Management of a Pt With sis

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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y Fresh clot (rebleed 30%)

yVisible vessel (rebleed 50%)


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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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Management of a Pt With sis