2 GI bleeding Never forget the general principle of internal medicine. Airway, Breathing, CirculationStabilize vital sign and aggressive resuscitation.Well explanation to the family.Acquire thorough history and past medical history.Differential diagnosis of GI bleedingUGI & LGIMake the diagnosis by yourself!Arrange adequate diagnostic procedure.Emperical treatment
3 一旦懷疑,利用vital sign評估出血量最重耍 (occult bleeding or overt bleeding) 消化道出血的間接症狀: dizziness , fainting, tachycardia, cold sweating, shock, abdominal fullness, poor appetite, cons. change一旦懷疑,利用vital sign評估出血量最重耍 (occult bleeding or overt bleeding)Orthostatic hemodynamic change – 10 to 20% blood lossDrop in systolic pressure > 10 mmHg, raise in pulse rate >15/minSupine hypotension – greater than 20% blood loss定位 UGI or LGI 同時評估 medical treatment or surgical treatmentGI bleeding vs Non-GI bleeding: 吐血 vs. 咳血 vs. internal bleeding
4 Study in GI bleeding Digital exam for collect stool NG aspiration for DDx UGI and LGIPES: Panendoscopy or EGD( esophago-gastro-duodenoscopy): should be perform early in the clinical course after vital sign stable or management.Colonoscopy/ rigid sigmoidscopyRBC scan: only in Taipei MMH: >0.1cc/min or 6 cc/hourAngiography: >0.5cc/min or 30 cc/hourEnteroscopy or capsule endoscopySurgery
5 Why the GI bleeding patient need NPO Not every GI bleeding patient should NPOPrepare for emergency study or managementAvoid aspiration
6 GI bleeding 處理原則 Again and again : Check vital sign Evaluate NPO or notIf NPO, IVF supplyArrange laboratory studyCBC, PT, PTT, Blood group and cross match, liver and renal function.Blood product : Whole blood vs. pack RBC, FFP vs. FP, 代用血漿(ex.6HES)MedicationHow to arrange the study: NG irrigation, Blood sampling, PES, Angiography, Colonofiberscope, RBC scan
7 Vital sign for GI bleeding Orthostatic hypotension: drop SBP over 10 mmHg, rise in pulse rate over 15 beat/min: blood loose 10-20%Supine hypotension: more than 20%Shock index: SBP/HR<1 which hint blood loose over 25%If the patient got Inderal using, the tachycardia may be disappear ( pacemaker also cover the risk sign)
8 IVF supply in GI bleeding Large-bore IV line ( gauge catheter) is better than central line. Isotonic solution (NS), LR can be initiated plus plasma expander ( ex 5% hetastarch or 6 HES)The IVF amount is dependent on: hemodynamic condition, other CV/renal condition, ageThe IVF content is dependent on: underline disease ( DM, LC, Uremia, CHF…)Some drug add in the IVF( KCL, HRI, st-B..) or the IVF is for therapy (PPI or H2RA for PUD; pitression/glypression, sandostadin in EV/GV)
9 Blood product using in UGI bleeding When transfusion is indicated: bleeding is massive, ongoing, or severe enough that colloid infusion alone is not adequate for tissue oxygenation. ( keep Ht over 25-30%)The unit is different in Taiwan( 1 unit is about 250cc but not 500cc)Whole blood is better than pack RBC if the patient got no risk for fluid overload ( ex. CHF, uremia..)Keep platelet over 50000, and correct the PT with vit K, PTT with FFP(also for massive transfusion)Add Bena/Decadron in allergy patient and Lasix avoid fluid overload, Sincal after massive transfusion
11 UGI bleedingDifferential diagnosis of Variceal and Non-variceal bleedingHistory of liver cirrhosis with/without variceal bleedingMassive hematemesisSigns of liver cirrhosis – Spider nevi, Gynecomastia, Splenomegaly, Ascites, JaundiceLab data suggest liver cirrhosis – Hypoalbuminemia, PT prolonged, Mild impaired liver function (GOT>GPT) with hyperbilirubinemia,History of alcohol abuse.
12 Treatment of variceal bleeding The most important of all:STABILIZED THE VITAL SIGN.WELL EXPLAIN TO THE FAMILY – on critical, 1/3 mortality in each episode.Pharmacological treatment:Glypressin (Terlipressin) : 1 amp iv stat and q6h.Sandostadin: 2 amp iv drip stat and 12 amp in 500 c.c. D5W run 24 hoursPitressin: 20 amp in 480 c.c. D5W or NS (conc. 0.8IU/ml), run 12 cc/hr to 54 cc/hr (0.2IU/min to 0.9IU/min), side-effect: chest pain, peripheral cyanosis– combine nitrate--- Seldom used in recently years
13 Treatment of variceal bleeding Endoscopic treatment – highly operator dependent, high failure rate in acute bleeding, once the procedure succeeded, the outcome is good.Esophageal varices: band ligationGastric varices: Scleosing therapySB tube – trachea intubation first, the effect is not good.
