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Master
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Continous Medical
Education (CME)
Md Azhari
HOSPITAL KAJANG
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Clinical Case Master
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68 / C/ Gentleman is admitted to the hospital with
CC: emesis of bright red blood.
Patient reports that he was shopping when he
began throwing up blood at the store. He denies any
associated pain, melena, hematochezia, liver
disease, or prior episodes.
Patient reports some lightheadedness with
standing, denies CP, SOB, visual disturbances.
He is taking indomethicin for gout. Patient denies
abdominal pain, chest pain, cough and diarrhea.
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PMHx:
Gout, HTN
He had a gout flare up while in the hospital 3 months
ago and was discharged home with a steroid taper. He
was prescribed Indomethacin 50 mg po q 8 hr prn pain
but he was taking it daily for the last month.
PSHX: Nil
Allergic Hx : NKA
FAMILY Hx : Gout
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Physical examination:
Alert and Concious, Lethargic, no stigmata of chronic
liver disease
Vital sign : BP – 104/70 PR-104 RR-26 T-37
Eyes: conjunctiva pale, no icterus
Chest: Clear
CVS: DRNM
Abdomen: Soff NT, No Organomegaly, +BS
Rectal: no stool
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Resuscitation Master
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• Airway
- secure the airway
- Intubate if necessary
- Prevent risk of aspiration pneumonia
• Breathing
- give supplemental oxygen
- Monitor SpO2 > 96%
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• Circulation
-Insert 2 large bore branula (16G) on each arm.
-Consider CVP line in elderly with profound shock and
significant comorbid.
-Do blood i(x) for : FBC, LFT, clotting profile, GXM,
BUSE and creatinine, Glucose level.
-Give crystalloid (Normal Saline, Hartman).
-Give colloid infusion (Gelofusil) if in shock.
-Monitor vital signs. Do baseline ECG in elderly.
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Investigations title style
• FBC- Hb, platelet
• Coagulation profile
• RP
• LFT
• GXM
• Endoscopy
• ECG
• Chest X-ray
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Blood transfusion should be given if:
- systolic BP < 110 mmHg.
- Significant postural hypotension.
- Persistent tachycardia >110/min
- Initial Hb < 8g/dL
- Hb < 10 g/dL + CVs Disease
Give FFP if INR >1.5 or PT is prolonged.
Transfuse platelet if <50,000/mm3
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Endoscopy Master
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Done after patient stable hemodynamically.
For diagnostic, therapeutic and risk stratification.
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Master
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Forrest Classification For
Bleeding Peptic Ulcer
Ia: Spurting bleeding
Ib: Non spurting active bleeding
IIa: Visible vessel (no active bleeding)
IIb: Non bleeding ulcer with underlying clot (no
visible vessel)
Ilc: Ulcer with hematin covered base
III: Clean ulcer ground (no clot, no vessel)
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Master
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Malaysian Society Of Gastroenterology & Hepatology
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Risk of Rebleeding And Mortality In title style
Patients With Peptic Ulcer Bleeding
Endoscopic Risk of Mortality (%)
Finding Rebleeding (%)
Active Bleeding 55 11
Visible vessel 43 11
Adherent clot 22 7
Flat spot 10 3
Clean base 5 2
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Esophageal Varices Master
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The Japanese classification is the preferred grading scale
for the staging of oesophageal varices
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Classification of gastric varices is based on location, size
and endoscopic features of the varices
Gasroesophageal Varices (GOV) extend beyond the
gastro-oesophageal junction (OGJ) and are always
associated with oesophageal varices
GOV Type I : The varices are a continuation of
oesophageal varices and extend for 2-5 cm below the
OGJ along the lesser curvature of the stomach.
GOV Type II : The varices extend below the OGJ
towards the fundus of the stomach.
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Isolated gastric varices (IGV) : Gastric varices in
the absence of oesophageal
varices
IGV Type I : The varices are located in the fundus
of the stomach and fall short of the cardia by a few
centimetres.
IGV Type II: Include isolated ectopic varices and
can present anywhere in the stomach.
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Peptic Ulcer
Oesophageal / Gastric Varices.
Other causes.
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Endoscopic
Medical
Surgical
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Medical treatment title style
High dose PPI needs to be given.
