logging in or signing up UPPER GI BLEEDING doctorarju Download Post to : URL : Related Presentations : Let's Connect Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Copy embed code: Embed: Flash iPad Dynamic Copy Does not support media & animations Automatically changes to Flash or non-Flash embed WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 2097 Category: Entertainment License: All Rights Reserved Like it (3) Dislike it (0) Added: December 24, 2011 This Presentation is Public Favorites: 5 Presentation Description No description available. Comments Posting comment... By: elsayedz (5 month(s) ago) very nice Saving..... Post Reply Close Saving..... Edit Comment Close By: hassansiraj (7 month(s) ago) email@example.com Saving..... Post Reply Close Saving..... Edit Comment Close By: hassansiraj (7 month(s) ago) hi .Dr.Arojuraye Soliudeen its a nice presentation ,and i need u to send me that on my Email plz.. Saving..... Post Reply Close Saving..... Edit Comment Close Premium member Presentation Transcript UPPER GI BLEEDING: UPPER GI BLEEDING DR AROJURAYE S.A ABUTH, ZARIA 28.11.2011OULINE: OULINE Introduction Aetiology Resuscitation Diagnosis i. History ii. P/E iii. Inv. Treatment Complications Follow up Prognosis Peculiarities of our environment ConclusionIntroduction 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 yearIntroduction 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 femalesAetiology 1: Aetiology 1 1) Peptic ulcer disease most common A) duodenal ulcers B) gastric ulcers C) stomal ulcersAetiology 2: Aetiology 2 2. Erosive gastritis, esophagitis, duodenitis some causes are ETOH, ASA, NSAID’sAetiology 3: Aetiology 3 3. Esophageal and gastric varices causes by portal hypertensionAetiology 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 alcoholicsAetiology 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 HaemobiliaAetiology 5: Aetiology 5 Malignancy a) Esophageal Ca b) Gastric CaAetiology 6: Aetiology 6 6. Arteriovenous malformationResuscitation 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 availableResuscitation 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 exsanguinationDiagnosis 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 bismuthDiagnosis 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 investigationsEndoscopy: Endoscopy Most important initial investigation For diagnosis and intervention Establishes diagnosis in 90% of pts May need to be done more than onceArteriography: 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 timeBarium swallow/meal: Barium swallow/meal Used when endoscopy is not available Double contrast study ideal May show varices, esophagitis, peptic ulcers, gastric tumours etcAbdominal 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-matchTreatment - 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 surgeryTreatment - 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 helpedTreatment - PUD: Treatment - PUD Triple drug therapy: very effective in eliminating H pylori and enhancing ulcer healing Surgery: Truncal vagotomy & drainage HSV Partial gastrectomyTreatment - 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 typeTreatment: Treatment GASTRIC EROSIONS/ STRESS ULCERS Intraluminal antacids IV proton pump inhibitors Treatment of underlying cause Bleeding subsides in24-48hrsTreatment: 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 disappearTreatment: 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 catheterTreatment: 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 veinTreatment: Treatment DEFINITIVE RX FOR VARICES Stapling transection of esophagus at CEJ Distal splenorenal shunt Portosystemic shunts Splenectomy in hypersplenism Liver transplantationTreatment: Treatment Mallory-Weiss Observe If persistent, suture mucosal tear Esophagitis observe Benign gastric tumours Excise Dieulafoy’s lesion Endoscopic electrocoagulation, sclerotherapyCOMPLICATIONS: COMPLICATIONS Of presenting problem Of resuscitative measures Of underlying disease Of treatmentCOMPLICATIONS OF MASSIVE HEMORRHAGE: COMPLICATIONS OF MASSIVE HEMORRHAGE Hemorrhagic shock Acute renal shutdown Loss of consciousness MODS DeathCOMPLICATIONS OF RESUSCITATION: COMPLICATIONS OF RESUSCITATION Fluid overload Pulmonary edema CCF Blood transfusion rxns Cardiac arrest Hypothermia Esophageal perforationCOMPLICATIONS OF UNDERLYING DISEASES: COMPLICATIONS OF UNDERLYING DISEASES Rebleeding in PUD & varices GOO in PUD Hepatic encephalopathy, hypersplenism, bleeding disorders in liver disease with portal HTNCOMPLICATIONS 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 encephalopathyFOLLOW-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 surgeryPROGNOSIS: 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 HTNPECULIARITIES 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 upCONCLUSION: 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 You do not have the permission to view this presentation. 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