Upper GIT Bleeding Kuliah

8/13/2019 Upper GIT Bleeding Kuliah

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NURSING CARE OFGASTRO INTESTINAL

TRACT BLEEDING

Purwoko Sugeng H


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Introduction

Upper gastrointestinal (GI) bleedingcommonly presents with hematemesis(vomiting of blood or coffee-ground likematerial) and/or melena and Hematochezia(usually indicate severe bleeding).A nasogastric tube lavage that yields blood orcoffee-ground like material confirms thediagnosis and predicts whether bleeding iscaused by a high-risk lesion.


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Introduction

Upper GI bleeds are considered medicalemergency, and require admission to hospitalfor urgent diagnosis and management.

Proximal bleeding to Ligament of Treits .


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Epidemiology

Incidence 150/100,000 population per year.

Overall mortality 10% in those admitted tohospital.

Mortality 30 % in the elderly.


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A prospective series of 1000 cases of severe UGI bleeding atthe UCLA and West Los Angeles Veterans AdministrationMedical Centers published in 1996 found the followingdistribution of causes:

Peptic ulcer disease 55 %Esophagogastric varices 14 %Arteriovenous malformations 6 %Mallory-Weiss tears 5 %Tumors and erosions 4 %eachDieulafoy's lesion 1 %Other 11 %

*Management of upper gastrointestinal bleeding in the patient with chronic liver disease. Jutabha R; Jensen DM Med Clin NorthAm 1996


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Etiology


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Patient assessment

Patient resuscitation

Risk assessment

Upper Endoscopy

Low risk lesion High risk lesion

SurgeryEndoscopic RxMedical Rx Rebleed


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Acute GI bleeding:

Immediate Assessment

Stabilization of hemodynamic status

Identify the source of bleeding

Stopping the active bleeding

Treat the underlying

Prevent recurrent bleeding


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Initial patient assessment

Initial approach to the patient with acute uppergastrointestinal bleeding should include near

simultaneous completion of the following:

Patient resuscitation and stabilization.Brief clinical history.

Limited physical examination.Both a gastroenterologist and a surgeonshould be promptly notified of all patientswith severe acute UGI bleeding.


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Patient resuscitation and

stabilization Check vital signsAssess airway and breathing

Assess circulatory status (posturalhypotension)Obtain intravenous access

Replace volumeTransfuse blood (if necessary)Measure urine output


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Cont.

Inspect airwayClear airwayCheck ventilation

Supplemental oxygenEndotracheal intubation:

Intubation and mechanical ventilation should be considered forthe following patients:

in shock from massive bleeding.on going hematemesis, especially if the bleeding is torrential.severe agitation.depressed sensorium.depressed respiratory status.


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A quick assessment of the circulatory status should bemade by:

pulse rate.measuring the supine blood pressurechecking for pallor and agitationpatients with normal supine blood pressure should be

checked for postural hypotension.


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Intravenous accessAt least two large bore (14 to 18 gauge) peripheralintravenous lines should be inserted for access and volume

replacement.Central Venous Catheter (CVC)

A CVC is usually not indicated because volume can easily bereplaced with large bore peripheral IV lines. However a CVCmay be useful in the following conditions:

failure to establish peripheral IV accesspatients who have an unstable cardiac disease or cirrhosis, inwhom measurement of left ventricular filling pressure isnecessary to accurately assess volume status.


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Volume replacement:

Volume should be replaced using crystalloids,such as 0.9% NaCl solution (normal saline) orRinger's lactate, as rapidly as the patient'scardiopulmonary status will allow, to stabilizevital signs


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Guidelines for transfusion of blood and blood products inUpper GI Bleed

Symptoms related to poor tissue oxygenation (e.g. angina).

If there is continued acute bleeding despite therapy.

If the patient is clinically shocked despite crystalloids.

If the hematocrit is low (in elderly, high risk patient Hct


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Nasogastric tube

Patients with definite or suspected acute uppergastrointestinal bleeding should have anasogastric (NG) tube inserted. There is nocontraindication to NG tube placement inpatients suspected to have esophageal or gastricvarices.

Once the NG tube has been placed, the stomachshould be lavarged with tap water or normalsaline at room temperature and then the tubeshould be connected to a gravity bag


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Brief History

Previous history of an upper gastrointestinalbleeding, if so what was the cause.

Symptoms or previous history of peptic ulcerdisease.Use of NSAID's, aspirin or anticoagulants.

Previous history of liver disease.

Risk factors for liver disease (e.g. alcoholconsumption, h/o blood transfusion, h/ohepatitis or jaundice).

Recent history of vomiting or retching.


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Brief History

History of heartburn.Abdominal pain.Any previous surgeries, especially recently.Any co morbid illnesses (e.g. cardiac,pulmonary or neurological illness, bleedingdisorders, etc).abdominal aortic aneurysm (AAA), orabdominal aortic vascular graft aortoenteric fistulaMelena.Hematochezia.


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Laboratory investigations

CBC

PT (INR), aPTTType and cross match bloodCreatinine, urea,Liver function testsHBSag and anti-HCV if liver disease is suspectedECG in patients over 50 years of age or h/ocardiac disease (boz they are more pron todevelop M.I.)


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Risk assessment

Mild to Moderate Upper GI Bleeding

The patient is < 60 years of age, and has nochronic medical illness.

There is no sign of hemodynamic instability.

Hematocrit is > 30%.


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Risk assessment

Severe Upper GI Bleeding

The patient is > 60 years old.

There are signs of hemodynamic instability (Pulse>100/min, SBP < 100 or postural hypotension).