24 Diagnosis of PUD Esophagogastroduodenalscopy (EGD) Gastric ulcer and duodenal ulcerDescription of PUD in EGDStage : A1, A2, H1, H2, ScarSize : the risk of recurrent bleeding increased if greater than 2 cmLocation : antrum, body, fundus, anterior wall, posterior wall, great curvature side, lesser curvatyre sideSRH (Stigmata of recent hemorrhage)Gastritis and Erosion.
28 Risky sign in the PES description of UGI bleeding Varix: RCS ( red color sign) which hint bleeding: red-whale marking, cherry-red spot, active bleeding; Cb>Cw,F3>2>1Ulcer: A1-2(active), H1-2(healing) and S1-2(scaring); active bleeding vs SRH (stigmata of recent bleeding)Bleeding with unknown cause
29 Medication/Management in UGI bleeding: PUD PPI ( losec/nexium, takepron, pariet,) : losec 1Amp + NS cc drip over 10 min st and q12h; the 1# qdH2RA (zantac , tazac, famox): Zantac 3 Amp + 500cc IVF run 20cc/hr ; then 1# bidSukit/gelfos 1pk q1h x4-6 timesSucrate gel 1Pk bid or ulsanic 1# qid (avoid using with antiacid, H2RA or PPI)Therapeutic endoscopy with bosmin injection, heat probe, hemoclip, laser..Sometimes, surgical intervention still indicated
31 Medication/Management in UGI bleeding: Surgical intervention in PUD or other Dx Hypovolemic shock can not control by medical treatmentMassive transfusion over 4-6U/8U(2000cc) in 24 hours or over 10U( cc) overallRecurrent or intractable bleeding after non-surgical treatmentRisk factor for OP: over 60y/o, transfusion over 5 unit, shock, hematemesis with hypotension, coagulopathy, large ulcer over 2 cm, emergency Op, co morbid illness, rebleeding within 72 hours
32 處理較特殊之處 一般內科病患需在最短時間內判斷病況是否危急(critical);但面對腸胃科病患時,必須同時找出有緊急手術適應症的患者 判斷是否有緊急檢查的適應症某些特殊的狀況(ex. Severe pancreatitis, hepatic failure, hypovolemic shock..)處置必須移入ICU處理( ex. SB tube, plasmaphrosis)檢查前的預備工作Call GI CR for emergent endoscopy!各護理站皆有on call CR 的電話, 若找不到CR, 直接找VS, 切勿猶豫
33 Low GI bleedingHemorrhoid, anal fistula, angiodysplasia, radiation proctitis/colitis, aortoenteric fistula, tumorUrgent colonoscopy : difficult due to poor preparationConsult Proctologist for the surgical interventionFortunately, most common LGI bleeding may stopped spontaneously.
41 Nausea and vomiting(1)Bowel obstruction or pregnancy must exclude first. Besides, extra-abdominal problem ( IICP, metabolic problem..)also need exclude.The vomitus also help for identified the obstruction level by colorNG decompression amount is another key for evaluate the degree for obstruction
42 Nausea and vomiting (2)Novamin( proclorperazine): ADR- drowsiness, acute dystonic reaction, EPS, postural hypotension..Dopamine antagonist - primperan (metoclopramide- EPS is notorious ADR) and motilium (domperidone). Cisparide is not approve in FDA nowOndansteron (zofran) and Granisetron ( kytril) are 5HT3 (serotonin) receptor inhibitor for C/T
43 Diarrhea(1)The definition of diarrhea include the BM increase over 3 times per day and the amount increaseAcute diarrhea vs chronic diarrhea : 2 weekNPO is the first step in DDx the secretary and osmotic diarrhea (but IVF supply also indicated after NPO especially in DM patient)Stool study : stool OB, pus cell and culture when infectious diarrhea is suspected esp. in bacterial infection). PMC need special agar for culture. Ameba and parasite ova in chronic diarrhea also need considered.
44 Diarrhea (2)Drug may be the most common cause of diarrhea in hospital( senokot, MgO, antacids, digitalis, quinidine, colchicine, antibiotic..)PMC( pseudomembranous colitis)must be carefully monitor when antibiotic usingParasite still need consider esp. in MMH Taitung branch.Most AGE is caused by virus and self-limiting.Diarrhea in cancer patients post radiotherapy is dangerous.
