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  1. 1. APPROACH TO PATIENT WITH Acute upper gastrointestinal haemorrhage / bleeding By:- Jwan Ali Ahmed AlSofi
  2. 2. Contents  Introduction. Definition and epidemiology  Etiology Risk factors Assessment Complications Prognosis
  3. 3. Introduction  Acute UGIB is a potentially life-threatening condition  It associated with 10 % mortality rate  UGIB is defined as bleeding derived from a source proximal to the ligament of Treitz  Can be divided into variceal and non-variceal. – Variceal is a complication of end stage liver disease. – While non variceal bleeding associated with peptic ulcer disease or other causes of UGIB.  UGIB is 4 times more common than bleeding from lower GIT, with a higher incidence in male.
  4. 4. Definition of UGIB Upper GI bleeding is a bleeding arising from a source above ligament of Treitz.ie above third part of duodenum
  5. 5. Definitions:- 1. Hematemesis: vomiting of blood ,could be: either 1. Digested blood in the stomach (coffee-ground ) emesis that indicate slower rate of bleeding 2. Fresh/unaltered blood (gross blood and clots, indicates rapid bleeding) 2. Melena: – stool containing of partially digested blood – Criteria:- black tarry, semi-solid, shiny and has a distinctive odor – when its present it indicates that blood has been present in the GI tract for at least 14 h. – The more proximal the bleeding site, the more likely melena will occur. 3. Hematochezia:- – usually represents a lower GI source of bleeding – an upper GI lesion may bleed so briskly that blood does not remain in the bowel long enough for melena to develop.
  6. 6. Clinical scenario  A 35 years old male patient presents with sudden onset of vomiting of blood of few hours duration  Approach to management of this patient entails a knowledge of : – The causes of UGIB – Assessing the severity of UGIB – The available diagnostic measures – The available therapeutic measures
  7. 7. Causes
  8. 8.  Dieulafoy's lesion (a vascular malformation of the proximal stomach).  Angiodysplasia.  Haemobilia (bleeding from the gallbladder or biliary tree).  Pancreatic pseudocyst and pseudo-aneurysm.  Aortoenteric fistula.  Bleeding diathesis.  Ehlers-Danlos syndrome.  Pseudoxanthoma elasticum.  Gastric antral vascular ectasia ( GAVE).  Osler-Weber-Rendu syndrome. Rare causes of Upper GI Bleeding:
  9. 9. Assessment  History  Examination  Investigation  Hospital admission  Management
  10. 10. Approach to a patient in distress  If the patient looks agitated, dizzy ,weak and pale, – 1st check the vital sign before taking full history – If hypotensive put an IV line and start IV fluid – Take blood sample for lab ix e.g. CBC. ,B.urea, INR , fibrinogen level….etc – Asses the Blatchford score:  history of : melena, liver ds , HF, syncope  Vital Sg,  Hb,  BU ,
  11. 11. Assessment: History: 1. Features of blood loss: wheather hematemesis , melena, hematochezia bright or clot of blood 2. Systemic manifestation of blood loss; shock syncope, anemia 3. Clincal features of underlying cause: dyspepsia, jaundice, weight loss 4. Ask about Other causes of black stool 5. History of epistaxis or hemoptysis: to rule out the GI source of bleeding.
  12. 12.  Drug history: NSAIDs, Aspirin, corticosteroids, anticoagulants, (SSRIs) particularly fluoxetine and sertraline.* Iron preparation, Bismuth cause blck stool;  Past medical :previous episodes of UGIB, DM; coronary artery disease; chronic renal or liver disease; or chronic obstructive pulmonary disease.  Past surgical: previous abdominal surgery
  13. 13. Examination  The main aim of examination is to:  assess the amount of blood loss and  look for signs of shock.  A secondary aim is to look for  signs of underlying disease and  significant comorbid conditions , for example: liver ds renal ds, COAD.
