9. WHEN CIRRHOTIC PATIENTS REQUIRE EGD?
⢠Expert opinion: EGD can be avoided in patients with
⢠Liver stiffness < 20 kPa
⢠Plt cont > 150,000/mm2
⢠Patients whom do not meet these criteria: EGD for GEV screening is
recommended
⢠Frequency:
⢠Q2yrs in ongoing liver injury (active alcoholic drinking)
⢠Q2yrs in presence of small varices
⢠Q3yrs in absence of ongoing injury
12. PATIENTS WITH UGIBâŚ
⢠Airway protection and resuscitation
⢠Define as EV or non-EV bleeding
⢠Mortality 20 â 80%
⢠Imaging study for ruling out HCC with portal vein thrombosis
⢠immediate goal of therapy in these patients is to
⢠control bleeding
⢠prevent early recurrence (within 5 days)
⢠prevent 6-week mortality
13. VARICEAL HEMORRHAGE MANAGEMENT
⢠Restrict PRC transfusion (threshold of Hb 7 g/dL and maintain Hb 7 â
9 g/dL)
⢠Correction of coagulopathy:
⢠NOT recommend to correct INR by FFP or FVII
⢠No recommendation for platelet transfusion
⢠High risk for bacterial infection: antibiotic prophylaxis by ceftriaxone
1 g IV q24h, maximum 7 days (discontinue when UGIB resolved and
vasoactive drug discontinued)
⢠Vasoactive drugs: somatostatin, octreotide, terlipressin show benefit
17. WHAT ABOUT SENGSTAKEN BLAKEMORE
TUBE
⢠Control bleeding by tamponade
effect
⢠Indications
⢠Active VH with fail med
⢠Active VH with EGD/vasoconstrictor
unavailable
⢠contraindications
⢠VH slow down
⢠Recent EGJ surgery
⢠Known esophageal stricture
18. SENGSTAKEN BLAKEMORE TUBE
PLACEMENT
⢠ETT intubation first
⢠Inflate GASTRIC balloon 50 ml ď Xray ď inflate balloon up to
250 ml
⢠1-kg traction
⢠Inflate ESOPHAGEAL balloon < 45 mmHg only when failed
gastric balloon
⢠Complication: esophageal or gastric rupture
24. INDICATIONS FOR SURGERY
⢠Uncontrolled bleeding by endoscopy
⢠Rebleeding after repeated endoscopic treatment
25. FORREST CLASSIFICATION: ENDOSCOPIC
FINDING
Forrest
classificatio
n
Endoscopic finding Incidence (%) Rebleed without Rx
(%)
Rebleed after Rx (%)
IA Spurting (active bleed) 12 55 15-30
IB Oozing (active bleed) 14 55 15-30
IIA Non-bleeding visible vessel
(recent bleed)
22 43 5
IIB Adherent clot (recent
bleed)
10 22
IIC Flat pigmented spot (recent
bleed)
10 10
III Clean base ulcer (no active
bleed)
32 5
26.
27.
28.
29.
30. TAKE HOME MESSAGEâŚ
⢠When an UGIB patients come to ER ď look for emergency
condition
⢠Define EV or non-EV
⢠Cause of bleeding can be from oral to ligament of Treitz
⢠EV: only medical and endoscopic
⢠Non-EV: medical ď endoscopic ď surgical
31. REFERENCES
Garsia-Tsao G, et al. Portal Hypertensive Bleeding in Cirrhosis: Risk
Stratification, Diagnosis, and Management: 2016 Practice Guidance by the
American Association for the Study of Liver Diseases. Hepatol.
2017:65(1);310-335.
Procopet B and Berzigotti A. Diagnosis of cirrhosis and portal hypertension:
imaging, non-invasive markers of fibrosis and liver biopsy. Gastroenterology
report. 2017:5(2); 79-89.
Brunicardi FC et al. Schwartzâs Principles of Surgery. 10th ed. McGraw-Hill Education, 2015.