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Upper GI bleeding.

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Presentation on theme: "Upper GI bleeding."— Presentation transcript:

1 Upper GI bleeding

2 ONE syndrome: a group of diseases
UGI bleding ONE syndrome: a group of diseases

3 Definitions Intraluminal, exteriorised bleeding
Hematemesis – above the angle of Treitz Melena – above the ileo-cecal valve Hematochezia – bellow the spelnic flexure

4 A major health problem 100-150/100.000 admission/year in US
Mortality is high ~10% even if: fiberoptic endoscopy - general better understanding of pathology high performance medication POPULATION IS GROWING OLDER Great variety of pathologies risk of rebleeding very difficult to evaluate

5 Major cause Duodenal ulcer 24% Gastritis 23% Gastric ulcer 21%
Esophageal varices 10% Esofagitis 8% Sdr. M-W 7% Duodenitis 6% Tumors 3% Large variations according to region

6 DIAGNOSTIC VS TRATAMENT
Major emergency Urgent treatment before ethiological diagnostic Sequence: Diagnostic of UGI bleeding Resuscitation Empiric treatment Ethiologic treatment Specific treatment

7 Emergency URGENT EVALUATION URGENT TREATMENT OF HYPOVOLEMIA
INSSURING A SECURE TRANSPORTATION TO A HOSPITAL

8 Anamnesis Describe bleeding Other symptoms on onset: ex cough
Quantification of blood loss is ridiculous Other symptoms on onset: ex cough Past medical history – associated with bleeding: hepatitis, chirrhosis… Family problems Alchool intake Previous bleedings Medication intake in the last week

9 FIRST AID Decubitus One or two large vein access Insure vital function
Safe transportation A sample for blood typing No macromolecules before sample Nill per mouth +/- nasogastric tube + drainage

10 Haemodynamic evaluation
Hypovolemic shock if: Systolic blood pressure <90 mmHg = 50% circulating volume NO shock – check for changes in blood pressure and puls in orthostatism BP< % loss BP-10 or puls rate >120/min %

11 EVALUATION BEFORE ETHIOLOGY IS ESTABLISHED
1. Hemoglobine 2. Platelets 3. Hematocrit 4. Screening test for coagulation 5. BUN 6. Screening for live function tests 7. Abdominal and/or thorax X-Ray for associated pathology that could change protocol

12 EVALUATION BEFORE ETHIOLOGY IS ESTABLISHED
Patient in ICU under gastroenterology care Supress HCl secretion (i.v. H2 bloxkers, PPI) Treat coagulation disfunctions Blood products Balance for risks – viral infections Risks vs benefits in continuous bleeding

13 SURVEILANCE -MODELES FOR REBLEEDING -
CONTINUOUS BLEEDING No response 42% do not present a major episode of rebleeding Aggressive monitoring = ESSENTIAL MAJOR EPISODE OF REBLEEDING 15,2% rebleeding in ICU 61% sudden onset ONLY shock is very unusual but possible

14 REBLEEDING MAJOR RISK FACTOR
Definition: new bleeding episode after an initial stop and haemodynamic stability High mortality: 20% (3x more then average for UGU bleeding) 3 major risk factors for in hospital morbidity and mortality: Major rebleeding during hospital stay Old age Total quantity of transfused blood

15 ETHIOLOGICAL EVALUATION
Clinical Rx + US endoscopy “GOLD DIAGNOSTIC”

16 ANAMNESIS PATIENT + FAMILY

17 Clinical Evaluation Haemodyanmic evaluation and stabilisation
Confirm the dg of UGI bleeding HEMATEMESIS, MELENA + rectal exam Ex oral cavity + ENT for swallowed blood Medicaton Clinical signs suggestive for liver chirrhosis Palpable tumors Other medical problems that can cause UGI bleeding

18 IMAGISTICS Can point to a possibel diagnostic Rx thorax Abdominal US
Pleural efusions TBC Primary or secondarty tumors Abdominal US Liver chirrhosis + portal hypertension Abdominal tumors Rx g-d Unusual alternative to explore UGI after the remission of signs or when endoscopic examination is incomplete.

