UPPER GASTROINTESTINAL BLEEDING - PowerPoint Presentation

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UPPER GASTROINTESTINAL BLEEDINGWhat Undergraduates should know ?

Prof SM

Chandramohan

Prof and HOD

Department of Surgical Gastroenterology and

Center of Excellence for Upper GI Surgery

Madras Medical College and

Rajiv Gandhi Government General Hospital

Chennai

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Can download this presentation from

www.esoindia.org

Prof SM

Chandramohan

Prof and HOD

Department of Surgical Gastroenterology and

Center of Excellence for Upper GI Surgery

Madras Medical College and

Rajiv Gandhi Government General Hospital

Chennai

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DEFINITION

CAUSES

EVALUATION

TREATMENT

PLAN OF THE TALK

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DEFINITION

CAUSES

EVALUATION

TREATMENT

PLAN OF THE TALK

MEDICAL

ENDOSCOPIC

SURGICAL

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DEFINITION

Any bleeding from

The gastrointestinalTract above the

Level of

ligament of

Treitz

is upper GI Bleeding

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DEFINITIONS

Acute

GI bleed< 3 days durationhemodynamic instability

requires blood transfusion

Overt vs. occult

overt = visible blood (melena, bright red blood, coffee grounds)

occult = only detected by lab tests

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COMMON CAUSES OF UGI BLEED

CAUSE

%

Peptic Ulcer

38%

Varix

16%

Tumor

7%

MW

Tear

4%

Erosions

4%

Esophagitis

13%

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NSAID

(1)

the risk of gastric ulceration is increased to a greater extent than that of duodenal ulceration

(2) the risk of bleeding varies with the individual NSAID; for example, the relative risk of bleeding is greatest with

piroxicam

and less with ibuprofen

(3) the risk of bleeding is dose dependent

-age greater than 75 years,

-history of heart disease,

-history of peptic ulcer

- history of previous gastrointestinal bleeding

RISK FACTORS

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AIRWAY

BREATHING

CIRCULATION

A

B

C

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Examination

Tell tale signs…

Chronic Liver DiseasePortal Hypertension

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ExaminationNot to miss……..

Haemodynamic

stabilitySigns of coagulation dysfunctionSigns of Liver cell failurePR

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Bleeding PR

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As he comes………….Resuscitate and Examine

Simultaneously…….

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Form a team……….Wide bore IV line……

preferably central line

(take samples at the same time)Naso gastric tubeUrinary CatheterALERT OTHERS IN TEAM…….

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Blood Sample for

Blood Group

Haemogram including plateletsCoagulation profileLiver function testRenal functionMarkers

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Blood Sample

TRY NOT TO TAKE SAMPLES

FREQUENTLYExcept for serial evaluation

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WHICH TUBE AND WHY?

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Naso Gastric Tube orSenstaken

tube?

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ROLE OF NASOGASTRIC TUBE

10 % of UGIB presents as LGIB

Red

blood

vs

c

offee grounds

NGT

clears the gastric field for endoscopic

visualization

prevent

aspiration of gastric content

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EndoscopyWhen to do?

What is Possible?

When not to do???

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EndoscopyOne stop Shop

Diagnose

AssessTreatReassess

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ENDOSCOPIC EVALUATION

If Hemodynamically stable

Identify Bleeding site

Delineate cause

Allow endotherapy

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ENDOSCOPIC MANAGEMENT

VARICEAL

NONVARICEAL

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ENDOSCOPIC VARICEAL LIGATIONA rubber band is placed over the varix which

then undergoes thrombosis,sloughing,fibrosis.

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ENDOSCOPIC SCLEROTHERAPY

Involves injecting a

sclerosant

Intravariceal

/

perivariceal

Common

sclerosants

Ethanolamine oleateAbsolute alcoholSodium morrhuate

Sodium

tetradecylHypertonic saline

Polidocanol

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GLUE THERAPY

Cyanoacrylate

is a glue that is injected intoGastric varicesActs by forming a Cast over the varix on contact

with blood

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Endoclip

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DEFINITIVE MANAGEMENT OF NON VARICEAL BLEED

HIGH RISK

ULCER

FOR

BLEED

SRH/LARGE ULCER >2 cm

ULCERS IN

POSTERIOR WALL

BULB-GDA

ULCERS IN THE HIGH LESSER CURVE - LGA

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Endoscopic Management

Non-Variceal - Modalities

Injection Therapy

(a) Adrenaline

(b) Sclerosants

Thermal Therapy

(a) Monopolar

(b) Bicap

(c) Heater Probe

(d) Argon Plasma Coagulation

(e) Laser

Mechanical Therapy

(a) Haemoclips

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Endoscopic Management

Bleeding Peptic Ulcer - Stigmata

1a – Spurting vessel

1b – Oozing from a vessel

2 – Clot in the ulcer base

3 – Ulcer without bleed

Forrest

Classification

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SECOND LOOK ENDOSCOPY

It is repeat endoscopy 24 hours after initial

Endoscopic hemostasis

INDICATIONS

1 Incomplete first endoscopic examination due

to blood obscuring the field

2 Patients with clinically significant

rebleeding

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WHEN TO CALL IT AS

FAILED ENDOTHERAPY?

