2ONE syndrome: a group of diseases UGI bledingONE syndrome: a group of diseases
3Definitions Intraluminal, exteriorised bleeding Hematemesis – above the angle of TreitzMelena – above the ileo-cecal valveHematochezia – bellow the spelnic flexure
4A major health problem 100-150/100.000 admission/year in US Mortality is high ~10% even if:fiberoptic endoscopy - generalbetter understanding of pathologyhigh performance medicationPOPULATION IS GROWING OLDERGreat variety of pathologies risk of rebleeding very difficult to evaluate
5Major 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
6DIAGNOSTIC VS TRATAMENT Major emergencyUrgent treatment before ethiological diagnosticSequence:Diagnostic of UGI bleedingResuscitationEmpiric treatmentEthiologic treatmentSpecific treatment
7Emergency URGENT EVALUATION URGENT TREATMENT OF HYPOVOLEMIA INSSURING A SECURE TRANSPORTATION TO A HOSPITAL
8Anamnesis Describe bleeding Other symptoms on onset: ex cough Quantification of blood loss is ridiculousOther symptoms on onset: ex coughPast medical history – associated with bleeding: hepatitis, chirrhosis…Family problemsAlchool intakePrevious bleedingsMedication intake in the last week
9FIRST AID Decubitus One or two large vein access Insure vital function Safe transportationA sample for blood typingNo macromolecules before sampleNill per mouth+/- nasogastric tube + drainage
10Haemodynamic evaluation Hypovolemic shock if: Systolic blood pressure <90 mmHg = 50% circulating volumeNO shock – check for changes in blood pressure and puls in orthostatismBP< % lossBP-10 or puls rate >120/min %
11EVALUATION BEFORE ETHIOLOGY IS ESTABLISHED 1. Hemoglobine2. Platelets3. Hematocrit4. Screening test for coagulation5. BUN6. Screening for live function tests7. Abdominal and/or thorax X-Ray for associated pathology that could change protocol
12EVALUATION BEFORE ETHIOLOGY IS ESTABLISHED Patient in ICU under gastroenterology careSupress HCl secretion (i.v. H2 bloxkers, PPI)Treat coagulation disfunctionsBlood productsBalance for risks – viral infectionsRisks vs benefits in continuous bleeding
13SURVEILANCE -MODELES FOR REBLEEDING - CONTINUOUS BLEEDINGNo response42% do not present a major episode of rebleedingAggressive monitoring = ESSENTIALMAJOR EPISODE OF REBLEEDING15,2% rebleeding in ICU61% sudden onsetONLY shock is very unusual but possible
14REBLEEDING MAJOR RISK FACTOR Definition: new bleeding episode after an initial stop and haemodynamic stabilityHigh mortality: 20% (3x more then average for UGU bleeding)3 major risk factors for in hospital morbidity and mortality:Major rebleeding during hospital stayOld ageTotal quantity of transfused blood
17Clinical Evaluation Haemodyanmic evaluation and stabilisation Confirm the dg of UGI bleedingHEMATEMESIS, MELENA + rectal examEx oral cavity + ENT for swallowed bloodMedicatonClinical signs suggestive for liver chirrhosisPalpable tumorsOther medical problems that can cause UGI bleeding
18IMAGISTICS Can point to a possibel diagnostic Rx thorax Abdominal US Pleural efusionsTBCPrimary or secondarty tumorsAbdominal USLiver chirrhosis + portal hypertensionAbdominal tumorsRx g-dUnusual alternative to explore UGI after the remission of signs or when endoscopic examination is incomplete.
19ENDOSCOPY - in emergency - not after 24 hourse Establishes SOURCE OR SOURCES of bleedingEvaluation of risk of rebleedingTHERAPEUTIC acces directly to the lesionENDOSCOPY - in emergency - not after 24 hourseSHORT LIVED LESIONS
20PREPARE FOR ENDOSCOPY Patient should be stable / in OR Empty stomach if possible+/- sedation – risk of aspirationPatient in left lateral position – prevent aspiration
21ENDOSCOPIC DIAGNOSTIC Portal hypertension: varices YES/NOSignificant in massive bleedingDiagnostic for all lesions with potential of bleedingEvaluation of RISK of rebleedingType of ACTIVE bleedingComplete vs incomplete examination: which areas not evaluated
22MIRAGE – the first lesion ? the most significant lesion?
