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UPPER GASTROINTESTINAL BLEEDING G.C. Sturniolo Nicoletta Merlini Dipartimento di Scienze Chirurgiche e Gastroenterologiche Sezione di Gastroenterologia.

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Presentation on theme: "UPPER GASTROINTESTINAL BLEEDING G.C. Sturniolo Nicoletta Merlini Dipartimento di Scienze Chirurgiche e Gastroenterologiche Sezione di Gastroenterologia."— Presentation transcript:

1 UPPER GASTROINTESTINAL BLEEDING G.C. Sturniolo Nicoletta Merlini Dipartimento di Scienze Chirurgiche e Gastroenterologiche Sezione di Gastroenterologia

2 ACUTE UPPER GI BLEEDING In UK hospital admission each year INCIDENCE: 50 to 150 cases per 10 5 per year Palmer, PMJ 2004

3 AUGIB ETIOLOGY  Peptic ulcer disease  Oesophageal/gastric varices  Mallory-Weiss tear  Oesophagitis  Duodenitis/gastritis/erosions  Vascular (Angiodysplasia, Dieulafoy)  Tumours  Aortoenteric fistula

4 ACUTE UPPER GI BLEEDING Adapted from Palmer, PMJ 2004

5 MORTALITY Rockall, BMJ upper GI bleeding Mortality % >

6 MORTALITY in UGIB Klebl, Int J Colorectal Dis 2005 Hospital mortality and mortality related to the source of bleeding in 362 UGIB 45,5% 22,7% 29,4% 9,1% 20% 3,8% 5,9% 0%

7 MORTALITY in UGIB 11% 40% p < 0,05 Mortality of patients during hospitalization Bleeding only before admission Bleeding before + after admission Adapted from Palmer, PMJ 2004

8 MORTALITY FOR UGIB: Time Trend ,7% 7,2% 19,5% 11,1% p=0,03 p=0,05 Fiore, Eur J Gastr Hep 2005

9 UGIB: Diagnostic Endoscopy Identifies the bleeding lesions >95% of sensitivity and specificity Morbidity Mortality Transfusions Length of stay Surgery Doesn’t alter patient outcome: Peterson, NEJM 1981 Cappell, Med Clin N Am 2002

10 UGIB: Therapeutic Endoscopy Only patients with persisten or recurrent bleeding 80% patients don’t have further bleeding Optimal utilization IDENTIFY HIGH RISK PATIENTS

11 UGIB: ROCKALL SCORE Developed in 1996 to assess risk of mortality and rebleeding in UGIB patients Rockall, BMJ 1996 Rockall risk score VariableScore 0 Score 1 Score 2 Score 3 AGE SHOCK CO-MORBID DIAGNOS MAJOR SRH < 60 None Mallory-Weiss No lesions None or dark spots Pulse > 100 bpm - All other diagnoses > 80 Fc>100,PAOs <100 Cardiac failure Malignancy upper GI Blood in upper GI tract, blood clot Renal,liver failure

12 UGIB: ROCKALL SCORE Retrospective study, 222 patients Distribution of Rockall Score % of patients Bessa, DLD 2006

13 UGIB: ROCKALL SCORE Retrospective study, 222 patients Rebleeding Risk Mortality Risk Rockall < 5Rockall > 6 p = ns Rockall < 5Rockall > 6 p < 0,001 Bessa, DLD 2006

14 UGIB WHICH PATIENTS ARE MORE LIKELY TO REBLEED?

15 UGIB: Clinical Risk Large volume bleeding Shock Age > 60 years Bleeding onset after admission Comorbidity Variceal Bleeding

16 Scoring Systems for UGIB Baylor bleeding score (1993) Cedars-Sinai predictive index (1996) Rockall Score (1996) Blatchford Score (2000) Das, Gastrointest Endosc 2004

17 UGIB: Blatchford Score Derived from clinical information at presentation such as: Urea Hb Blood pressure Comorbidity (syncope, melena, heart and/or liver disease) Blatchford, Lancet 2000

18 BLATCHFORD vs ROCKALL Blatchford, Lancet 2000 BETTER ROC FOR “CLINICAL INTERVENTION”

19 PEPTIC ULCERS CLASSIFICATION FORREST CLASSIFICATION ACUTE HEMORRHAGE Forrest I aArterial, spurting hemorrhage Forrest I bOozing hemorrhage SIGNS OF RECENT HEMORRHAGE Forrest II aVisible vessel Forrest II bAdherent clot Forrest II cHematin covered lesion LESIONS WITHOUT RECENT BLEEDING Forrest III No signs of recent hemorrhage