45 Diarrhea (3) Review the drug sheet Evaluate the risky sign: BM over 6 times, bloody stool or tenesmus, fever, severe abd pain, dehydrationHydration by enteral feeding if possibleSymptomatic treatment with : Kaopetin cc/ Tannalbin for loose stool, Anti-muscarinics ( buscopan-scopolamine, trancolon-mepenzolate, bentyl-dicyclomine, esperan-oxapium), Smooth muscle relaxant ( Spasmonal-alverine, Cospanon-Flopropione, Duspatalin-Mebeverine)Imodium 2# stCodeine and MorphineAntibiotic in Infectious diarrhea after stool culture and study: FQ and sulfa drug
46 PMC or AAC Pseudomenbranous colitis or antibiotic-associated colitis C. difficle is not the only causeCleocin is most notorious drug. PCN and Cepha got most patient!Dx: scope , toxin, culture( in anaerobic condition)Tx: stop antibiotic, symptomatic control, oral antibiotic ( metronidazole, vancomycine), IV antibiotic may be the last choice. Inferon Berna enema…
47 Constipation(1)Medication also the main cause of constipation ( Calcium channel blocker, opiates, anticholinergic, iron, barium sulfate)Besides, old age and several disease (DM, hypothyroidism, scleroderma, myotonic dystrophy..) patient also got constipation tendencyIntestinal obstruction must exclude first
49 TPN Indication: 不能吃,不想吃,吃不下 Time: not over 7 days NPO How to order: gradually increase the dose and concentrationHow to calculate the water amountHow to calculate the calori demandHow to calculate the protein demandHow to calculate the fat supplyHow to supply the trace element, Vit…
50 TPN(2) Complication of TPN Mechanical problem: caused by CVP insertion Chemical problem: BS, electrolyte balance..Infection problemOther problem: GB stasis and stone, LFT impairment, drug interaction
52 Hepatic failure How to identified the hepatic failure? PT is more important than AST/ALTBilirubin also very important parameterHypoglycemia and hypocholesterol also risky signCons. Level must evaluate carefully and closelyThe NH3 level is not parallel to cons. LevelVery high mortality if no chance for liver transplantThe Child-Turcott-Pugh score ( A: , A: slightly, Bil: 2-3, Encephalopathy 1-2, PT 4-6) – A: 5,6 ; B: 7-9 ; C: 10-15
53 Hepatic encephalopaghy ( HE) Correct the precipitating factor: azotemia, tranquilizer, opioid, sedative-hyponotic, GI bleeding, hypokalemia, alkalosis, constipation, infection, diarrhea, porto-systemic shuntMedication : lactulose po and enema; Neomycine po and enema, Metronidazole po, BCAA chain supply (aminopoly-H)The possibility of intra-cranial lesion must exclude ( ex. ICH, SDH, brain tumor)
54 Hepato-pulmonary sndrome Intra-pulmonary shunt increaseHypoxiaProve by angiography or contrast heart echo.
55 Hepato-renal syndrome Similar to pre-renal azotemiaDifficult in DDxCheck Urine NaAlso caused by peripherial arteriol dilatationAcute vs. ChronicThe kidney is normal !!
56 Portal HTN PE: caput medusa, hemorrhoid… Normal portal presssure: 7 mmHg ( about 10 cm H2O)Portal HTN: over 10 mmHg ( got S/S if over mmHg)EV or GV bleeding (dependent on which collateral circulation)
57 Ascites and SBPAldactone is the first choice for diuretic in LC related ascitesAny LC patient with fever, abdominal pain need screen the SBPNeutrophile over 250/ulE coli, KP and Strep pneumoniaeEmpiric antibiotic: 3rd cephalosporine or 1st + aminoglycoside ( risk for renal toxicity)Norfloxcin 400 mg qd can reduce the recurrence for SBP
58 Coagulopathy PT prolong Thrombocytopenia PTT prolong if the condition worsen or complication
59 Pancreatitis Lab data can not complete exclude or include all cases CT is most sensitive diagnosis tool in severe pancreatitisHydration is the key point for treatmentBiliary pancreatitis is more common in Taiwan and female patient.Alc related pancreatitis is most common cause in USA and increase in TaiwanHypertriglycemia vs. DM vs. pancreatitis
60 Pancreatitis (2) Biliary pancreatitis need drainage ASAP Ranson criteria and APACHE II: if Ranson over 3 point or APACHE over 5, the patient got severe pancreatitisIdentified the severe vs mild pancreatitis: clinical course (CV, chest, GI, nephro complication), scoring system, CT staging
61 Ranson criteria On admission: Alcoholic (Non-alcoholic) WBC: >16000 (18000)Blood sugar: >200 (220)LDH: >350 (400)AST: >250 (440)Age: >55 (70)During the first 48 hours of admissionFall in hematocrit: >10% (10%)Serum calcium: <8 mg/dl (8 mg/dl)Base deficit: >4 mEq/L (5 mEg/L)Increase in BUN: >5 mg/dl (2 mg/dl)Fluid sequestration: >6L (6L)Arterial PO2: <60 mmHg (60 mmHg)
62 Pancreatitis (3) Nature course: Acute renal failure and M. acidosis Lung complication (ARDS..)Ileus and GI bleeding2nd infection of necrotic tissue (2week)Pseudocyst (6weeek)
63 Acute cholangitis vs cholecystitis Comparison of the triade:RUQ pain+ fever+ leucocytosisRUQ pain + fever+ jaundice (Charcot triade)+shock+ cons change (Raynold pentade)