UPPER GI BLEED-final - Copy

8/7/2019 UPPER GI BLEED-final - Copy

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PRESENTER- PRASANNAKUMAR KAMBLE

MODARATOR- DR H M VIJAYKUMAR



` A common ,potentially DEADLY condition .

` Accounts for 170 cases/100000

` 1-2% of all admissions

` Men > women .3:1

` Mortality 10%.

Sabiston



` Bleeding from a source proximal to the ligament of

Trietz .



` Upper: Lower GI bleeding = 5:1

` Incidence: 50-100 per 100,000 pts.

` 100 per 100,000 hospital admission.

` 30% pts are older than 65 years 80% are self-limited.

20% of pts who have recurrent bleeding (within

48-72 hrs) have poor prognosis.



1) Peptic ulcer disease - most common

cause

A) duodenal ulcers 29%

will rebleed in 10% of cases within24-48h

B) gastric ulcers 16%

more likely to rebleed

C) stomal ulcers <5%



` 2) Erosive gastritis, esophagitis, duodenitis

some causes are ETOH, ASA, NSAID¶s

` 3) PORTAL HYPERTENSION RELATED

esophageal varices gastric varices

portal hypertensive gastropathy

` 4) Mallory-Weiss syndrome ± longitudinal

mucosal tear in the cardioesophageal

region

caused by repeated retching



` WATER MELON STOMACH

` ESOPHAGITIS ±INFECTION

` DIEULAFOY S LESION

` AORTODUODENAL FISTULA

` ANGIODYSPLASIAS

` CROHN S DISEASE

` HEMOBILIA

` HEMORRHAGE FROM PANCREATIC SOURCE.









` Get to patient¶s bedside, assess ABC` Can the patient protect his airway?

Does he need to be intubated?

` Is the patient hemodynamically unstable?

Is he in hemorrhagic shock?` 2 large bore IV, Bolus 2L fluids, Type & Cross

blood, send CBC & Coags

` Place patient on O2 & continuous monitor

`

Place an NGT and lavage with NS To confirm if the bleeding source is upper GI

look for need for blood transfusion



Estimated Fluid and Blood Losses in Shock

Class 1 Class 2 Class 3 Class 4

Blood Loss,mL

Up to 750 750-1500 1500-2000 >2000

Blood Loss,%blood volume

Up to 15% 15-30% 30-40% >40%

Pulse Rate,bpm

<100 >100 >120 >140

BloodPressure

Normal Normal Decreased Decreased

RespiratoryRate

Normal orIncreased

Decreased Decreased Decreased

UrineOutput,mL/h

14-20 20-30 30-40 >35

CNS/MentalStatus

Slightlyanxious

Mildlyanxious

Anxious,confused

Confused,lethargic

Fluid

Replacement,3-for-1 rule

Crystalloid CrystalloidCrystalloidand blood

Crystalloidand blood



Criterion Score` Age <60 years 0

60-79 yrs 1

>80 years 2

` Shock None 0Pulse & sBP >100 1

sBP <100 2

` Co-morbidity None 0

Cardiac/any major 2Renal/liver/malig. 3

` Total initial score (max = 7)



Initial risk 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%

R ockall TA et al Gut 1996; 38: 316-21







Signs of shock Cold clammy extremitiesPoor mentation

Rectal examinationOccult bloodGross bloodBright red blood per rectumMelena

Blood coating stools versus within stoolsBloody diarrhea



` CBC; BUN, Cr; LFT, PT, PTT in all cases

` Others as indicated: Type and crossmatch

AST, ALT, GGTP, bilirubin Albumin, total protein



Packed cells are the preferred

Aim -restore lood volume and pressure and to

correct anaemia to maintain the oxygencarrying capacity.

Fresh frozen plasma given prothrom in time is

at least 1.5 times higher than the control value.

Platelet transfusion platelet count is elow

50 000/mm3.





` Age >60 yr

` Comorbid disease

` Renal failure

` Liver disease

` Respiratory insufficiency

` Cardiac disease

` Magnitude of the hemorrhage

` Systolic blood pressure <100 mm Hg on

presentation

` Transfusion requirement >4 units

` Persistent or recurrent hemorrhage

` Onset of hemorrhage during hospitalization

` Need for surgery



` History

` NG Tube

` EGD

` Colonoscopy` Tagged RBC Scan

` Angiography



Probable Source of GI Bleeding Within the Gut

ClinicalIndicator

Probability of Upper GI

Source

Probability of Lower GISource

HematemesisAlmostcertain

Rare

Melena Probable Possible

Hematochezia Possible Probable

Blood-

streaked stoolRare

Almost

certain

Occult bloodin stool

Possible Possible

HISTORY



Effect of the Color of the Nasogastric Aspirate and of the Stool onUGIB Mortality Rate

Nasogastric

Aspirate Color

Stool

Color

Mortality

Rate, %

Clear Brownor red

6

Coffee-groundBrown

or black8.2

Red 19.1

Red blood Black 12.3

Brown 19.4

Red 28.





` PHARMACOLOGICAL

` ENDOSCOPIC

` Topical treatment

` Injection treatment` Mechanical treatment

` Thermal treatment

` ANGIOGRAPHIC

` SURGICAL



` Most common cause ~ 25 %

` Mortality rates slight declining !

` 5 % initial manifestation.

` 20 % at least once.

` Hemorrhage lethal ; 80 % deaths due to acuteepisode..



