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8/6/2019 Management of a Pt With sis
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Dr. Salem Mohammad Bazarah
MD, M.Ed, FACP, FRCPC, FRCPC (GI) & PhD
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A common medical conditiony 250,000 500,000 admissions/year US
y UGI bleeding incidence 100/100,000 adults
y Incidence increases 20-30 fold from third to ninthdecade of life
y LGI bleeding incidence 20/100,000 adults
y Overwhelmingly disease of the elderly
y GI bleeding stops spontaneously in 80 %
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Morbidity Datay Majority will receive blood transfusions
y 2 10 % require urgent surgery to arrest bleeding
y
Average LOS 4 7 daysy Mortality rates for UGI bleeding 2 15 %
y Mortality for patients who develop bleeding afteradmission to hospital for another reason is 20 30 %
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CostsyAverage hospital costs exceed $ 5,000 per admission
y Most of this for hospital bed and ICU stays rather than
physician fees, blood products, diagnostic tests, ormedications
y Reduction of hospital admissions and LOS hasgreatest potential to reduce costs
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UGI bleeding:Nomenclaturey Hematemesis 25 %
y Melena alone 25 %, 50 100 cc of blood will render
stool melenicy Hematochezia 15 %, seen in massive UGI hemorrhage
y Red blood hematemesis
y Coffee ground emesis
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Historyy 45 yrs male with 1 day hx of vomiting blood
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Approach
yAssess the severity
y Resuscitate
y Establish the site of bleeding
y Endoscopic intervention
y Reassess severity: liase with surgical team
y Medical treatment
y
Indications for surgery
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Assessing severity: Rockall criteria
Criterion Scorey Age 80 years 2
y Shock None 0
Pulse & sBP >100 1
sBP
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Resuscitate
y Large bore intravenous cannula x 2
y X-match 4 units, give colloid & transfuse if
y Fresh melaena on PR
y Postural hypotension >15mm/Hg
y
sBP
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Resuscitation
y Indications for CVPy Rockall score > 3, first rebleed, or inadequate accessy Insert urinary catheter if CVP appropriate
y Urea/creatinine ratioy If >unity (eg 12.4/90), then upper GI bleed likely
y Monitor Pulse & BP ?hrlyy Guide of halves: if pulse higher or BP lower than last
recording, then halve the time to the next recordingy If pulse trend rises on 3 occasions, call senior cover
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Establish site of bleeding
y Endoscopy on next available listy Ideally
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Stigmata of recent haemorrhage
y Clean ulcer base (rebleed
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Stigmata of recent haemorrhage
y Fresh clot (rebleed 30%)
yVisible vessel (rebleed 50%)
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Stigmata of recent haemorrhage
y Bleeding vessel (rebleed 80%)
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Upper GI Bleeding
Klaus Gottlieb, MD, FACP, FACG
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Source of bleeding
Common
y DU (35%)
y GU (20%)
y Oesophagitis (6%)
y Mallory-Weiss (6%)
y No source found (20%)
Uncommon/Rare
yVarices
y Tumour
yAortoenteric fistula
y Dieulafoy
y
HaemobiliayAngiodysplasia
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Interventiony Endoscopic injectionwith
y Adrenaline 1:10000, thrombin, sclerosant, or saline allhalve the risk of rebleeding
y As good as heater probe, laser therapy
y Tranexamic acidy
1g iv three times daily for 72hr reduces mortality
y Omeprazole 60mg iv stat and infusion 8mg/hr for72hry may reduce mortality after endoscopic interventiony Nothing else has been shown to work
Do not prescribe iv ranitidine, or oral PPIuntil after endoscopy
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Reassess severity: update Rockall
Scorey Endoscopic diagnosis
y No lesion, or M-Wtear 0
y All other diagnoses 1
y Malignancy of upper GI tract 2y Stigmata of recent haemorrhage
y None/haematin 0
y Clot, visible vessel,blood in stomach 2
y Final score after endoscopy (max11)
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Updated Rockall score
Initial score (pre-endoscopy)Score Mortality
0 0.2%
1 2.4%
2 5.6%
3 11.0%
4 24.6%
5 39.6%
6 48.9%
7 50.0%
Final score (after endoscopy)Score Mortality
0 0%
1 0%
2 0.2%
3 2.9%
4 5.3%
5 10.8%
6 27.0%
7 17.3
8+ 41.1%
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Further management
y Liase with surgeons ify Initial score >3 (ie if CVP necessary)
y Posterior duodenal ulcer
y Final Rockall score >4
yAfter endoscopyy Eat & drink if no stigmata, or haematin only
y Clear fluids for 12 hr if endoscopic intervention
y N
BM only if haemostasis not secure (varices)y Re-examine after 4-8hr for signs rebleeding
y Ring blood bank to keep blood available for24hr after endoscopic intervention
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Signs of rebleedingy
Rise in pulse ratey Fall in CVP
y Decrease in hourly urine output
y Further haematemesis or fresh melaena
y Look at the patient as well as the charts!
yAct if rebleeding suspected
y FBC and transfuse
y Ensure large bore access, central line and catheter
y Call surgical team
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Special notes - Variceal bleeding
y
Suspect variceal bleeding if..
-AlcoholHx- Deranged LFTs
- Jaundice*- Hyponatraemia*-Ascites*- Coagulopathy- Low platelets- PreviousHx of varices*
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Special notes Variceal Bleeding
y Resuscitatey Correct coagulopathy(FFP x 4 and vit K IV)y Endoscopy and banding/sclerotherapyy Glypressin 2mg iv stat and 1-2mg repeated 4hrlyy Treat other aspects of decompensation
y Ascites (spironolactone, no N/saline)y Encephalopathy (lactulose, no sedation)y Renal impairment (avoid hypovolaemia)y Malnutrition (iv vitamins, fine bore feeding)y Underlying liver disease (hepatic screen, EFP etc)
y Post-bleed prophylaxis
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Summary
y Objective assessment (Rockall criteria)
y Resuscitation before endoscopy
y Monitor by rule of halves: look fortrends
y No role for empirical acid suppression
y Critical appraisal of endoscopy report
y Liaise with surgeons earlyy Discriminate between high & low risk patients
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