PROF. IBRAHIM A. AL-MOFLEH Professor of Medicine, College of Medicine & University Hospitals, KSU PROF. IBRAHIM A. AL-MOFLEH Professor of Medicine, College of Medicine & University Hospitals, KSU

ACUTE GI – BLEEDING (AGIB)

Forms Upper Lower Obscure AGIB

Epidemiology Common (e.g deaths/yr in USA) Upper is 5 x more than lower More frequent in men and elderly Spontaneous cessation in 80% Mortality in general 10% in elderly 20% cont. bl/rebleeding >30% AGIB

A 60 yrs old patient was brought with the ambulance to the emergency room with acute GI-bleeding ; you are asked to care for this patient What are your plans (objectives) ? How would you approach him ? Mention the adverse prognostic factors ? AGIB

Objectives Maintain the hemodynamics Determine the level Determine the cause Treat and prevent rebleeding AGIB

How to approach the patient ? 1.Initial assessment 2.Resuscitation 3.History and exam 4.Lab evaluation 5.Localization 6.Treatment AGIB

Initial assessment – A How urgent is the situation stable or in shock ? What are the features of shock ? What is the magnitude of blood loss ? ( 1 ) AGIB

Initial assessment – B What are the features of shock ? Agitation Pallor Hypotension Tachycardia ( 1 ) AGIB

VS Blood loss (% of total volume) Severity of bleed VS Blood loss (% of total volume) Severity of bleed Normal< 10% Mild Postural drop 10 – 20% Moderate Shock> 20% Severe How to assess the magnitude of blood loss? AGIB

How to approach the patient ? 1.Initial assessment 2.Resuscitation 3.History and exam 4.Lab evaluation 5.Localization 6.Treatment AGIB

Resuscitation Hemodynamically unstable patient Restore and maintain hemodynamics Oxygen Monitor VS and urinary output Admission to ICU Blood transfusion ? FFP ( 2 ) AGIB

Resuscitation Indications for blood transfusion Unstable VS Continuous bleeding Bright blood Age > 60 Concomitant CPD ( 2 ) AGIB

How to approach a patient with AGIB? 1.Initial assessment 2.Resuscitation 3.History and exam 4.Lab evaluation 5.Localization 6.Treatment AGIB

History and examination History Exam AgeStigmata of CLD DyspepsiaHereditary vascular anomalies Previous bleeding Scars Previous PUDPalpable organs / masses Previous endoscopy Lymphadenopathy Previous surgery PR (PUD aortic graft etc..) Drugs CLD Weight loss, Anorexia Changing bowel habits ( 3 ) AGIB

How to approach a patient with AGIB? 1.Initial assessment 2.Resuscitation 3.History and exam 4.Lab evaluation 5.Localization 6.Treatment AGIB

Laboratory parameters Type and crossmatchingType and crossmatching CBC, PT, PTT,CBC, PT, PTT, BUN, BUN / Creatinin ratioBUN, BUN / Creatinin ratio LFTLFT ABGABG ( 4 ) AGIB

How to approach a patient with AGIB? 1.Initial assessment 2.Resuscitation 3.History and exam 4.Lab evaluation 5.Localization 6.Treatment AGIB

Localization Clinical Endoscopy RBC scan Angiography ( 5 ) AGIB

How to approach a patient with AGIB? 1.Initial assessment 2.Resuscitation 3.History and exam 4.Lab evaluation 5.Localization 6.Treatment AGIB

Treatment Medical Endoscopic Angiographic Surgical ( 6 ) AGIB

Adverse prognostic factors Clinical Old age Comorbid diseases Bright blood (NGA, vomitus, stool) Onset of bleeding in the hospital Amount of blood lost Shock or hypotension on presentation Emergency surgery AGIB

Adverse prognostic factors Endoscopic Vascular bleeding Active bleeding Visible vessel Clot Giant ulcer AGIB

Indications for emergency endoscopy Cause Severity Age Cirrhosis Persistent bleeding Rebleeding AGIB

Role of endoscopy Site of bleeding Source of bleeding Stigmata of bleeding PUD −Active bleeding −Visible vessel −Clot −Black spot Endoscopic therapy AGIB

Endoscopic hemostatic methods Variceal bleeding Injection Banding Non-variceal bleeding Injection Thermal Clips

Bleeding Esophageal Varices

EVL

Gastric Varices

GU – Visible Vessel

Sentinel Clot

Gastric Angiodysplasia

Bleeding Angiodysplasia

DU – Bleeding Control

DU – Bleeding

GU Clips

Bleeding GU

Bleeding Diverticulum

Diverticulum Visible Vessel

Bleeding hemorrhoids

Dieulafoy - Colon

Thank you !