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Discuss the management of upper gastrointestinal haemorrhage

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material for step by step management of upper GI bleeding

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Discuss the management of upper gastrointestinal haemorrhage

  1. 1. DISCUSS THE MANAGEMENT OF UPPER GASTROINTESTINAL HAEMORRHAGE DR BASHIR YUNUS SURGERY DEPARTMENT AKTH 14th October 2014 10/13/2014 1
  2. 2. OUTLINE •INTRODUCTION •PRINCIPLE OF MANAGEMENT •COMPLICATIONS •PROGNOSIS •CONCLUSION •REFERENCES 10/13/2014 2
  3. 3. INTRODUCTION • The gastrointestinal tract extend from the mouth to the anus and divided into two parts; • Upper GIT • Lower GIT • By the ligament of treitz at the duodenojejunal junction. 10/13/2014 3
  4. 4. INTRODUCTION • The part above the ligament is the upper GI Definition: Any bleeding from GI tract proximal to ligament of treitz. It is a common cause of emergency hospital admission and accounts for 5-10% mortality which increase in the elderly. 10/13/2014 4
  5. 5. INTRODUCTION • modes of presentation – Hematemesis- 40-50% – Melena-70-80% – Hematochezia- 15-20% 10/13/2014 5
  6. 6. INTRODUCTION • Hematemesis Vomiting of fresh or old blood (40-50%) Proximal to Treitz ligament Bright red blood = significant bleeding Coffee ground emesis = no active bleeding • Melena Passage of black & foul-smelling stools (70-80%) Usually upper source – may be right colon • Hematochezia Passage of bright red blood from rectum (15-20%) If brisk & significant → UGI source 10/13/2014 6
  7. 7. PRINCINPLES OF MANAGEMENT • INITIAL ASSESSMENT • RESUSCITATION • DETERMINATION OF BLEEDING SITE • TREATMENT/INTERVENTION • PREVENTION OF RECURRENCE 10/13/2014 7
  8. 8. PRINCIPLES Immediate Assessment Stabilization of hemodynamic status Identify the source of bleeding Stopping the active bleeding Treat the underlying Prevent recurrent bleeding 10/13/2014 8
  9. 9. ASSESSMENT Patient presenting with cardiovascular instability requires prompt resuscitation before detailed history and examination to find the cause of bleeding and other co-morbidity 10/13/2014 9
  10. 10. ASSESSMENT Severity of bleeding can be determined: • Level of consciousness - obtundation • Pulse rate >100bpm • Postural hypotension. • Severe blood loss—Vagal slowing of the heart 10/13/2014 10
  11. 11. ASSESSING SEVERITY eeding Bleeding severity Vital Signs Blood loss (%) Minor Normal < 10 % Moderate Postural (Orthostatic hypotension) 10 – 20 % Massive Shock (Resting hypotension) 20 – 25 % 10/13/2014 11
  12. 12. RESUSCITATION • Aggressiveness of resuscitation depends on the bleeding severity • Resuscitation is proportional to bleeding severity • Inadequate resuscitation leads to Multi-organ failure. 10/13/2014 12
  13. 13. RESUSCITATION • Ensure a patent airway and breathing. • Elevate foot of bed to about 15⁰ • Secure IV access, take samples; PCV, U/Ecr, GXM, Platelet count, LFT. • IV crystalloid, N/S R/L 1L over 30-45min • Pass urethral catheter, empty the bladder then monitor urine output. (0.5-1ml/kg/min) • Reassess PR,BP,CVP, urine output, to determine the rate of infusion • Supplemental Oxygen---enhances oxygen carrying capacity of blood 10/13/2014 13
  14. 14. RESUSCITATION • Pass N-G tube- – Decompression, prevent aspiration – Cold saline lavage • Transfuse; – significant blood loss or pcv <30 – on going bleeding, – inadequate response to fluid resuscitation, – elderly and – presence of cardiopulmonary disease • Sedation – Phenobarb to quieten patient. 10/13/2014 14
  15. 15. HISTORY • History to find the cause, co-morbidity and character(onset, volume and frequency) of bleeding. Careful history and physical examination may yield no definitive cause in 50%. – HX of PUD – Alcohol ingestion – NSAID – Dysphagia 10/13/2014 15
  16. 16. HISTORY • COMMON CAUSES • Duodenal ulcer • Gastric ulcer • Stress ulcer • Oesophageal varices 10/13/2014 16
  17. 17. HISTORY • LESS COMMON CAUSES • Oesophagitis • Mallory- Weiss syndrome • Malignant gastric tumours • Benign gastric tumours • Oesophageal ulcers or tumour • Para-oesophageal hiatal hernia 10/13/2014 17
