Stomach Raj 6 Sem UGI Bleed

8/2/2019 Stomach Raj 6 Sem UGI Bleed

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Dr RAJESH SISODIYA


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OVERT

OCCULT- chronic iron-deficiency anemia or a positive

FOBT without any visible bleeding. OBSCURE- recurrent overt or occult bleeding after an

initial negative endoscopic examination.


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Risk factors for upper GI bleeding Older age (>60 years)

Severe comorbidity

Active bleeding Hypotension or shock

Red blood cell transfusion 6 units

Severe coagulopathy

High risk endoscopic stigmata


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ETIOLOGY most common causes of upper gastrointestinal

bleeding are

peptic ulcer (60%),

erosive gastritis (15%),

gastroesophageal varices (6%),

arteriovenous malformations,

Mallory-Weiss tears, neoplasms, both benign and malignant.


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HISTORY prior episodes of upper gastrointestinal bleeding

(ulcers or varices), liver disease, intestinal polyps orcancer, and blood transfusions.

Alcohol abuse and illicit drug use should also beinvestigated.

medication use including aspirin, nonsteroidal anti-

inflammatory drugs (NSAIDs), and anticoagulationdrugs (warfarin, heparin).


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Clinical presentation hematemesis,

hematochezia,

hypotension-related symptoms as dizziness, light-

headedness, weakness, pallor, palpitations,tachycardia, orthostatic hypotension, shock, and

melena or with a positive screening fecal occult bloodtest (FOBT) or

chronic iron-deficient anemia with no obvious sourceof blood loss

Symptoms such as abdominal pain, nausea, vomiting,early satiety, anorexia, and weight loss should be

sought.


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GPE signs of chronic liver disease, such as jaundice, caput

medusae, spider telangiectasia, and/or ascites.

digital rectal examination and an NG tube aspiration.


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INVESTIGATIONS complete blood count,

liver and renal function tests, coagulation parameters

(PT/INR, PTT), typing and crossmatching.

Chest and abdominal x-rays (these tests may indicateperforation or aspiration), and

ECG


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Esophagogastroduodenoscopy Esophagogastroduodenoscopy (EGD) is the diagnostic

examination of choice

Gentle gastric lavage with 0.9% normal saline electrocautery, heat probe, laser therapy, band

ligation, clip placement, injection sclerotherapy, andinjection of cryanoacrylic glue can be done.


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Enteroscopy Push enteroscopy, in which an enteroscope is pushed

beyond the ligament of Trietz


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Enteroclysis Enteroclysis is a double-contrast study

performed by passing a tube into the proximal small

bowel and injecting barium, methylcellulose, and air. greater diagnostic yield than conventional imaging

because of its increased resolution and lack of anoverlapping, barium-filled stomach.


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Video capsule endoscopy a small capsule (11 mm with camera, lens, and

transmitter) is ingested orally

can diagnose a site of bleeding in over 50% of patients be considered, especially in patients with obscure

bleeding in whom an exploratory operation is the nextstep.

should not be used in patients with suspectedstrictures or known extensive adhesions.


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Radionucleotide scanswith either Technetium pertechnate-labeled

autologous red blood cells or Technetium sulfurcolloid can detect bleeding at a rate of 0.10.4 ml/min.


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Operative exploration/intraoperativeenteroscopy


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EMERGENT MANAGEMENT a large-bore intravenous (IV) catheter

Resuscitation

the hematocrit should be kept above 30%, while inyoung, healthy patients, the target hematocrit shouldbe above 20%.

GASTRIC LAVAGE

ESOPHAGOGASTRODUODENOSCOPY Red blood cell-tagged radionucleotide scan

Video capsule endoscopy


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Peptic Ulcers Endoscopy is the first line therapy

if the patient requires more than 46 units of blood

and the bleeding is not controlled endoscopically, thepatient should be managed operatively.

hemodynamically unstable and have ongoinghemorrhage should also be treated operatively.

Other criteria for operative intervention include arebleeding ulcer that is not controlled by endoscopyand medical therapy and possibly those patients withgiant ulcers and a visible vessel.


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For duodenal ulcers, vessel ligation through alongitudinal duodenotomy over the site of the ulcer isperformed.

high-dose, intravenous PPI therapy.

H. pylori, antibiotic eradication should be initiatedand later confirmed.


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Variceal Bleeding Endoscopic hemostasis with band-ligation, injection

sclerotherapy, or clip placement

Concomitant drug therapy with octreotide,somatostatin, or glypressin

Sengstaken Blakemore tube

a transjugular intrahepatic portosystemic shunt (TIPS)

to decompress the portal system. not candidates for liver transplantation and who are

stable should undergo a distal splenorenal shunt,amesocaval graft, a porto-caval shunt, or a gastric

devascularization with esophageal transection


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Hemorrhagic Gastritis PPIs, H2 receptor blockers, antacids, and/or sucralfate.

If medical treatment fails, administration ofvasopressin via the left or right gastric arteries.

If severe bleeding persists, a total or sub-totalgastrectomy


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Mallory-Weiss Tears result from repeated vomiting

most patients, the bleeding stops without therapy.

If bleeding persists, endoscopic coagulation high anterior gastrotomy


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Dieulafoy lesions intermittent, recurrent, acute upper GI bleeding.

abnormally large-caliber submucosal artery becomesexposed at the surface of the mucosa and thenruptures, usually in the stomach.

Diagnosis may be quite difficult as lesion is focal andbleeds only intermittently.

endoscopic visualization or demonstration byangiography.

banding, clipping, electrocautery, cyanoacrylate glueinjection, sclerosant injection, epinephrine injection,

heat probe, banding, and laser therapy.


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Hemobilia Loss of blood through biliary tree directly into the

duodenal lumen

secondary to operative trauma, prior percutaneousbiliary intubation.

Melena, jaundice and abdominal pain

angiography and treated by arterial embolization


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Thanks

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Stomach Raj 6 Sem UGI Bleed