` H.PYLORI INFECTION

` NSAID¶S

` ANTICOAGULANTS

` CHONIC SYSTEMIC DISEASES` HOSPITALISED PATIENTS

` ETHANOL

` GLUCOCORTICOIDS

` COX-2 INHIBITORS

` ZOLLINGER SYNDROME



` Ongoing leed

` Low systolic pressure ( i. e.,<100 mmhg excludingothostatic measures)

` Elevated prothrom in time (i.e.,>1.2 times the control)

` Altered mental status

` Presence of co mor id disease ( define)

Presence of any one 3 fold risk ,independent of endoscopy findings







Bleeding vessel (re leed 80%)Visi le vessel (re leed 50%)Fresh clot (re leed 30%)

Black spots ulcer ase (re leed 5%)Clean ulcer ase (re leed <1%)





Nuclear Medicine Techniques in the

Diagnosis of Gastrointestinal Bleeding

After the intravenous injection of either sulfur colloid

or

la eled red lood cells, images are made over theupper and lower a domen

.Bleeding rates as low as 0.1 ml per minute may e

detected.





H. pylori eradication

1st line

x PPI + clarithromycin (500mg OD) +

amoxicillin (1000mg BID) or metronidazole(500mg) if patient has a penicillin allergy

2nd linex PPI + ismuth + metronidazole + tetracycline







INJECTION THERAPY

Adrenaline

The ethanol is injected slowly, in amounts of

0.1 to 0.2 ml per injection, at three or four sites

surrounding the leeding vessel and 1 or 2 mm

from the vessel .



Sclerosants

1% polidocanol, alcohol and ethanolamine .

Polidocanol causes haemostasis y inducing

owel wall spasm and early oedema with

su sequent inflammation and throm osis of

the vessel.

A solute alcohol stops leeding y causing

rapid dehydration and fixation of the tissue,

thus o literating the leeding vessel.



Procoagulants (Throm ogenic Agents)

Human throm in and fi rin sealant

Technique

video-gastroscope (3.7 or 4.2mm workingchannel) with a disposa le 23 or

25 gauge sclerotherapy needle is

recommended.

4-16 ml of 1:10,000 adrenaline,

in 0.5ml aliquots is injected into and around

the leeding point until the leeding stops



Thermal Modalities

Contact and non-contact methods

. Monopolar elect rocoag ulationDue to an unpredicta le depth of coagulation,

monopolar electrocoagulation is no longer recommended

M ul ti polar elect rocoag ulation

Consists of 3 pairs of electrodes arranged in a linear array at the tip and connected to a power generator.

The flow of the electrical current is limited thus

avoiding pro lems with grounding and a errant current.





Thermal non-contact methods

Argon Plasma Coagulation

Argon plasma coagulation (APC) is a special

electrosurgical modality in which high

frequency electric current is conducted

µcontact-free¶ through ionized and thus

electrically conductive argon (argon plasma)into the tissue to e treated.







` FAILED E NDOSCOPY

` EVIDE NCE OF ER OSIO N OF MAJOR VESSEL

` BLOOD LOSS EXCEEDING HALF A BLOOD

VOLUME

` NO E NDOSCOPY.



































` Vasopressin potent splanchnic vasoconstrictor.

I v olus 20 u over 20 mins and then continuous

infusion of 0.2 to 0.4 u/min ,then taper to 0.1u/min.

` Causes hypertension, radycardia decreased

cardiac output and coronary vasoconstriction. Nitroglycerin adminstered simultaneously

40 micro g / min .



` Somatostatin 250 micro g I v olus followed y

continuous infusion of 250 micro g / hr for 2-4 days.

` Now octreotide 50 micro g olus plus infusion is eing

used .













` Stress gastritis , acute mucosal ischemia, erosive

gastritis or stress ulcer

` Predominant in ody

` Distinct from

NSA

IDassoc mucosal erosion

` Sepsis, respiratory failure,coma following head injury

or intracranial operation



` 10 % UGIB

` Tear in proximal gastric mucosa near esophagogastric junction

` History vomiting, retching or coughing followed y

hemetemesis` Mean age >60 years ; 80 % men

` 90 % stop spontaneously

` Antisecretory drugs.



` Laporotomy for oversewing of the mucosal tear

through high gastrotomy

` Acid reducing procedure not required.

` Photo



Bleed from cancer of thegastrointestinal tract,esophageal cancer,gastric cancer gastriclymphoma,gastrointestinal stromaltumors, and metastatic

tumorsSource Only 15%



` These lesions are unusually large su mucosal or

mucosal vessels

` R are cause

`

Superficial erosion usually lesser curvature` Sclerotherapy ,electrocoagulation not effective

` Surgical excision



` R ecently recognised

` When arranged in linear pattern in antrum of the

stomach gastric antral vascular ectasia (GAVE)or

WATER MELO N stomach

` Pathogenesis unknown.

` Surgical excision.



` Uncommon` Inflammator tract e elops bet een aorta and IT

` Infectious aortitis,or inflammator aortic aneur sms or

f ollowing aortic re placements

` ndoscopy mandator y

` T ,ot ers emer gency angiogra phy

` Emer gency la por otomy,contr ol of pr oximal aorta.

`

Extra anatomic ascular bypass.



Protective role for nitric oxide no

Video capsule endoscopy

Endoloops detacha le nylon snares.



PillCam SB

± 11 mm x 26 mm

± 1 camera

± 2 frames per second

± Std optics / 1 lens

± Standard lighting control

± Standard angle of view (AOV)

140°

± Depth of field 0-30 mm

PillCam SB 2

± 11 mm x 26 mm

± 1 camera

± 2 frames per second

± New optics / 3 lenses

± Advanced Automatic Light Control

± Extra wide angle of view (AOV)

156°

± Depth of field 0-30 mm



Bleeding

Celiac DiseaseTumors

Suspected Crohn¶s



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UPPER GI BLEED-final - Copy