23TREATMENT Stabilise and monitor patient STOP THE BLEEDING Prevent recurrent bleedingTreat the disease CAUSETreat complications and associated diseases
24TRATAMENT according to cause ENDOSCOPY: Oclude the vesselthe least aggressive for patientimmediate after diagnosisvery efficientrequired in all cases with major risk of rebleedingMedicationSurgicalInterventional radiology
31TRATAMENTMEDICATION - OCTREOCTIDE: decreases portal flux and pressure in varicesTAMPONDE – Segstaken Blackmore tubeNot a first choiceSURGICAL SHUNT~70% mortality in emergency casesTIPS~50% mortality on emergency
32M-W SYNDROM Diagnostic only with endoscopy in emergency Short lived lesionsUsually with small quantity of blood but may produce shockShort monitoring~0% risk of rebleedingConservative treatment ~ 100%
34HIATUS HERNIA AND GERD dg+ EDS – stigmata of recent bleeding HH very frequent encounterTreatment: H2 blockers, PPI
35TUMORS of ESOPHAGUSVery unusual cause of clinical manifest bleeding: occultEndoscopic hemostasisLaser YAGArgon plasma
36GASTRIC ORIGINE Hemorrhagic gastritis Gastric ulcer Benign tumors Malignant tumors
37HEMORRHAGIC GASTRITIS Morfologic criteriaEDS aspect may varyRadiology useless and pointlessEDS: if late may not show anything
38HEMORRHAGIC GASTRITIS H2 blockers and PPI – routine but doubtful benefitRebleeding extremely rareEndoscopic treatment: not recommended (numerous lesions with small risk of rebleeding)SURGICAL(unusual: doubtfull diagnostic + hemodynamic instability)In situ hemostasissutura in situVagotomy + gastrectomy
39GASTRIC ULCER Some localisations are difficult to see EDS needs to evaluateStigmata of bleedingRisk of rebleeding
50DUODENAL ORIGINVery frequentJustifies the empiric treatment with PPI
51EROSIVE DUODENITIS BIG BAG with different pathologies: erosions Confusion in term with ulcer/superficial ulcerFrequent association with Helicobacter PyloriTreatment conservative: H2 blockers, PPI and antiobiotics
52DUODENAL ULCER Incidence is constant 53% known ulcer in PMH HDS iterative: 17%High gravity and high risk25% in difficult localizationsRequires a new approach
53ASSOCIATED LESIONS Multiple ulcers Association with varices!!!!! Duodenal stenosis: may be associated with postbulbar ulcerAssociation of bleeding and perforation
66Risk stratificationSeven independent predictors of severity in acute LGIBhypotensiontachycardia,syncope,nontender abdominal exam,bleeding within 4 hours of presentation,aspirin use, andmore than two comorbid diseases
67LOCALIZATIONThe duration, frequency, and color of blood passed per rectum.Characteristically, melena or black, tarry stool, indicates bleeding from an upper gastrointestinal or small bowel sourceMaroon color suggests rt. Sided lesionwhereas 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 inconsistentIn addition, even with objectively defined bright red bleeding, significant proximal lesions can be found on colonoscopy
68LOCALIZATION 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), andvascular disease/hypotension (ischemic colitis).A family history of colon cancerNonetheless, 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.
69LOCALIZATIONMultiple 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, andThe intermittent nature of bleeding.In up to 40% of patients with LGIB, more than one potential bleeding source will be noted andStigmata of recent bleeding in LGIB are infrequently identifiedAs a result, no definitive source will be found in a large percentage of patients
70Clinical scenariosPt. continued to bleed with hypotension and tachycardia. Patient requires 2 units of PRBCsPt. stopped bleeding. Vitals normalizes
71Options to diagnose and control the bleeding RBC scan, requires ml/min bleedingMesenteric angiography, requires ml/min bleedingColonoscopySurgeryMeckels scan
72Scenario one- Pt. continues to bleed and is unstable.
74COLONOSCOPYColonoscopy 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 moreCan provide endoscopic therapymost patients undergoing radiographic evaluation for LGIB regardless of findings and interventions will subsequently require a colonoscopy to establish the cause of bleeding.
75CLINICAL 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?
76RADIONUCLIDE SCANradionuclide 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 timeIn one study, 42% of patients underwent an incorrect surgical procedure based on scintigraphy results.
77CLINICAL SCENARIO Patient underwent angiogram with embolization Vitals improvedWhat are the chances that pt. will rebleed?Colonoscopy?
78MESENTERIC ANGIOGRAMSelective embolization initially controls hemorrhage in up to 100% of patients, but rebleeding rates are 15% to 40%Advantages:Precise localizationCan provide therapy with intra-arterial vasopressin or coil embolizationProcedure of choice in briskly bleeding ptsMinor complication rate of 9% and a 0% major complication rate
79Disadvantages: Invasive Less sensitive in detecting venous bleeding Can cause ischemia, contrast reactions, arterial injury
80DIAGNOSTIC 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.
81SURGERYSurgery usually is employed for hemorrhage in two settings: massive or recurrent bleeding.It is required in 15% to 25% of patients who have diverticularRecurrent bleeding from diverticula occurs in 20% to 40% of patients and generally is considered an indication for surgeryIn 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.