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upper gastro-intestinal bleeding slide ppt
- 1. UGIB Gada L.(MD) ,internist,GI fellow, assistant professor of medicine ,SPHMMC Feb.2016
- 2. Objective • By theend of this session students will be able to: – Define UGIB – Evaluate patient with UGIB – List DDx/identify causes – Formulate basic diagnostic investigations – Manage common cause of UGB – Apply primary and secondary preventions of VB/PUD
- 3. 3 Topic Out line •Introduction: • Etiology/DDx of UGIB: • General management: • Specific management: • Summary:
- 4. 4 • Define upperGI bleeding:
- 5. 5 Definitions: • Upper GIBleeding = proximal to ligament of Treitz • Hematemesis = vomiting blood • Melena = passage of tarry or maroon stool – Can be upper(90%) or lower – Melena indicates blood has been present in the GI tract for at least 14 h, and as long as 3–5 days. • Hematochezia = Bright red blood per rectum – Usually characteristic of colonic hemorrhage,or can be upper(Severe UGIH).
- 6. 6 Introduction Upper gastrointestinalbleeding (UGIB)-bleeding from UGI proximal to the ligament of Treitz. • Incidence 100 cases per 100,000 population per year. • The incidence is twice as common in males as in women, and increased with age. • UGIB more common than LGIB.
- 7. 7 Introduction… • 80% selflimiting , 20% rebleed --usu.in 72 hrs. • Etiologies vary from place to place • PUD is the most common cause of UGI • Prognosis:depends on etiology and age/comorbidity o Mortality = 5-10 %(OVER ALL). o Ranges 1-30%
- 8. 8 UGIB… • What arethe common causes of UGIB?
- 9. 9 Most common causesof upper gastrointestinal bleeding : • Gastric and/or duodenal ulcers-PUD • Esophagogastric varices with or without portal hypertensive gastropathy • Esophagitis • Erosive gastritis/duodenitis • Mallory-Weiss syndrome • Angiodysplasia • Mass lesions (polyps/cancers) • Dieulafoy's lesion.
- 10. Cause of upperGI Bleeding 10
- 11. 11 UGIB… • What arethe uncommon causes of UGIB?
- 12. 12 Uncommon causes ofUGIB • Hemobilia= bleeding into bileduct and gallblader • Hemosuccus pancreaticus • Aortoenteric fistula • Upper GI tumors • Cameron lesion=ulcer from hiatal hernia
- 13. 13 UGIB… • HOW doyou diagnose UGIB?
- 14. 14 Diagnosis • Hx/PE • Lab.Profiles • Endoscopy • Imagings – Barium study-c/I-in active bleeding – Angiography • Wireless video capsule endoscopy-PillCam.
- 15. 15 UGIB…. • Outline Generalmanagement approach to a patient with UGIB:
- 16. 16 Management of UGIB •Urgent Hemodynamic evaluation and resuscitation: • Initial Management: – Assess severity: – Tachycardia suggests 10% volume loss – Orthostatic hypotension 20% loss, – Shock 30% loss
- 17. 17 Management -general • Managementof acute gastrointestinal bleeding: – Monitor the pulse and blood pressure half-hourly. – Establish intravenous access - central line if brisk bleed. – Take blood for haemoglobin, urea, electrolytes, grouping and cross matching (2 units initially). – Give blood transfusion/colloid if necessary. – Indications for blood transfusion are: • (a) SHOCK (pallor, cold nose, systolic PB below 100 mmHg, pulse > 100 b.p.m.) • (b) Haemoglobin < 10 g/dL in patients with recent or active bleeding. – Oxygen therapy for shocked patients. – Urgent endoscopy in shocked patients/liver disease. – Continue to monitor pulse and BP. – Re-endoscope for continued bleeding/hypovolaemia. – PPI? – Surgery if bleeding persists.
- 18. 18 Cont… • Resuscitation goals: •High risk pts-HCt/HGB-30/1o • Young and otherwise healthy patients should be transfused to maintain their hemoglobin above 7 gm/dL. • Patients with active bleeding and a coagulopathy ( INR >1.5) or low platelet count (<50,000/micr.L) should be transfused with fresh frozen plasma and platelets, respectively.
- 19. 19 Nasogastric tube/NGT • Toremove particulate matter, fresh blood, and clots to facilitate endoscopy and confirm an upper source of bleeding.
- 20. 20 Factors That affectmanagement/outcome: • Age • The amount of blood lost • Signs of chronic liver disease on examination • Evidence of co-morbidity: • Cardiac failure • Ischemic heart disease • Renal disease and malignant disease. • Shock
- 21. 21 ESOPHAGOGASTRIC VARICES • Esophagogastricvarices develop as a consequence of portal hypertension. • What are the causes of PHTN? – Pre hepatic – Hepatic – Post hepatic
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- 24. 24 EV… • A majorcomplication ofportal hypertension -cirrhosis – 10~30 % of UGIB – 25 ~ 35%of patientswith cirrhosis • Risk related to: • Variceal size, appearanc “Red color signs”, Childs class and location. • 1/3 of deaths from cirrhosis
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- 26. 26 Outcomes • Torrential bleeding ofvarix! • Acute Bleeding Episodes: < 48 hours – 50 % stop spontaneously – 1 episode → 30 % mortality – Death: aspiration, sepsis, coma, renal failure. • The risk of rebleeding is high (60 to 70 %) until gastroesophageal varices are obliterated. • High Risk Period: < 6 weeks – Rebleeding: 40 – 50 %-in the first 10 days.