19 ENDOSCOPY - in emergency - not after 24 hourse
Establishes SOURCE OR SOURCES of bleeding Evaluation of risk of rebleeding THERAPEUTIC acces directly to the lesion ENDOSCOPY - in emergency - not after 24 hourse SHORT LIVED LESIONS

20 PREPARE FOR ENDOSCOPY Patient should be stable / in OR
Empty stomach if possible +/- sedation – risk of aspiration Patient in left lateral position – prevent aspiration

21 ENDOSCOPIC DIAGNOSTIC
Portal hypertension: varices YES/NO Significant in massive bleeding Diagnostic for all lesions with potential of bleeding Evaluation of RISK of rebleeding Type of ACTIVE bleeding Complete vs incomplete examination: which areas not evaluated

22 MIRAGE – the first lesion
? the most significant lesion?

23 TREATMENT Stabilise and monitor patient STOP THE BLEEDING
Prevent recurrent bleeding Treat the disease CAUSE Treat complications and associated diseases

24 TRATAMENT according to cause
ENDOSCOPY: Oclude the vessel the least aggressive for patient immediate after diagnosis very efficient required in all cases with major risk of rebleeding Medication Surgical Interventional radiology

25 ESOPHAGIAN CAUSES - 4% a. Congenital Weber-Rendu-Osler
Blue rubber bleb nevus Bullous epidermolisis Esophageal duplication b. Inflamatory GERD Barrett disease Infectious esophagitis Caustic lesions RT induced lesions CHT induced lesions Crohn disease Behcet disease pemfigoid

26 b. Traumatic or mechanic
Hiatus hernia Mallory-Weiss syndrome Boerhaave syndrome Foreign body Iatrogenic c. Neoplasia malignant benign d. Vascular Varices Aortic aneurism After cardiac surgery e. Hematological anticoagulants coagulation disorders

27 ESOPHAGIAN CAUSES Esophagus varices Mallory-Weiss sundrome
Hiatus hernia and GERD Tumors

28 Varices 10% of cases Associated with alcohol abuse and hepatitis: clinical signs of chirrhosis ESSENTIAL to exclude variceal haemorrhage Endoscopy may be difficult but very important

29 VARICELE ESOFAGIENE Endoscopic difficulties
Important bleeding Stomach full of cloths Gastric varices Encephalopathy BUT ONLY 60% of patients with chirrhosis bleed from varices

30 DIAGNOSTIC

31 TRATAMENT MEDICATION - OCTREOCTIDE: decreases portal flux and pressure in varices TAMPONDE – Segstaken Blackmore tube Not a first choice SURGICAL SHUNT ~70% mortality in emergency cases TIPS ~50% mortality on emergency

32 M-W SYNDROM Diagnostic only with endoscopy in emergency
Short lived lesions Usually with small quantity of blood but may produce shock Short monitoring ~0% risk of rebleeding Conservative treatment ~ 100%

33 Mallory Weiss

34 HIATUS HERNIA AND GERD dg+ EDS – stigmata of recent bleeding
HH very frequent encounter Treatment: H2 blockers, PPI

35 TUMORS of ESOPHAGUS Very unusual cause of clinical manifest bleeding: occult Endoscopic hemostasis Laser YAG Argon plasma

36 GASTRIC ORIGINE Hemorrhagic gastritis Gastric ulcer Benign tumors
Malignant tumors

37 HEMORRHAGIC GASTRITIS
Morfologic criteria EDS aspect may vary Radiology useless and pointless EDS: if late may not show anything

38 HEMORRHAGIC GASTRITIS
H2 blockers and PPI – routine but doubtful benefit Rebleeding extremely rare Endoscopic treatment: not recommended (numerous lesions with small risk of rebleeding) SURGICAL(unusual: doubtfull diagnostic + hemodynamic instability) In situ hemostasissutura in situ Vagotomy + gastrectomy