  14. 14. • SIGNS of shock: Cold extremeties, Tachycardia, Hypotension Chest pain, Confusion, Delirium, Oliguria, and Vital Sign (VS): Pulse = Thready pulse BP = Orthostatic Hypotension • postural hypotension may be detected and usually indicates a blood loss of 20% or more. Approach Cont. Examination :
  15. 15. • Skin changes: Cirrhosis – Palmer erythema, spider nevi Bleeding disorders – Purpura /Echymosis Sign of Coagulation disorders – Haemarthrosis, Muscle hematoma. • Signs of dehydration (dry mucosa, sunken eyes, skin turgor reduced). • Signs of a tumour may be present (nodular liver, abdominal mass, lymphadenopathy, and etc. • Subcutaneous emphysema and vomiting suggests Boerhaave's syndrome. • DRE : fresh blood, occult blood, bloody diarrhea • Respiratory, CVS, CNS  For comorbid diseases
  16. 16. Investigations Laboratory - CBC - Cross matching. - Coagulation profile - LFT - RFT & electrolyte. - Gastrin level. Imaging - CXR - Abdominal X-ray - CT scan & US - Nuclear medicine - Angiography
  17. 17. • complete blood count (CBC):- • amount of blood loss. • CBC should be checked frequently(q4-6h) during the first day. • Hemoglobin Value, Type and Cross match Blood – Hb < 10gm is an indication for blood or packed RBC transfusion – The patient should be cross matched for 2-6 units, based on the rate of active bleeding. – The hemoglobin level should be monitored serially in order to follow the trend. – An unstable Hb level may signify ongoing hemorrhage requiring further intervention. – normal Hb level at presentation doesn't exclude severe bleeding, up to 48 hr may take for complete hemodilution to occurs Lab Diagnosis :
  18. 18. Lab.Investigations  The BUN-to- Creatinin ratio increases in (UGIB). – A ratio of greater than 36 in a patient without renal  The prothrombin time (PT), International Normalized Ratio (INR) and activated partial thromboplastin time( APTT), should be checked to document the presence of a coagulopathy • Prolongation of the PT based on an INR of more than 1.5 may indicate moderate liver impairment. • A fibrinogen level of less than 100 mg/dL also indicates advanced liver disease with extremely poor synthetic function
  19. 19. • Liver FT- to detect underlying liver disease • Renal FT- to detect underlying renal disease • Calcium level- to detect hyperparathyroidism and monitoring calcium in patients receiving multiple transfusions of citrated blood • Gastrin level • Cardiac enzymes and ECG- An electrocardiogram (ECG) should be ordered to exclude arrhythmia and cardiac disease, especially acute myocardial infarction due to hypotension
  20. 20. Investigations Endoscopy : Endoscopy is the primary diagnostic investigation in patients with acute UGIB.  Endoscopy should be undertaken immediately after resuscitation and stabilization of the hemodynamic status Preferably within 24 hours of admission  endotracheal intubation (may be needed), and adequate monitoring in an intensive care unit (ICU) setting have been achieved.
  21. 21. Aetiology  Common causes: Peptic ulceration
  22. 22. • Computed tomography (CT) and ultrasonography may be indicated for the evaluation of • liver disease with cirrhosis, • cholecystitis with hemorrhage, • pancreatitis with pseudocyst and hemorrhage, • aortoenteric fistula, and • other unusual causes of upper GI hemorrhage. • Nuclear medicine scans may be useful in determining the source of active hemorrhage when the cause of bleeding is obscure Cont, Investigations of UGIB
  23. 23. Angiography :  Angiography may be useful if bleeding persists and endoscopy fails to identify a bleeding site. Angiography along with transcatheter arterial embolization (TAE) should be considered for pt – with a known source of arterial UGIB that does not respond to endoscopic management, – with active bleeding and a negative endoscopy.  In cases of aortoenteric fistula, angiography requires active bleeding (1 mL/min) to be diagnostic.