- 27. 27 Management of EVB Active variceal hemorrhage accounts for about one-third of all deaths related to cirrhosis. • Four major issues related to the prevention and treatment of variceal hemorrhage: 1.Prediction of patients at risk 2.Prophylaxis against a first bleed 3.Treatment of an active bleed 4.Prevention of re-bleeding
- 28. 28 PREDICTIVE FACTORS — Clinicaland physiologic factors are useful in predicting the risk of variceal hemorrhage in patients with cirrhosis: • Location of varices • Size of varices: • Appearance of varices • Clinical features of the patient/Child class • Variceal pressure.
- 29. 29 Primary prophylaxis • Whatis primary prophylaxis? • How do you prevent VB(primary prophylaxis)?
- 30. 30 Primary prophylaxis • Goal: • To reduce portal pressure / intravaricealpressure. – Drugs that reduce portal venous flow or intrahepatic vascularresistance have been used. • Prophylactic propranolol or nadolol therapy is the only cost- effective therapy. • Endoscopic variceal ligation- beneficial for high-risk patients.
- 31. 31 Treatment of activebleeding: • There are three primary goals of management during the active bleeding episode: – Hemodynamic resuscitation – Prevention and treatment of complications; and – Treatment of bleeding.
- 32. 32 Criteria for ICUAdmission • Institution specific • In general: – Ongoing hemodynamic instability despite IV fluids. – Evidence of active bleeding: hematemesis, large volume bloody lavage, hematochezia – Significant comorbidities: ischemic liver, CAD – Advanced age
- 33. 33 Prophylactic antibiotic: • Bacterialinfections ; up to 20% of patients with cirrhosis, hospitalized with UGIB: – The most common sites are : • urinary tract infections (approximately 12 to 29 percent) • spontaneous bacterial peritonitis (7 to 23 percent) • respiratory infections (6 to 10 percent), and • primary bacteremia (4 to 11 percent). – Antibiotics may also reduce the risk of recurrent bleeding.
- 34. 34 Management of activebleeding… Vasopressin: Terlipressin -a synthetic vasopressin analogue with fewer side effects and a longer half-life than vasopressin and thus can be used in bolus form. SOMATOSTATIN AND ITS ANALOGS – Syntheticanalogues; octreotide and vapreotid.
- 35. 35 ENDOSCOPIC TREATMENT • Endoscopictherapy is currently the definitive treatment of choice for active variceal hemorrhage. • Two forms of endoscopic treatment are commonly used: –Sclerotherapy-best for active bleeding – variceal band ligation
- 36. 36 Prevention of rebleeding/recurrentbleeding • What is secondary prophylaxis? • How can you prevent recurrent VB?
- 37. 37 Prevention of recurrentbleeding • Over 70 percent of patients experience recurrent variceal hemorrhage within one year of their index bleed. • The risk of rebleeding is greatest immediately after cessation of active bleeding and then declines, reaching close to baseline values by six weeks. • Approximately 70 percent of all untreated patients die within the first year after their initial variceal bleed • Propranolol plus ligation..
- 38. 38 Cont… • AASLD GUIDELINES— • The approaches recommended by the guidelines (nonselective beta blockers, endoscopic variceal ligation, transjugular intrahepatic portosystemic shunts, and liver transplantation).
- 39. 39 UGIB -PUD GU/DU There are four major risk factors for bleeding peptic ulcers: – Helicobacter pylori infection – Nonsteroidal antiinflammatory drugs (NSAIDs) – Stress – Gastric acid. • The majority of patients with UGI bleeding due to peptic ulcer disease will stop bleeding spontaneously and most will not rebleed during hospitalization. • Reduction or elimination of these risk factors reduces ulcer recurrence and rebleeding rates.
- 40. 40 Summery • Causes ofUGIB • MX of VB • MX of PUD(discussed)
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- 42. 42 References • UpTodate • GUIDELINES –AASLD/EASLD
Editor's Notes
- #14 Upper GI barium studies are contraindicated in the setting of acute upper GI bleeding because they will interfere with subsequent endoscopy, angiography, or surgery
- #28 The risk of variceal bleeding correlates independently with the diameter (size) of the varix. The explanation for the relationship between variceal size and bleeding risk is derived from Laplace's law; small increases in the vessel radius result in a large increase in wall tension (which is the force tending to cause variceal rupture).
- #35 A number of sclerosant solutions are available and one has not been found to be superior to another. The volume and frequency of injections also vary widely. We use 1 to 2 mL of 5 percent sodium morrhuate per injection for a total of 12 to 20 mL per session.