UPPER GI BLEEDING

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UPPER GI BLEEDING: 

UPPER GI BLEEDING DR AROJURAYE S.A ABUTH, ZARIA 28.11.2011

OULINE: 

OULINE Introduction Aetiology Resuscitation Diagnosis i. History ii. P/E iii. Inv. Treatment Complications Follow up Prognosis Peculiarities of our environment Conclusion

Introduction 1: 

Introduction 1 Bleeding of GIT proximal to ligament of treitz. Ligament of treitz - a fibromuscular band which extends from rt crus of diaphragm to duodenojejunal flexure .

Introduction 2: 

Introduction 2 Present as Haematemesis, hematochezia, maleana or occult blood May be Acute or chronic 100 cases per 100,000 person year

Introduction 3: 

Introduction 3 Accounts for 3-5% of all hospitalizations The incidence is 2-fold greater in males than in females but death rate is similar in both sexes Mortality and morbidity increase with older age (>60 yrs) in males and females

Aetiology 1: 

Aetiology 1 1) Peptic ulcer disease most common A) duodenal ulcers B) gastric ulcers C) stomal ulcers

Aetiology 2: 

Aetiology 2 2. Erosive gastritis, esophagitis, duodenitis some causes are ETOH, ASA, NSAID’s

Aetiology 3: 

Aetiology 3 3. Esophageal and gastric varices causes by portal hypertension

Aetiology 4: 

Aetiology 4 4. Mallory-Weiss syndrome longitudinal mucosal tear in the cardioesophageal region caused by repeated retching. it result from prolonged vomiting or retching patient is usually male alcoholics

Aetiology 5: 

Aetiology 5 Less common Oesophagitis Malignant gastric tumours Benign gastric tumours Oesophageal ulcer Oesophageal tumours A-V malformations Rare Duodenal tumours Pancreatic tumours Arterial aneurysm Blood dyscrasia Hereditary telangiectasia Haemobilia

Aetiology 5: 

Aetiology 5 Malignancy a) Esophageal Ca b) Gastric Ca

Aetiology 6: 

Aetiology 6 6. Arteriovenous malformation

Resuscitation 1: 

Resuscitation 1 Initial mgt has 4 primary goals: quick assessment with attention to hemodynamic status appropriate resuscitation & monitoring identifying major source of bleeding specific therapeutic intervention.

Resuscitation 2: 

Resuscitation 2 Airway cleared of clots O2 may have to be administered Brief hx as 2 wide-bore cannulae are passed Sample to blood bank to GXM blood Class I + II hemorrhage replace with crystalloid. Class III + IV hemorrhage replace with crystalloid and blood.

Resuscitation 3: 

Resuscitation 3 NPO IVF commenced as blood is awaited Urethral catheter is passed, urine monitored. NGT passed for diagnostic & therapeutic Sedation may be needed Blood is transfused as soon as available

Resuscitation 4: 

Resuscitation 4 If stable following resuscitation, pt is prepared for upper GI endoscopy. Endoscopy done within 4-24hrs If pt could not be stabilized, an emergency laparotomy may be necessary to prevent exsanguination

Diagnosis 1: 

Diagnosis 1 Questions to ask in history Any hematemesis, coffee-ground emesis, melena, or hematochezia. Any weight loss or changes in bowel habits. Any vomiting and retching. Any history aortic graft. Any history of ASA, NSAID’s, steroids. Any ETOH abuse. Any history of iron or bismuth

Diagnosis 2: 

Diagnosis 2 Physical exam Vital signs may show hypotension and tachycardia. Cool, clammy skin in shock. Spider angiomata, palmer erythema, jaundice, and gynecomastia seen in liver disease. Petechiae and purpura seen in coagulopathy. Proper abdominal exam and rectal exam.

Investigations: 

Investigations Upper GI endoscopy Arteriography Barium swallow USS Lab investigations

Endoscopy: 

Endoscopy Most important initial investigation For diagnosis and intervention Establishes diagnosis in 90% of pts May need to be done more than once

Arteriography: 

Arteriography In pts who continue bleeding & site not identified Has accuracy of 50-90% Accuracy is increased if there is active bleeding during investigation Demonstrates bleeding of 0.5-1.0ml/min With technetium- labelled rbc , 0.1-0.5ml/min Embolisation may be done at same time

Barium swallow/meal: 

Barium swallow/meal Used when endoscopy is not available Double contrast study ideal May show varices, esophagitis, peptic ulcers, gastric tumours etc

Abdominal USS: 

Abdominal USS To assess both liver architecture & portal circulation More widely available than Arteriography Should be performed before more invasive procedures.