  18. 18. HISTORY • RARE CAUSES – Duodenal tumours – Aorto-enteric fistula – Blood dyscrasia – Hereditary talengiectasia – Angiodysplasia – Dieulafoy’s lesion 10/13/2014 18
  19. 19. EXAMINATION – Pallor – Sweating – Cold extremities – Nostrils/ pharynx – Epigastric tenderness 10/13/2014 19
  20. 20. EXAMINATION • Collapse subcutaneous veins • Tachycardia • Hypotension • Restlessness • Features of CLD, gastric ca, abdominal masses, 10/13/2014 20
  21. 21. RISK SCORING • ROCKALL’S RISK SCORE • Score that predicts poor prognosis, i.e. rebleeding and mortality from upper GI haemorrhage • It uses clinical criteria (increasing age, co-morbidity, shock) as well as endoscopic finding (diagnosis, stigmata of spontaneous haemorrhage -SSH) 10/13/2014 21
  22. 22. ROCKALL’S SCORE 10/13/2014 22
  23. 23. Risk category: High (> 5) Intermediate (3–5) Low (0–2) 10/13/2014 23
  24. 24. MANAGEMENT AS PER RISK • Low risk (0-2);usually 80% of patients recovers spontaneously with medical treatment(PPI) + hospitalization for 24hrs and may be discharge if uneventful. • Intermediate risks(3-5); same treatment + hospitalization for at least 72 hrs. • High risk(>5); same treatment + hospitalization in ICU 10/13/2014 24
  25. 25. DETERMINATION OF BLEEDING SITE • NG-tube aspiration • Endoscopy • Barium studies • Angiography • Tagged rbc scan 10/13/2014 25
  26. 26. LOCALIZATION 10/13/2014 26
  27. 27. N-G TUBE ASPIRATION Nasogastric aspiration with saline lavage is beneficial • to detect the presence of intragastric blood, • to determine the type of gross bleeding, • to clear the gastric field for endoscopic visualization • to prevent aspiration of gastric contents. 10/13/2014 27
  28. 28. ENDOSCOPY • Diagnostic; direct visualization of source of bleeding • Therapeutic; control of active bleeding • To assess the prognostic indicator using the Forrest classification 10/13/2014 28
  29. 29. Modified Forrest Classification for Upper GI bleeding 10/13/2014 29
  30. 30. 10/13/2014 30
  31. 31. BARIUM MEAL • In the absence of endoscopy, barium is attempted. It may show ulcer craters, varices, filling defect or tumors in the stomach. • Double contrast is preferred; it shows small ulcers • Disadvantages; – Source remains undetected in ≥ 50% of patients – Blood clot obscures gross lesion 10/13/2014 31
  32. 32. ANGIOGRAPHY • It identifies the bleeding vessel • Targeted therapy for ongoing hemorrhage; may prevent need for surgery (with embolization). • Angio ≥ 1 ml/min • Disadvantages; Invasive,expensive,requires special expertise, exposure to radiation, risk of contrast media–induced nephropathy, bleeding from arterial puncture site 10/13/2014 32
  33. 33. TAGGED RBC SCAN • Utilizes technetium labelled rbc extravasation into bowel is detected by scintillation camera. • RBC scan may not accurately locate bleed. • 0.5 – 1 ml/min bleeding requirement, set up req. 1-2 hours, test time 1-2 hours • Contraindicated in; – initial Hct < 24, – hemodyn unstable patient, – ongoing > 100-200 cc/h bleed 10/13/2014 33
  34. 34. TREATMENT • Non-operative • Operative 10/13/2014 34
  35. 35. NON OPERATIVE Peptic ulcer disease • Endoscopic • PPI • Elimination of H. pylori • Endoscopic therapy: – Injection of adrenaline at the base of the vessel/ Sclerotherapy – Bipolar electro- / thermal probe coagulation – Argon plasma / laser photocoagulation – Hemostatic materials, including biologic glue 10/13/2014 35
  36. 36. ENDOSCOPIC MODALITIES AVAILABLE FOR THE MANAGEMENT OF U.G.I. BLEED  INJECTION  Adrenalin  Fibrin glue  Human Thrombin  Sclerosants  Alcohol  THERMAL  Heater Probe  Bicap Probe  Gold Probe  Argon plasma coagulation  Laser therapy  MECHANICAL  Haemoclips  Banding  Endoloops  Staples  Sutures 10/13/2014 36
  37. 37. NON-OPERATIVE • If bleeding controlled: • PPI- proton pump inhibitor – omeprazole/pantoprazole, 80 mg bolus then 8 mg/hr infusion x 24 hrs. then 40 mg IV OD/BD then transition to oral PPIs for 6-8 wks. • Helicobacter pylori treatment, if present triple drug regimen x 2-3 wks. recurrent colonization 70-90% within few month to years. • Repeat endoscopy < 6-8 wks. 10/13/2014 37