  24. 24. • CHEST X-RAY-Chest radiographs should be ordered to exclude aspiration pneumonia, effusion, and esophageal perforation. • Abdominal X-RAY- erect and supine films should be ordered to exclude perforated viscous and ileus. Imaging :
  25. 25. Nasogastric Lavage  A nasogastric tube is an important diagnostic tool. 1. Give crude estimation of rapidity of bleeding 2. Better visualization during endoscopy 3. Prevent the development of Porto systemic encephalopathy in cirrhosis 4. Increases PH of stomach, and hence, decreases clot desolation due to gastric acid dilution 5. Tube placement can reduce the patient's need to vomit – During gastric lavage use saline and not use large volume of water to avoid water intoxication. – Gastric lavage should be done in alert and cooperative patient to avoid bronco-pulmonary aspiration
  26. 26. Steps of Management 1. Resuscitation to Stabilize the patient hemodynamic stutus by restoring the circulation. 2. Assess the Blatchford score severity of the UGIB 3. Identify the source of bleeding. 4. Definitive treatment of the cause.
  27. 27. Resuscitation and initial management  Protect airway: position the patient on side  IV access: use 1-2 large bore cannula  Restore the circulation: – Either colloid or crystalloid solutions may be used to achieve volume restoration prior to administering blood products; if pts haemodynamically stable give 5%G.W. infusion, if not give colloid 500ml/1hr and then crystalloid and continue until blood is available.  Assess Blatchford score : this need knowledge of the following: – Hb, B.urea, BP. PR, presence of melena or syncope, sg&sx of heart failure or liver disease
  28. 28. Hospital admission Consider for admission and early endoscopy (and calculation of full Rockall score) if:  aged ≥60 years (all patients who are aged >70 years should be admitted); or  witnessed haematemesis or haematochezia (suspected continued bleeding); or  haemodynamic disturbance (systolic blood pressure <100 mm Hg, pulse ≥100 bpm); or  liver disease or known varices.
  29. 29. Risk assessment Use the following formal risk assessment scores for all patients with acute upper gastrointestinal bleeding: – the Blatchford score at first assessment, and – the full Rockall score after endoscopy.
  30. 30. Interpretation of Blatchford score  A score of 0 is the cut-off with any patient scoring >0 being at risk of requiring an intervention e.g. endoscopy or blood transfusion.  Score >6 were ass.w >50% risk of needing an intervention  Score 0 indicate low risk, pt suitable for out patient management. If:  Hb>12.9g/dl (men )or >11.9gm/dl (women) ,Systolic BP>109mm Hg, PR<100 bpm, BUN<18.2mg/dl, no melena or syncope, no past or present liver or heart disease
  31. 31. Risk assessment The full Rockall score  This is determined after endoscopy  used to assess the risk of re- bleeding  Attempts to identify patient of adverse outcome and predict mortality  A convenient mnemonic is ABCDDE- i.e. Age, BP fall (shock),Co-morbidity, Diagnosis, and Evidence of bleeding  National Institute for Health and Clinical Excellence (NICE)
  32. 32. Blood and blood product transfusion:  Decisions on blood transfusion should be based on the full clinical picture  red cell transfusion should be considered after loss of 30% of the circulating volume  Prothrombin complex concentrate should be used for patients who are taking warfarin and actively bleeding.  Recombinant factor Vlla should not be used except when all other methods have failed.
  33. 33.  Platelet transfusions should be offered to patients who are actively bleeding and have a platelet count of less than 50 x 109/litre.  Fresh frozen plasma should be used for who are actively bleeding and have either  a prothrombin time (INR) or activated partial thromboplastin time (APTT) greater than 1.5 times normal.  a. a fibrinogen level of less than 1 g/litre,  If a patient's fibrinogen level remains less than 1.5 g/litre despite fresh frozen plasma use, offer cryoprecipitate as well.
  34. 34. Proton pump inhibitors  Do not offer acid-suppression drugs (proton pump inhibitors or H2-receptor antagonists) before endoscopy to patients with suspected non-variceal upper gastrointestinal bleeding.  Offer proton pump inhibitors to patients with non-variceal upper gastrointestinal bleeding and stigmata of recent haemorrhage shown at endoscopy.