There is active bleeding (bright red hematemesis, brightred blood in NG tube or hematochezia with hypotension).

Drop in hematocrit of 6% or more.

There is severe co morbid disease (liver, cardiac, pulmonaryor renal)


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Endoscopic diagnosis &treatment

Upper Endoscopy is the procedure of choice in majority ofpatients with an acute upper gastrointestinal bleeding, for thefollowing reasons:

It can define the source of bleeding in the majority ofpatients with an upper gastrointestinal bleeding.

It can stratify the patients risk of rebleeding.

It can provide endoscopic therapy for esophageal andgastric varices, peptic ulcer disease and vascularmalformations.


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Other diagnostic tests

For acute UGI bleeding include angiographyand a tagged red blood cell scan, which candetect active bleeding. UGI barium studies are contraindicated in thesetting of acute UGI bleeding because theywill interfere with subsequent endoscopy,angiography, or surgery.


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Balloon TamponadeSengstaken-Blakemore tube can control variceal hemorrhagein 40 80% patientsInflate gastric balloon first, the esophageal balloon if noimprovement


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Medication

Somatostatin: or its analog octreotide, whichhave been best studied in the treatment ofvariceal bleeding, may also reduce the risk ofbleeding due to nonvariceal causes . It can beused as adjunctive therapy before endoscopy,or when endoscopy is unsuccessful,

contraindicated, or unavailable.*Somatostatin or octreotide compared with H2 antagonists and placebo in the management of acute nonvariceal upper

gastrointestinal hemorrhage: a meta-analysis. Imperiale TF; Birgisson S Ann Intern Med 1997

*Failures of endoscopic therapy for bleeding peptic ulcer: an analysis of risk factors. Choudari CP; Rajgopal C; Elton RA; Palmer KRAm J Gastroenterol


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Medication

Erythromycin two randomized controlled trials (oneinvolving 105 patients and the other involving 41 patients),which have suggested that a single dose of intravenousErythromycin given 20 to 120 minutes before endoscopy cansignificantly improve visibility, shorten endoscopy time, and

reduce the need for a second-look endoscopy. Erythromycinpromotes gastric emptying based upon its ability to be anagonist of motilin receptors. Treatment appeared to be safe inboth studies. Thus, this approach can be considered in patientswho are likely to have a stomach full of blood such as thosewith severe bleeding. A reasonable dose would be to give 3mg/kg intravenously over 20 to 30 minutes, 30 to 90 minutesprior to endoscopy.

*Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial.AFrossard JL; Spahr L; Queneau PE; Giostra E; Burckhardt B; Ory G; De Saussure P; Armenian B; De Peyer R; Hadengue A .Gastroenterology 2002

*Erythromycin improves the quality of EGD in patients with acute upper GI bleeding: a randomized controlled study. Coffin B;Pocard M; Panis Y; Riche F; Laine MJ; Bitoun A; Lemann M; Bouhnik Y; Valleur P Gastrointest Endosc 2002


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Medication

Acid suppression . In the setting of active UGIbleeding, acid suppressive therapy with H2 receptorantagonists has not been shown to significantlylower the rate of ulcer rebleeding. By contrast, high dose antisecretory therapy withan intravenous infusion of proton pump inhibitor (IVPPI with pantoprazole or omeprazole) bloodtransfusion in high-risk ulcer bleeders treated withendoscopic therapy.

*Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinalbleeding. Dorward S; Sreedharan A; Leontiadis GI; Howden CW; Moayyedi P; Forman DCochrane Database Syst Rev. 2006

*Proton pump inhibitors versus H2-antagonists: a meta-analysis of their efficacy in treating bleedingpeptic ulcer. Gisbert JP; Gonzalez L; Calvet X; Roque M; Gabriel R; Pajares JM Aliment PharmacolTher 2001

*Estrogen/progesterone treatment of diffuse antral vascular ectasia. Manning RJ Am J Gastroenterol1995


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Surgical

If all the previous trearment fail consider thesurgical treatment


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Identify bleeding source:

1. N-G tube differentiate between upper/lowerGI bleeding.

2. Lavage

color and rapidity of clearing; clearthe field for esophagogastroduodenoscopy(EGD).

3. Initial EGD: within 24 hrs of bleeding.


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Stopping the active bleeding:

Most effective method: endoscopic therapy Laser therapy : requires significant training.Thermal contact : mono- (greater tissue injury)and bipolar electrocautery, heater probes.Widely available and require minimal training.Injection therapy : epinephrine (1:10,000

dilution) with or without various sclerosantsolutions. ( or + thermal contact).Rubber band ligation, metal clips.


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Treating the underlying Causes of acute Upper GI bleeding Ulcers: duodenal, gastric, esophageal Varices : esophageal, gastric, duodenal Mallory-Weiss tear

Dieulafoy's lesions Arteriovenous malformations Portal hypertensive gastropathy Gastric antral vascular ectasias (watermelon stomach)

Erosions Aorto-enteric fistula Crohn's disease Malignancy Hemobilia Pancreaticsource Foreign body ingestion or bezoar Causticingestion No site found


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Riwayat penyakit

Nyeri (kalau ada)

Perkiraan jumlahdarah


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Keadaanumum

kesadaran

TTVTandaanemia

Gejalahipovolemi


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Defisit volume cairan b.d kehilangan darahakut

Resti terhadap infeksi b.d aliran intravena

Ansietas b.d sakit kritis, ketakutan akankematian

Kerusakan pertukaran gas b.d penurunankapasitas angkut oksigen


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Upper GIT Bleeding Kuliah