39 GASTRIC ULCER Some localisations are difficult to see
EDS needs to evaluate Stigmata of bleeding Risk of rebleeding

40 Treatment H2, IPP +/- i.v route Endoscopic direct treatment Sclerosis
Thermocoagulation Clips

41 Surgical treatment If so, resection of lesion is better
Frozen section pathology: malignnancy always in doubt Limited resections for bening disease

42 Benign gastric tumors Bleding is RARE
Polipoid lesions can be resected endoscopically Surgical excision

43 Malignant gastric tumors
6% Special characteristics High mortality 9% Frequently non-resectable Large costs little benefit in survival

44 ENDOSCOPY Examination: advanced lesion
Hemostasis (laser or argon plasma) Ex. Echografic Ultrasound: MTS and large LN: inoperable

45 Surgical treatment Laparotomy or laparoscopy: confirm advanced disease vs operability Massive bleeding: most often advanced lesions Paliation ~25% bypass gastrostomy jejunostomy

46 Vascular malformations Dielafoy (exulceratio simplex)
~5% Congenital anomaly Abnormal artery protruding in submucoasa

47 Echoendoscopy

48 Treatment Mechanic destruction of the vascular anomaly
Surgery: in situ hemostasis Endoscopy – GOLD STANDARD Correct diagnostic Banding Hemoclips Laser thermocoagulation

49 Bading

50 DUODENAL ORIGIN Very frequent Justifies the empiric treatment with PPI

51 EROSIVE DUODENITIS BIG BAG with different pathologies: erosions
Confusion in term with ulcer/superficial ulcer Frequent association with Helicobacter Pylori Treatment conservative: H2 blockers, PPI and antiobiotics

52 DUODENAL ULCER Incidence is constant 53% known ulcer in PMH
HDS iterative: 17% High gravity and high risk 25% in difficult localizations Requires a new approach

53 ASSOCIATED LESIONS Multiple ulcers Association with varices!!!!!
Duodenal stenosis: may be associated with postbulbar ulcer Association of bleeding and perforation

54 RISK QUANTIFICATION

55 ENDOSCOPIC TREATAMENT
Standard Very good results Little requirement of surgical procedures

56 Heater probe Very good on visible vessels

57 Clips Visible vessels Difficult and expensive

58 SURGICAL Emergency operation Major indication: Massive bleeding
More then 6 units of blood/24 hours = continuous bleeding

59 SURGICAL PROCEDURES In situ hemostasis: the most used technique
Resections (limited in number and extent)

60 CONCLUSIONS UGI bleeding is still a significant problem
Endoscopy is mandatory for diagnostic and treatment Surgery is limited in emergency situations

61 LOWER GI BLEEDNG

62 ETIOLOGY

63 CLINICAL PRESENTATION
History taking-type of bleeding Careful interpretation of data Blood on paper Red blood vs feaces mixed with blood Quantity etc

64 Paraclinical Wbc Hct Plt Coagulation profile LFT
+ numerous other according to associated pathology

65 Risk stratification

66 Risk stratification Seven independent predictors of severity in acute LGIB hypotension tachycardia, syncope, nontender abdominal exam, bleeding within 4 hours of presentation, aspirin use, and more than two comorbid diseases

67 LOCALIZATION The duration, frequency, and color of blood passed per rectum. Characteristically, melena or black, tarry stool, indicates bleeding from an upper gastrointestinal or small bowel source Maroon color suggests rt. Sided lesion whereas bright red blood per rectum signifies bleeding from the left colon or rectum. However, patient and physician reports of stool color are often inaccurate and inconsistent In addition, even with objectively defined bright red bleeding, significant proximal lesions can be found on colonoscopy

68 LOCALIZATION past medical history.
antecedent constipation or diarrhea (hemorrhoids, colitis), the presence of diverticulosis (diverticular bleeding), receipt of radiation therapy (radiation enteritis), recent polypectomy (postpolypectomy bleeding), and vascular disease/hypotension (ischemic colitis). A family history of colon cancer Nonetheless, even after a detailed history, physicians cannot reliably predict which patients with hematochezia will have significant pathology and a history of bleeding from one source does not eliminate the possibility of bleeding from a different source.