  36. 36. Management of non- variceal bleeding Endoscopic treatment one of the following interventions should be used: 1. A mechanical method (eg: clips) with or without adrenaline (epinephrine). 2. Thermal coagulation with adrenaline (epinephrine). 3. Fibrin or thrombin with adrenaline (epinephrine). *** Do not use adrenaline as monotherapy for the endoscopic treatment of non-variceal upper GI bleeding.
  37. 37. Treatment after first or failed endoscopic treatment:-  Indications for a repeat endoscopy:- 1. for all patients at high risk of re-bleeding, 2. if there is doubt about adequate haemostasis at the first endoscopy. 3. patients who re-bleed with a view to further endoscopic treatment or emergency surgery.  Offer interventional radiology to unstable patients who re-bleed after endoscopic treatment.  Refer urgently for surgery if interventional radiology is not promptly available.
  38. 38. Argon plasma coagulation (APC) 42
  39. 39. 43
  40. 40. Surgical intervention in UGIB Age over 60 years: • Transfusion >4 units in 24 hours. • One re-bleeds. • Continued bleeding. Age under 60 years: • Transfusion >8 units in 24 hours. • Two re-bleeds. • Continued bleeding.
  41. 41. Managment of variceal bleeding  Vasopressin is a potent splanchic vasoconstrictor agent continuous IV infusion of 0.2-0.4 IU/min, (should not be given via a central IV line,)  Vasopressin always sb accomp. By IV nitroglycerin at a dose of 40mcg/min not to excced 400 mcg/min to maintain systolic BP greater than 90mmHg  Terlipressin is a synthetic analogue to Vasopressin have longer biologic activity and fewer SE than vasoprissin.  Treatment should be stopped after definitive haemostasis has been achieved, or after five days, unless there is another indication for its use.  Octeriotide a synthetic analogue of somatostatin is DOC in acute variceal bleeding is usually adminstered at a dose of 50mcg/hour (i.e 1 vial of 0.1mg in 2 hours -12 vial for 24hours)
  42. 42.  Prophylactic antibiotic therapy should be offered at presentation to all patients with suspected or confirmed variceal bleeding.  Balloon tamponade should be considered as a temporary salvage treatment for uncontrolled variceal haemorrhage Management of Variceal bleeding Cont.
  43. 43. Complications could be: -gastric and oesophageal ulceration. -pneumonia. -oesophageal perforation. Balloon tamponade
  44. 44. Band ligation
  45. 45. Stent insertion Oesophageal stent insertion is generally a very safe procedure,but there are some risks: 1- Occasionally a little bleeding can occur during the procedure. 2- Some people get heartburn and acid reflux afterwards. 3- Rarely the stent may slip out of the position. 4- Very rarely, the placement of a stent may cause a tear in the oesophagus.
  46. 46. Transjugular intrahepatic portosystemic shunts (TIPS) *Transjugular intrahepatic portosystemic shunting is an effective salvage procedure for stopping acute variceal haemorrhage, controlling bleeding from gastric varices, and congestive gastropathy after failure of medical and endoscopic treatment.
  47. 47. Gastric varices 1. Endoscopic injection of Nbutyl-2cyanoacrylate. 2. Transjugular intrahepatic portosystemic shunts Gastric varices are difficult to be banded
  48. 48. Control of bleeding and prevention of re-bleeding in patients on NSAIDs, aspirin or clopidogrel  Continue low-dose aspirin for secondary prevention of vascular events in patients with upper gastrointestinal bleeding in whom haemostasis has been achieved.  Stop other non-steroidal anti-inflammatory drugs (including cyclooxygenase-2 [COX-2] inhibitors) during the acute phase in patients presenting with upper gastrointestinal bleeding.  Discuss the risks and benefits of continuing clopidogrel (or any other thienopyridine antiplatelet agents) in patients with upper gastrointestinal bleeding with the appropriate specialist (for example, a cardiologist or a stroke specialist) and with the patient.
  49. 49. Questions