20 Forrest IIb Forrest IIa

21 FORREST CLASSIFICATION Forrest 2c Forrest 3 Ulcer with haematin-covered base Ulcer with clean base Forrest 1b Non-spurting active bleeding Forrest 1a Spurting bleeding Forrest 2a Non-bleeding visible vessel Forrest 2b Non-bleeding with adherent clot

22 PEPTIC ULCERS: RISK FACTORS? Male, Advanced age History of ulcer disease Helicobacter Pylori Corticosteroids NSAIDs Blood-thinning drugs

23 MANAGEMENT OF UGIB Resuscitation Endoscopy and endoscopic therapy Drug Therapy

24 MANAGEMENT OF UGIB Resuscitation Endoscopy and endoscopic therapy Drug Therapy

25 RESUSCITATION Airway, Breathing, Circulation Central Venous Pressure (elderly and cardiopathic) Crystalloids (carefully in liver disease!) Colloids in major hypotension Shocked Actively bleeding Hb < 10 g/dL Blood transfusion Palmer, PMJ 2004

26  Blood Transfusion Age > 60 years Hb < 8.2 g/dL WHEN SHOULD WE TRANSFUSE PATIENTS?  Cardiologic Evaluation  cTropI Curve Gastro PD, BLISC

27 MANAGEMENT OF UGIB Resuscitation Endoscopy and endoscopic therapy Drug Therapy

28 UGIB: TO SCOPE Early endoscopy identifies and treats patients with high risk of rebleed improving patient outcomes PPI therapy alone is not as effective as endoscopic therapy for high risk lesions

29 UGIB: NOT TO SCOPE No benefit from early endoscopy if the findings do not change patient care

30 DRUG THERAPY Merki, Gastroenterology 1996 Time with intragastric pH>4 / 24h p<0,001 93% 96% 67% 43% IV PPI vs IV RANITIDINE

31 MANAGEMENT OF NON VARICEAL BLEEDING Non-variceal, upper GI bleeding IV PPI bolus + infusion Upper Endoscopy Low-risk stigmata Oral PPI therapy High-risk stigmata Endo therapy + IV PPI Triadafilopoulos, Alim Pharm Ther 2005

32 OESOPHAGEAL VARICES 80-90% CIRRHOSIS BLEEDING PREVALENCE: 30-40% MORTALITY I BLEEDING: 20-45% PRIMARY PREVENTION SECONDARY PREVENTION TREATMENT ACUTE BLEEDING

33 CIRRHOSIS SMALL VARICES LARGE VARICES INCIDENCE/YEAR 5-10% INCIDENCE/YEAR 5-30% ACUTE BLEEDING INCIDENCE/YEAR 5-50% MORTALITY 30-50% PRIMARY PREVENTION  50% BLEEDING  25-45% MORTALITY’ REBLEEDING 60% 1 YEAR

34 RISK FACTORS CHILD B-C EXTENSION (63% Ls vs 45% Li) DIMENSION (F1,15%;F2,32%;F3,68%) RED WALL MARK (red spots e wall marking 76% vs 17% without) COLOR (blue 80% vs white 45%) PORTAL VEIN PRESSURE (> 12 mmHg) HIGHER BLEEDING RISK

35 VARICEAL BLEEDING RESUSCITATION UEC PLASMA EXPANDERS EGDS IN 12 HRS De Franchis, J Hepatol 2000 ANTIBIOTIC VASOACTIVE DRUGS

36 MEDICAL TREATMENT ANTIBIOTICS INFECTIONS  35-66% BLEEDING CIRRHOTICS UTI 12-29% E.Coli + Klebsiella SBP 7-23% Gram -/+ PULMONARY INFECTIONS 6-10% SEPSI 4-11% Dell’Era, APT 2004

37 INFECTIONS  BLEEDING CONTROL FAILURE  MORTALITY RELATED BLEEDING PREDICTIVE FACTOR OF REBLEEDING

38 MEDICAL TERATMENT VASOACTIVE DRUGS TERLIPRESSIN 2 mg e.v. qd 4-6 hrs per 24 hrs then 1 mg e.v. qd 6 hrs per 4 days

39 VASOACTIVE DRUGS, BLOOD TRASFUSION RESUSCITATION, COLLOIDS, ANTIBIOTICS EGDS MEDICAL TREATMENT Vasoactive drugs (5 days long) VARICEAL BAND LIGATION SCLEROTHERAPY Failure II EGDS BLAKEMORE Surgery (child A) TIPS (child B,C) Lata J et al Dig Dis 2003 Failure TAKE HOME MESSAGES


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