upper gi bleed

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Bleeding from upper gastrointestinal tract.Recent management strategies.

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UPPER GI BLEED:MANAGEMENT-WHAT’S NEW : 

UPPER GI BLEED:MANAGEMENT-WHAT’S NEW M.Misra PGT,R.G.Kar Medical College,Kolkata

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Introduction: Responsible for 90% of GI bleed >350000 hospital admissions/yr Mortality 10% Causes:1.Duodenal ulcer(30-37%) 2.Gastric ulcer(19-24%) 3.Gastritis and duodenitis(5-10%) 4.Esophagitis and esophageal ulcer(5-10%) 5.Mallory-weiss tear(3-7%) 6.Malignancy(1-4%) 7.Dieulafoy lesion(1%) 8.AVM 9.Angiodysplasia

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Recent advances and consensus in management: 1.Pharmacotherapy 2.Endoscopic management Endoscopic management: 1.Variceal bleed 2.Nonvariceal bleed

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Pharmacotherapy:profound acid suppression Low pH associated with: 1.Decreased clot 2.Increased fibrinolysis 3.Increased platelet disintegration Goal:pH >6 IV PPI post-endoscopic hemostasis in peptic ulcer: 1.Decreased rebleed 2.Decreased surgery Few trials:high dose oral also effective Immediate release preparations may be alternative

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Pharmacotherapy contd. IV PPI before endoscopy(metaanalysis of 23 RCTs): 1.Deceased endoscopy 2.Decreased stay in hospital Omeprazole 80mg bolus,then 8 mg/hr(before endosco- py) 1.Speeding up of resolution of bleeding stigmata 2.Decreased need for endoscopic hemostasis RCT by Lau etal. Efficacy to reduce all cause mortality not shown

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Pharma. Contd. Asian trials with adjuvant PPI: Reduction in all cause mortality irresepective of dose and route Magnitude of benefit is higher in Asia-Pacific- 1.Lower parietal cell mass 2.High prevalence of H.Pylori 3.Genetic polymorphism of cy 2 c 19 Slow metaboliser

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Endoscopic management: Varices in 1.30% with well-compensated cirrhosis 2.60% with decompensated cirrhosis Small varices-lower risk Increases from small to large @10-20%/yr. Variceal bleeding @10-20%/yr. @20-30%/yr with larger varices Bleeding varices responsible for 25% of deaths in cirrhosis

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Thearapeutic endoscopy: Goal:1.stop active bleeding 2.obliterate varices with repeated procedures Techniques: 1.Endoscopic sclerotherapy- Irritant:Na morrhuate,polidocanol,ethanolamine Dehydrant:Na tetradecyl sulfate Achieves hemostasis in 95% with variceal bleeding Drawbacks:1.3-6 sessions to obliterate 2.No role in portal hypertensive gastropathy 3.Rarely successful in emergent control of bleeding fro a large gastric varix 4.Complications-10-20%.Mortality-1-2% Esophageal ulcer.Stricture and dysmotility in 1.6-3%. Others:perforations(0.5%),systemic infections,pleural effusion, mediastinitis,portal and mesenteric vein thrombosis, ARDS. 5.May worsen portal hypertensive gastropathy and may increase size of gastric varices above level of obstuction

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Endoscopic variceal ligation(EVL): Promising and better alternative Similar to hemorrhoid banding Special ligating chamber attached to endoscope Elastic O rings applied over varices aspirated into ligating chamber Multi-band ligating devices available Endoloop ligation:only method to stop bleeding from vessel 3-5 mm in diameter Greater tissue compression Method of choice for junctional varices at cardia with thicker tissue

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EVL vs. ES vs. Endoloop: Compared to ES,EVL associated with:1.significant reduction in rebleed and mortality 2.Lesser sessions to obliterate 3.Fewer ulcers and other complications 4.Fatal complication-1% (c.f. ES 3.3%) Some studies:higher recurrence with EVL(48%) compared to ES(30%) EVL and endoloop-equally effective in hemostasis and reduction in recurrence Variceal eradication higher with endoloop Chance of damage to scope less with endoloop

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Alternative endoscopic approaches and the future: Gasatric varices now the focus of research One approach:N-butyl-2-cyanacrylate injection Cyanacrylate with simultaneous sclero- therapy-very promising Other recent advances:endoscopy to deploy detacha- clips and detachable snares in an attempt to entrap and throm- bose varix At present-EVL procedure of choice for esophageal variceal bleeding EVL may be difficult with large amount of blood and at initial endoscopy sclerotherapy may control bleeding more easily Sclerotherapy more useful near end of a cou- rse of EVL