Lab Investigations: 

Lab Investigations CBC Electrolytes Glucose Coagulation studies Liver function studies Type and cross-match

Treatment - PUD: 

Treatment - PUD At endoscopy: 10ml epinephrine at ulcer base Thermal Rx with bipolar diathermy Laser photocoagulation Rebleed is treated similarly A second rebleed is treated by surgery

Treatment - PUD: 

Treatment - PUD Octreotide (somatostatin analogue) is given by continuous infusion Inhibits gastric secretion of acid and pepsin Reduces splanchnic blood flow by vasoconstriction Proton pump inhibitors decrease gastric secretions At pH 7.0, coagulation is enhanced, pepsin inactivated, ulcer healing helped

Treatment - PUD: 

Treatment - PUD Triple drug therapy: very effective in eliminating H pylori and enhancing ulcer healing Surgery: Truncal vagotomy & drainage HSV Partial gastrectomy

Treatment - PUD: 

Treatment - PUD Indications for surgery: Exsanguinating hemorrhage Visible spurting arterial bleed Concomitant perforation Pts >60yrs who rebleed once or need 4 units at resuscitation or 8 units in 48hrs Younger pts requiring 8 units at initial resuscitation or 12 units in 48hrs Rare blood type

Treatment: 

Treatment GASTRIC EROSIONS/ STRESS ULCERS Intraluminal antacids IV proton pump inhibitors Treatment of underlying cause Bleeding subsides in24-48hrs

Treatment: 

Treatment ESOPHAGEAL VARICES At endoscopy: sclerotherapy is started Some sclerosants are ethanolamine oleate, sodium morrhuate, 3% tetradecyl sulphate , absolute alcohol Repeated at 3 wkly intervals, then 3 mthly until varices disappear

Treatment: 

Treatment ESOPHAGEAL VARICES Rubber band ligation Vasoconstriction therapy Octreotide, Vasopressin, propranolol Balloon tamponade: if above measures fail Modified Sengstaken-Blakemoore tube Minnesota tube, Linton tube, Foley catheter

Treatment: 

Treatment ESOPHAGEAL VARICES Balloon tamponade applied for 12hrs Stops bleeding in 80% of cases Must be followed by surgery as bleeding is likely to recur after removal TIPPS: in refractory bleeding Shunt established btw portal vein & Rt or middle hepatic vein

Treatment: 

Treatment DEFINITIVE RX FOR VARICES Stapling transection of esophagus at CEJ Distal splenorenal shunt Portosystemic shunts Splenectomy in hypersplenism Liver transplantation

Treatment: 

Treatment Mallory-Weiss Observe If persistent, suture mucosal tear Esophagitis observe Benign gastric tumours Excise Dieulafoy’s lesion Endoscopic electrocoagulation, sclerotherapy

COMPLICATIONS: 

COMPLICATIONS Of presenting problem Of resuscitative measures Of underlying disease Of treatment

COMPLICATIONS OF MASSIVE HEMORRHAGE: 

COMPLICATIONS OF MASSIVE HEMORRHAGE Hemorrhagic shock Acute renal shutdown Loss of consciousness MODS Death

COMPLICATIONS OF RESUSCITATION: 

COMPLICATIONS OF RESUSCITATION Fluid overload Pulmonary edema CCF Blood transfusion rxns Cardiac arrest Hypothermia Esophageal perforation

COMPLICATIONS OF UNDERLYING DISEASES: 

COMPLICATIONS OF UNDERLYING DISEASES Rebleeding in PUD & varices GOO in PUD Hepatic encephalopathy, hypersplenism, bleeding disorders in liver disease with portal HTN

COMPLICATIONS OF DEFINITIVE RX: 

COMPLICATIONS OF DEFINITIVE RX PUD Coronary ischemia Early/ late dumping Gastric tumours Fe deficiency anemia Liver dx / portal HTN: Mucosal ulceration Hepatic encephalopathy

FOLLOW-UP: 

FOLLOW-UP To monitor progress of non-surgical Rx To prepare pt for elective definitive procedure To look out for, and treat complications of surgery

PROGNOSIS: 

PROGNOSIS Depends on energetic resuscitation Also depends on underlying disease: Better in acute gastric erosion 2 0 to NSAID ingestion Worse in bleeding varices 2 0 to portal HTN

PECULIARITIES OF OUR ENVT: 

PECULIARITIES OF OUR ENVT Blood bank may be overwhelmed Some lab inv. cannot be done as an emergency Endoscopes may not be available No skilled personnel for endoscopic intervention Patient may be lost for follow up

CONCLUSION: 

CONCLUSION Upper GI bleeding is not uncommon & may be life threatening, prompt intervention could be life-saving, mgt is multi-disciplinary and definitive treatment depend on the final diagnosis.

Thank you for listening: 

Thank you for listening