Presentation on theme: "DDx, Manangement, Treatment"— Presentation transcript:
1DDx, Manangement, Treatment Upper GI BleedingDDx, Manangement, Treatment
2IntroductionDefinition: bleeding originating proximal to the ligament of Treitz (suspensory muscle of duodenum)Incidence: 47 per 100,000bleeding stops spontaneously in 75% of casesMore common in males and the elderly
3Emergency Care Look for signs of shock massive digestive hemorrhage pallor, prostration, perspiration, pulselessness and pulmonary insufficiencyPrevent aspiration of bloodProvide definitive airway managementStabilize the circulatory dynamic stateintravenous injection of extracellular fluidAdminister oxygenInstitute cardiac monitoring.Give gastric acid secretion inhibitorsgastric acid inhibits blood coagulationReplace volume with crystalloids.
4Transfusion If coagulopathy is present, transfusion is necessary. Transfusions should be based on the clinical findings of volume depletion or continued bleeding rather than initial hematocrit values.General guidelines for initiation of blood transfusioncontinued active bleedingfailure to improve perfusion and vital signs after the infusion of 2 L of crystalloid.The threshold for blood transfusion should be lower in the elderly. Coagulation factors should be replaced, as needed.When the circulatory dynamic state is stable and UGIH has been judged as cause of shock, urgent endoscopy is performed.
5Medical HistoryHx of GI bleeding, esophageal varices, alcohol use, medications recent weight loss, change in stools, abdo pain, abdo aneurysm repair, liver disease, or abdo surgery.Vomiting/retching suggestss Mallory–Weiss tearsHx of hemorrhoids, anal fissures, or rectal traumaIn AIDS/ immunocompromised patients, bleeding may be related to Kaposi sarcoma, lymphoma, or cytomegalovirus ulcerations.
6Physical Examinations Vital signs: hypotension, tachycardia, decreased pulse pressure or tachypnea.Spider angiomata, palmar erythema, jaundice, and gynecomastia suggest liver disease.Petechiae and purpura suggest an underlying coagulopathy.Skin findings may be suggestive of the Peutz-Jeghers, Rendu- Osler-Weber, or Gardner syndromes.An ENT examination can reveal an occult bleeding source that has resulted in swallowed blood and subsequent coffee-ground emesis or melena.The abdominal examination may disclose tenderness, masses, ascites, or organomegaly.A rectal examination is indicated to detect the presence of blood and its appearance (bright red, maroon, or melanotic).
7Diagnostic StudiesEndoscopy: gold standard tool for Dx of UGI bleedingLocates source of bleed 75-95% of timeIf actively bleeding, performed ASAPIf not, and patient is stable, performed within 24 hrsAngiography:1% of patients with upper GI bleedingmay be useful if endoscopy cannot identify a bleeding source even when active bleeding is suspectedExploratory laparoscopy:a group of operations that are performed with the aid of a camera placed in the abdomen
8Treatment Endoscopic hemostasis Mechanical Hemoclip, balloon tamponade, ligationPhysically stops the bleedingInjectionEthanol, epinephrine, monoethanolamine oleateInduces: thrombosis, vasoconstriction, vascular tamponade, sclerosisThermocoagulationAPC, laser, hemostatic forceps, microwavesTriggers blood coagulation upon contactHemostyptic spray/Tissue adhesivesThrombin, fibrin glue, sodium alginatePhysically stops bleeding by formation of a solid plastic cast
9Laboratory Tests Type and cross-match blood. FBC, BUN, creatinine, electrolyte, glucose, coagulation, and liver function studies should be consideredElevated BUN levels due to digestion and absorption of hemoglobin, and a BUN:creatinine ratio 30 is suggestive of a UGI source of bleeding.Coagulation studies: INR, PTT, and platelet count
10Monitoring for Rebleeding Gastric lavage:Via nasograstic (GN) tubeReassess with using intermittent low continuous suctionContinued bleeding or rebleeding emergent endoscopyStool:Record frequency, color, and approximate amount of stoolContinued passage of bright red, maroon, or melenic stools further studies or transfusionHemoglobin/Hematocrit:Check every 4 hours
14Peptic Ulcer Disease (PUD) Clinical Findings: epigastric to LU quadrant burning pain, pain can be made worse/better with food depending on location of ulcerTreatment:PPIsSomatostatin: peptide reduce splanchnic blood flow, GI motility, inhibit acid secretion, etc.Disposition:Admit patients with: active bleeding, tachycardia, hypotension, anaemia, >65 yo, significant comorbid disease.Otherwise, a follow up with gastroenterologist and discharged
15Gastritis Definition: inflammation of the lining of the stomach Clinical Findings: Although gastritis is asymptomatic in many cases, patients may experience anorexia, nausea, dyspepsia, pain, and immediate postprandial emesis.Gastritis rarely results in massive bleeding by itself, but it can occur in the presence of portal hypertension and coagulopathies.Treatment: Continue nasogastric lavage until brisk bleeding has resolved.For nonbleeding, clinically suspected gastritis, a trial of an antacid with viscous lidocaine ("GI cocktail") may provide quick relief.Consider prescribing a proton-pump inhibitor or any of the many over-the-counter histamine H2 antagonists.
16Esophageal Varices Cause underlying liver disease and portal hypertension are at increased risk for esophageal or gastric variceal bleeding. 40% develop this symptomMortality 30-50%Alcohol-induced and viral cirrhosis most common in USAParasite most common in developing countriesClinical: cannot be clinically diagnosed on the basis of signs and symptoms alone.approximately 50% of patients with known varices who present with GI bleeding, the bleeding is from a source other than the varices. Endoscopic verification is mandatory for accurate diagnosis and treatment.
17Treatment Medical Therapy Endoscopic Therapy Sclerotherapy evacuation of gastric contents including blood.octreotide has been proven effective in controlling bleeding. Octreotide decreases splanchnic and hepatic blood flow as well as transhepatic and variceal pressures.Endoscopic TherapyEndoscopic variceal ligation (EVL)- banding of blood vesselsRepeated every 2 weeks until variceals are gone (2-4 sessions)Sclerotherapyinvolves the injection of various sclerosing agents to promote thrombus formation. Band ligation uses endoscopically placed rubber bands, which block blood flow and promote thrombus formation. Both therapies work well in over 90% of patients, but band ligation is associated with fewer complications.Balloon TamponadeIn rare circumstances it may be necessary to insert the Sengstaken–Blakemore tube to tamponade uncontrolled hemorrhage prior to endoscopic confirmation.It compress swollen blood vessels called
19Mallory-Weis Syndrome Definition: Tears in the esophageal mucosa and submucosa that usually occur after forceful retching and vomiting. Bleed stops spontaneously.3% mortalityClinical Findings: retching, vomitingthis disorder has been reported following chest compressions, coughing, sneezing, or even straining with bowel movement.Many cases have no discernible predisposing factor.Treatment: Provide emergency management.Nasogastric lavage until clear. For persistent bleeding, consult with an endoscopist for emergent EGDA proton-pump inhibitor may be used to reduce acid or bile that may impair healing of the mucosal tear.Treating precipitating factors such as antiemetics for nausea and vomiting.most patients stop bleeding spontaneously with healing of the mucosal tear in 48–72 hours.
20Other Causes Stress ulcer arteriovenous malformation malignancy Ear, nose, and throat sources of bleeding can also masquerade as GI hemorrhage.