69 LOCALIZATION Multiple factors make the identification of a precise bleeding source in LGIB challenging. The diversity of potential sources, The length of bowel involved, The need for colon cleansing, and The intermittent nature of bleeding. In up to 40% of patients with LGIB, more than one potential bleeding source will be noted and Stigmata of recent bleeding in LGIB are infrequently identified As a result, no definitive source will be found in a large percentage of patients

70 Clinical scenarios Pt. continued to bleed with hypotension and tachycardia. Patient requires 2 units of PRBCs Pt. stopped bleeding. Vitals normalizes

71 Options to diagnose and control the bleeding
RBC scan, requires ml/min bleeding Mesenteric angiography, requires ml/min bleeding Colonoscopy Surgery Meckels scan

72 Scenario one- Pt. continues to bleed and is unstable.

73 Rbc scan vs colonoscopy

74 COLONOSCOPY Colonoscopy is undoubtedly the best test for confirming the source of LGIB and for excluding ominous diagnoses, such as malignancy. The diagnostic yield of colonoscopy ranges from 45% to 95% Identifies lesion in 75 % or more Can provide endoscopic therapy most patients undergoing radiographic evaluation for LGIB regardless of findings and interventions will subsequently require a colonoscopy to establish the cause of bleeding.

75 CLINICAL SCENARIO Patient continues to bleed
RBC scan is positive on the left side? How much true this information is?? What to do next? surgery, ?angio with embolization?

76 RADIONUCLIDE SCAN radionuclide scanning has variable accuracy, cannot confirm the source of bleeding, Correct localization rate is % Accuracy appears to be best when the scan becomes positive within a short period of time In one study, 42% of patients underwent an incorrect surgical procedure based on scintigraphy results.

77 CLINICAL SCENARIO Patient underwent angiogram with embolization
Vitals improved What are the chances that pt. will rebleed? Colonoscopy?

78 MESENTERIC ANGIOGRAM Selective embolization initially controls hemorrhage in up to 100% of patients, but rebleeding rates are 15% to 40% Advantages: Precise localization Can provide therapy with intra-arterial vasopressin or coil embolization Procedure of choice in briskly bleeding pts Minor complication rate of 9% and a 0% major complication rate

79 Disadvantages: Invasive Less sensitive in detecting venous bleeding
Can cause ischemia, contrast reactions, arterial injury

80 DIAGNOSTIC DIFFICULTIES
the diagnostic modalities for lower GI bleeding are not as sensitive or specific in making an accurate diagnosis (versus UGIB) Diagnostic evaluation is complicated: more than one potential source of hemorrhage is identified. If more than one source is identified, it is critical to confirm the responsible lesion before initiating aggressive therapy. This approach may occasionally require a period of observation with several episodes of bleeding before a definitive diagnosis can be made. In fact, in up to 25% of patients with lower GI hemorrhage, the bleeding source is never accurately identified.

81 SURGERY Surgery usually is employed for hemorrhage in two settings: massive or recurrent bleeding. It is required in 15% to 25% of patients who have diverticular Recurrent bleeding from diverticula occurs in 20% to 40% of patients and generally is considered an indication for surgery In patients with serious comorbid medical conditions and without exsanguinating hemorrhage, this decision should be made carefully. Great effort should be made to accurately localize the site of bleeding preoperatively so that segmental rather than subtotal colectomy can be performed Operative mortality is 10% even with accurate localization and up to 57% with blind subtotal colectomy.


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