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

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. 15000 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)VS Blood loss (% of total volume) Severity of bleed 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

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

HistoryHistory Exam Exam

Age Stigmata of CLD

Dyspepsia Hereditary vascular anomalies

Previous bleeding Scars

Previous PUD Palpable 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

ClinicalClinical

• 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

EndoscopicEndoscopic

• 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 !Thank you !