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Upper GI Bleed James Peerless April 2011. Introduction Incidence of 100/100 000 population per year (UK & USA) >80% occur as acute admissions ‘Hospital-acquired’

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Presentation on theme: "Upper GI Bleed James Peerless April 2011. Introduction Incidence of 100/100 000 population per year (UK & USA) >80% occur as acute admissions ‘Hospital-acquired’"— Presentation transcript:

1 Upper GI Bleed James Peerless April 2011

2 Introduction Incidence of 100/ population per year (UK & USA) >80% occur as acute admissions ‘Hospital-acquired’ – Critically ill patients – Prolonged NG tube – Drug Rx Associated with high rate of mortality and long ICU stay Incidence of 100/ population per year (UK & USA) >80% occur as acute admissions ‘Hospital-acquired’ – Critically ill patients – Prolonged NG tube – Drug Rx Associated with high rate of mortality and long ICU stay

3 Objectives Definitions Anatomy Sources of Bleeding Presentation Assessment Management Definitions Anatomy Sources of Bleeding Presentation Assessment Management

4 Definitions Upper GI Tract The oral cavity, pharynx, oesophagus, stomach & proximal duodenum Upper GI Tract The oral cavity, pharynx, oesophagus, stomach & proximal duodenum Haematemesis The act of vomitting blood; swallowed or that arisen from the bleeding within the upper GI tract Haematemesis The act of vomitting blood; swallowed or that arisen from the bleeding within the upper GI tract Melaena Black discoloured faeces due to the presence of partly-digested blood from the upper GI tract Melaena Black discoloured faeces due to the presence of partly-digested blood from the upper GI tract

5 Anatomy Hepatic a. Left gastric a. Right gastric a. Left gastro- epiploic a. Right gastro- epiploic a. Splenic a. Coeliac trunk

6 Azygous v. L + R gastric vv. Portal v.

7 Causes Upper GI Bleed GUDUCa Oe Varices M-W Tear Oeso- phagitis Gastri- tis

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9 Varices Secondary to portal hypertension Dilated collateral veins formed at G-Oe junction These portosystemic anastomoses are superficial and prone to rupture High pressure veins in a hyperdynamic circulation Secondary to portal hypertension Dilated collateral veins formed at G-Oe junction These portosystemic anastomoses are superficial and prone to rupture High pressure veins in a hyperdynamic circulation

10 Presentation Active bleeding History of haematemesis Melaena Shock/hypotension/collapse Anaemia Active bleeding History of haematemesis Melaena Shock/hypotension/collapse Anaemia

11 Acute Management Supportive Resuscitation – A B C History & Examination Recruit help Investigations Continuous monitoring Blood products Correction of coagulopathy Corrective Medical Balloon tamponade Endoscopy Surgical

12 Assessment Acute Assessment History & Examination Is the airway safe? Is the patient at risk of further events?

13 Identifying Risk Rockall Score

14 Rockall Criteria Predictors of Mortality Age Co- morbidity DiagnosisSRHRe-bleed

15 Rockall Score 0123 Age< >80 ShockNo shockHR >100HR >100, SBP <100 ComorbidityCardiac failure, ischaemic heart disease Renal failure, liver failure, disseminated malignancy DiagnosisMallory Weiss, no lesion, no stigmata of recent haemorrhage All other diagnoses Malignancy of upper gastrointestinal tract SRH (Endoscopy) None, or dark spot Fresh blood, adherent clot, visible or spurting vessel

16 Mortality Rates Total (%) Re-bleed (%) Death (non re- bleed) (%) Death (re- bleed) (%) Death (total) (%) Rockall TA, Logan RF, Devlin HB, Northfield TC (1996) Risk assessment after acute upper gastrointestinal haemorrhage. Gut 38:316 – 21

17 Scoring Systems Rockall Score Forrest Classification – Active haemorrhage – Signs of recent haemorrhage – Lesions without active bleeding Glasgow-Blatchford Score – Scored on Hb, urea, BP, presentation/comorbidities (no endoscopy) Rockall Score Forrest Classification – Active haemorrhage – Signs of recent haemorrhage – Lesions without active bleeding Glasgow-Blatchford Score – Scored on Hb, urea, BP, presentation/comorbidities (no endoscopy)

18 Management Pathway Resuscitation No: Endoscopy <24h Conservative Management Yes: Endoscopy <4h Endoscopy Suspicion of Variceal Bleeding?

19 Oesophagogastroduodenoscopy Offers diagnostic information and opportunity for therapeutic intervention Scoping within 24 hours has a proven reduction in rebleed, mortality and length of admission For ulcers: – Adrenaline injection (temporary efect) – Diathermy/haemocoagulation – Endocscopic clips Offers diagnostic information and opportunity for therapeutic intervention Scoping within 24 hours has a proven reduction in rebleed, mortality and length of admission For ulcers: – Adrenaline injection (temporary efect) – Diathermy/haemocoagulation – Endocscopic clips

20 Variceal Bleeding Endoscopy is the definitive treatment of choice for variceal bleed

21 Drugs & Secondary M X Drugs Vasopressin/somatostatin Anti- biotics PPI Vitamin K

22 Sengstaken-Blakemore Tube

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24 Linton-Nachlas Tube

25 TIPSS Transjugular Intrahepatic Portosystemic Shunt Radiologically guided stent – Drilled through the liver and connects the portal and hepatic vein Available in specialised units Complications – Thrombosis (10%) – Bleeding – Infarction Transjugular Intrahepatic Portosystemic Shunt Radiologically guided stent – Drilled through the liver and connects the portal and hepatic vein Available in specialised units Complications – Thrombosis (10%) – Bleeding – Infarction

26 Summary Hidden clinical picture Supportive and Corrective Management Endoscopic therapy mainstay of treatment Risk of rebleeding remains high – keep monitoring the patient!

27 The End


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