon 50 ml Xray inflate balloon up to 250 ml • 1-kg traction • Inflate ESOPHAGEAL balloon < 45 mmHg only when failed gastric balloon • Complication: esophageal or gastric rupture
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- 20. SURGICAL MANAGEMENT IN NON-VARICEALHEMORRHAGE
- 21. TREATMENT MODALITIES FORBLEEDING PEPTIC ULCER: ENDOSCOPIC TREATMENT ADRENALINE INJECTION HEAT PROBE
- 22. MASSIVE UGIB • Hemodynamicallyunstable • Require PRC > 4 U in 24 hr
- 23. TREATMENT MODALITIES FORBLEEDING PEPTIC ULCER: ENDOSCOPIC TREATMENT HEMOCLIP
- 24. INDICATIONS FOR SURGERY •Uncontrolled bleeding by endoscopy • Rebleeding after repeated endoscopic treatment
- 25. FORREST CLASSIFICATION: ENDOSCOPIC FINDING Forrest classificatio n Endoscopicfinding Incidence (%) Rebleed without Rx (%) Rebleed after Rx (%) IA Spurting (active bleed) 12 55 15-30 IB Oozing (active bleed) 14 55 15-30 IIA Non-bleeding visible vessel (recent bleed) 22 43 5 IIB Adherent clot (recent bleed) 10 22 IIC Flat pigmented spot (recent bleed) 10 10 III Clean base ulcer (no active bleed) 32 5
- 30. TAKE HOME MESSAGE… •When an UGIB patients come to ER look for emergency condition • Define EV or non-EV • Cause of bleeding can be from oral to ligament of Treitz • EV: only medical and endoscopic • Non-EV: medical endoscopic surgical
- 31. REFERENCES Garsia-Tsao G, etal. Portal Hypertensive Bleeding in Cirrhosis: Risk Stratification, Diagnosis, and Management: 2016 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatol. 2017:65(1);310-335. Procopet B and Berzigotti A. Diagnosis of cirrhosis and portal hypertension: imaging, non-invasive markers of fibrosis and liver biopsy. Gastroenterology report. 2017:5(2); 79-89. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015.