H.pylori eradication regime
Pantoprazole 40 mg bd
Amoxycillin 1 gm bd 1/
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Clarithromycin 500 mg bd
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Surgical Treatment Master
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INDICATION
• Bleeding cannot be control endoscopically
• Failure conservative therapy
• Malignancy cannot be excluded or suspected
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GASTRIC ULCER edit
Master
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Billroth I gastrectomy ( distal ulcer )
Billroth II gastrectomy ( proximal ulcer)
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DUODENAL ULCER title style
Partial gastrectomy (Polya or Billroth II)
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COMPLICATIONS title style
Early complications
Hemorrhage
Suture line leakage - peritonitis
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Intermediate complications (for title style
gastrtic resection)
Vomiting
Dumping
Diarrhoea
General nutritional effects
Anaemia – megaloblastic anaemia ( def B12 and folate )
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Late complications
Carcinoma
Cholelithiasis
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Master
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Esophageal Varices
Gastric Varices
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Esophageal Varices title style
1-Resuscitation
2-Pharmacotherapy
IV Terlipressin: 2mg bolus and 1mg every 6 hours for 2-5 days
IV Somatostatin: 250mcg bolus followed by 250mcg/hour infusion
for 5 days
IV Octreotide: 50mcg bolus followed by 50mcg/hour for 5 days
Metoclopramide - constrict lower oesohageal sphincter and empty the stomach
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3-Antibiotic prophylaxis in patients with
cirrhosis
Norfloxacin 400mg bd
/ Ciprofloxacin 500mg bd
/ IV 200mg bd 1/
/ Third generation cephalosporins 52
(e.g. Ceftriaxone 1g daily)
4-Upper GI Endoscopy
- As soon as possible
-If endoscopy is unavailable and there is presence of active
bleeding, consider balloon tamponade and referral to tertiary centre
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5-Control of Bleeding
-Endoscopic variceal ligation (EVL) is recommended
-Endoscopic sclerotherapy can be used if EVL is
technically difficult
6-Persistent Active Bleeding
-Consider repeating endoscopy, TIPS or surgical
intervention
-Balloon tamponade may be considered
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Secondary PROPHYLAXIS
-Non-selective beta-blockers, EVL or both should be
used Rx offirst choice
• Propanonol 20mg bd stat and increase to 40-80 mg tds until resting HR is
reduced by 25%
-TIPS or shunt surgery if non-compliant or refractory to
pharmacological and/or endoscopic therapy
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Gastric Varices title style
GOV Type 1
Treat as for oesophageal varices
GOV Type 2 and IGV
- For acute bleeding: injection with cyanoacrylate
-If persistent active bleeding
• TIPS or surgical intervention
• Balloon tamponade should be considered
-Secondary prophylaxis
• Beta-blockers, injection with cyanoacrylate or TIPS
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ALGORITHM: MANAGEMENT OF ACUTE VARICEAL BLEEDING
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Sengstaken-Blakemore Tube title style
Indication
-bleeding from oesophagus or gastric varices that
fails medical treatment or endoscopic heamostasis
failed or unavailable.
Contraindication
Variceal bleeding stops or slows
Recent surgery that involved the esophagogastric
junction
Known esophageal stricture
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Steps edit
Master
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• Positioning- 45⁰ / left lateral decubitus
• Analgesia- spray / jelly
• Check balloons
• Estimate length
• Lubricant
• Insert the tube preferably through mouth but can
also thorough nostril.
• Suction of gastric content
• Inflate gastric balloon (450-500mL water)
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• Secure proximal end using traction device (0.45-
0.91 kg) or use 500mL bag of IV fluid or use
football helmet
• Inflate oesophageal balloon (30-45mmHg air)
• If bleeding persist increase external traction
(max 1.1kg)
• If bleeding controlled deflate oesophagus
balloon by 5mmHg every 4-6hrs for 5-10 minutes
maintain 12-24 hrs remove
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• If bleeding recurs reinflate gastric ballon ± Master
oesophageal balloon for another 24 hrs title style
• If fail consider :
• Stapled oesophago-gastric junction
• Portosystemic shunting/ tranjugular
intrahepatic portosystemic stent
shunting (TIPSS)
• Liver transplant
For benign distal ulcer. The distal part of the stomach removed and anastomosed to duodenum. If proximal ulcer need polya invlving anastomosis of gastric remnant to jejunum
Aim to reduce acid n pepsin secretion by stomach. Ach cmpnt of secretion pathway interrupted. But drawback is stomach motility is decreased and pyloric sphincter fails to relax. Need drainage.