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Endoscopic management of non-variceal bleed: Peptic ulcer-50-70% of all UGI bleeds Dieulafoy lesion-up to 5% Gastric antral vascular dysplasia(GAVE) Angiodysplasia Bleeding from peptic ulcer stops spontaneously in~80% Mortality-5-10% up to 50% with rebleed So clinical and endoscopic stratification into high and low risk groups

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Rockall numerical scoring system: 0 1 2 1.Age <60 60-79 >80 2.Shock absent tachycardia hypotension 3.Comor- bidity absent IHD/CHF/any hepatic or renal failure other comorbidity 4.Dx. no lesion or all other lesions malignancy SRH/MWT 5.Major none or dark blood,adherent SRH spot only clot,visible vessel, spurting vessel Score:<2-rebleed 4.3% and mortality 0% 3-5-14% and 4.6% >6-37% and 22%

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Modified Forrest criteria(risk stratification of PU): Type 1:actively bleeding 1a:spurting 1b:oozing Type 2:non-actively bleeding 2a:nonbleeding visible vessel 2b.ulcer with clot 2c.ulcer with red/dark blue spot Type3:clean base 2c and 3-no endotherapy rebleed-5-10% 1,2a and 2b-rebleed-40-55% endoscopic intervention advocated

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Endoscopic hemostasis: key tool for management of all high risk non-variceal bleeds 2 meta-analysis of 30 RCTs- significant reduction in rebleed, mortality,need for emergent surgery Role in adherent clot not yet established Techniques: Injection Thermal Mechanical 1.Adrenaline 1.Heater probe 1.Clips 2.Fibrin glue 2.Bicap probe 2.Banding 3.Human thrombin 3.Gold probe 3.Endoloop 4.Sclerosant 4.Argon plasma 4.Staples coagulation 5.Alcohol 5.Laser therapy 5.Sutures

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Thermal devices:generates heat 1.Directly-heater probe 2.indirectly by tissue absorption of light-laser 3.Passage of electric current through tissue-multipolar probes,Argon plasma coagulator Coventional gold probe-effective cheaper widely available Laser-effective,precise, expensive,limited portability Both-causes injury to adjacent as well as deeper tissue perforation-1.8-3% bleeding-~5% Complicatons related to:power setting duration of application distance of probe tip from tissue

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Argon plasma coagulation: Superficial tissue damage Penetration only 1-2mm Easier to use Cheaper than laser Spray coagulation:Encouraging and very cost effective results reported (Asian Institute of Gastroenter- ology,Hyderabad)

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Injection needles: Simple Cheapest Adrenaline(1/10000) safe and effective for active bleeding Rebleeding reduced by addition of thrombin or thrombin-fibrinogen mixture Sclerosant/alcohol sparingly used because of risk of rebleeding,ulcer, perforation

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Mechanical devices: Clips-effective 84-100% with PU,MWT,Dieulafoy,ectasia tumor,following polypectomy,sphincterectomy, biopsy Advantage-no tissue damage no impairment of healing safely and quickly applied with impro- ved applicators particularly suited for arterial bleeding and visible vessel Band/endoloop-small focal bleeders Newer suture devices being introduced-further experience needed

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Combined modality: Recent trend towards using two modalities eg. 1.injection+mechanical device 2.injection + thermal probe Injection + thermocoagulation-lesser rebleed demonstrated

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Consensus recommendation for endoscopic mnanage- ment of non-variceal UGI bleed: 1.Early endoscopy within 24 hrs with risk stratificartion by clinical and endoscopic criteria allows for prompt and safe discharge with low risk, improves outcome with high risk and ensures better resource utulisation. 2.Low risk endoscopic stigmata not an indication for endoscopic hemostasis. Clot in an ulcer bed warrants irrigation to dislodge and appropriate treatment of underlying lesion. 3.No single soution for endoscopic therapy is superior to another for hemeostasis. 4.Monotherapy is effective for high risk stigmata but combination is better. 5.Clips are very promising. 6.Routine second endosvopy not recommended. 7.With rebleed a second attempt at endotherapy is recommended.

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As it stands today- Optimal use of endoscopic modalities with pharma- cotherapy shall continue to play pivotal role in manage- ment of UGI bleed in years ahead. Thank you