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SURGICAL MANAGEMENT OF UGI BLEEDING

The Need

Only in Select Situations

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Role of Surgery

5-10% of UGI Bleed Mortality

3% to

14

%

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TV Vs H.PYLORI Eradication

40% to 70% of patients with a bleeding duodenal ulcers- positive for

H. pylori

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Bleeding Gastric Ulcer

Simple excision alone -

rebleed in 20% of patients10% incidence of malignancy

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Surgical options- Variceal bleeding

Shunt

Or Devascularisation

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Less Common Causes of UGIB

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MALLORY WEISS TEARS

Managed with

1 Hemoclips2 MPEC Probes

3 PPI

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Mallory-Weiss TearsAngiographic embolization – in cases of failed endoscopic therapy

High gastrotomy and suturing of the mucosal tear – failure of all methodes

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DIEULAFOY’S LESION

large

submucosal artery that protrudes through mucosa

at the gastric

fundus

.

bleeding can

be massive

Endoscopic Doppler USG can

help

localizeEndoscopic

hemostasis

-injection therapy , Thermal probe, clips.

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Dieulafouy’s lesion

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DIEULAFOY'S LESIONFailed endoscopic therapy - angiographic coil embolization

Surgical intervention - prior endoscopic tattooing

Gastrotomy - bleeding source can be oversewn Partial gastrectomy - the bleeding point not identified

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GASTRIC ANTRAL VASCULAR ECTASIA-GAVE

rows

of

ectatic

mucosalVessels

(WATERMELON

STOMACH)

most

patients present with persistent, iron deficiency anemia from continued occult blood loss.

It is managed with1 APC-argon Plasma coagulation2 MPECMultiple sessions may be needed to eradicate

the lesions.

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PP

PRE APC

PP

POST APC

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Gastric Antral Vascular Ectasia

Endoscopic therapy - successful in up to 90% of patients

Failure of endoscopic therapy - antrectomy

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SEVERE PORTAL HYPERTENSIVEGASTROPATHY

May present with acute or

chronic bleed.

No role for endoscopic

management.

Managed with B Blockers, TIPS,

Surgical Porto

Caval

shunt,

Liver transplantation.

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HEMOBILIA

The diagnosis can be confirmed

By Side viewing ScopyOngoing or Recurrent bleed isTreated with

angioembolization

CAUSES-HEMOBILIA

Liver

trauma

Liver biopsy

ERCP/PTC/TIPS

HCC,

CHOLANGIOCARCINOMABiliary parasite infestations

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HEMOSUCCUS PANCREATICUS

The diagnosis can be made

by Side viewing scopyManagement is by angioembolization

CAUSES-HEMOSUCCUS PANCREATICUS

Acute pancreatitis/chronic pancreatitis

Pancreatic pseudocyst

Pancreatic cancer

ERCP manipulation of PD

Rupture of

splenic

artery pseudoaneurysm into PD

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ANGIOEMBOLIZATION

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STRESS GASTRITISSurgery - rarely indicated

Vagotomy and pyloroplasty, with oversewing of the hemorrhage, or near-total gastrectomy - mortality rates as high as 60%

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MalignancyEndoscopic therapy - successful in controlling hemorrhage, the rebleeding rate is high

Standard cancer operations - indicated when possible

Palliative wedge resections – to control bleed

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Aortoenteric Fistula

Ligation of the aorta proximal to the graft

Removal of the infected prosthesisExtra-anatomic bypassDefect in the duodenum - small and can be repaired primarilyTypically, patients with bleeding from an aortoenteric fistula will present first with a “sentinel bleed.”

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MORTALITY

7% to 10%.

The mortality has decreased only minimally during the last 30 years, despite the introduction of endoscopic therapy that reduces the rate of

rebleeding

.

increasing percentage of UGIB occurring in the elderly

frequent use of antiplatelet medications or anticoagulants

frequent comorbid conditions.

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Conclusion