  38. 38. NON-OPERATIVE • VARICES • Balloon tamponade • Pharmacological • Endoscopic • Transjugular intrahepatic portosystemic stent-shunt (TIPSS) – Balloon tamponade: – Initially temporizing measure in all pts, now < 10% temporary hemostasis in 85%, near 100% re-bleed on removal – 20% complication rate Esophageal rupture, Tracheal rupture, Duodenal rupture, Respiratory tract obstruction, Aspiration, Tracheoesophageal fistula, Esophageal necrosis / ulcer 10/13/2014 38
  39. 39. Sengstaken blakemore tube 10/13/2014 39
  40. 40. Sengstaken blakemore tube 10/13/2014 40
  41. 41. • Pharmacologic treatment : • Vasopressin splanchnic vasoconstriction; 20IU in 250ml of 5% DW over 30min, 4hrly. It improves hemostasis. Telipressin (pro-drug) better hemostasis and survival benefits. And longer duration of action. – Side effects • Pallor • Hypertension • Abdominal colic • Cerebral and coronary ischemia • purgation – Nitroglycerine 40 mcg/min may be given simultaneously to prevent coronary ischemia. 10/13/2014 41
  42. 42. • Nitroglycerine systemic hypotension and venous pooling, counteract cardiac effects of vasopressin; titrate to SBP 90-100. • Glypressin; contains both nitroglycerin and vasopressin • Beta-Blockers: Propranolol 40 mg bd; lowers portal pressure. Daily oral dose after bleeding has stopped is found to stop re-bleeding in about 80%. • Octreotide: 250 mcg bolus, 250 mcg/hr infusion; Decreases gastric acid, pepsin, gastric blood flow 10/13/2014 42
  43. 43. Endoscopy • Sclerotherapy; – Ethanolamine oleate (3-5ml) or sodium morrhuate is injected into each varies. – If the bleeding is controlled, injection is repeated weekly, then at 3weeks and at 3monthly until varies obliterate. – Use of cyanoacrylate tissue adhesive. • Initial success rate -> 90%, re-bleed 30-50% 10/13/2014 43
  44. 44. • Band Ligation; is efficacious and is now preferred to Sclerotherapy • Endoscopic surveillance; – 3 monthly for 1year then – 6monthly for 1year then – Annually 10/13/2014 44
  45. 45. • TIPSS; – In refractory bleeding after sclerotherapy or band ligation. – A shunt is established between the portal vein and the right or middle hepatic vein 10/13/2014 45
  46. 46. OPERATIVE • Indications; – Massive bleeding – Severe haemorrhage continues or recurs/not responsive to resuscitative efforts – Associated perforation – Blood not readily available – Failure of medical therapy and endoscopic hemostasis with persistent / recurrent bleeding – A second hospitalization for peptic ulcer hemorrhage 10/13/2014 46
  47. 47. OPERATIVE • Factors predicting further bleeding from a peptic ulcer and possible need for surgery – Age > 60years – Hb <8g/dl – Shock on admission – Visible spurting vessel on endoscopy – Giant ulcer >2cm – Ulcer on the posterior lesser curvature or posterior inferior wall of the duodenal bulb 10/13/2014 47
  48. 48. OPERATIVES • AIMS; – To stop the bleeding – To prevent a recurrence – To cure underlying cause 10/13/2014 48
  49. 49. DEFINITIVE PROCEDURES • Peptic ulcer disease – Laparotomy – Upper mid-line incision – Duodenal ulcer: most common, posterior bleed; • longitudinal anterior duodenotomy • Under-run the vessel (i.e. gastroduodenal artery) using non-absorbable suture preferable prolene 4-O. • Quickest and safest operation 10/13/2014 49
  50. 50. Anterior longitudinal duodenotomy 10/13/2014 50
  51. 51. • Common complications – Re-bleeding – Injury to the common bile duct. 10/13/2014 51
  52. 52. Gastric ulcer: 1 • wedge excision gastric ulcer – (always send for frozen to r/o cancer) • Under-running the vessel • Followed by post-OP PPI, H.P. therapy, follow-up endoscopy • Effective and quicker 2 Billroth 1 partial gastrectomy 3 truncal vagotomy and pyloroplasty with excision of the ulcer 10/13/2014 52
  53. 53. vagotomy 10/13/2014 53
  54. 54. vagotomy 10/13/2014 54
  55. 55. • Complications – gastric atony, – alkaline reflux gastritis, – Dumping – diarrhea. 10/13/2014 55
  56. 56. VARICES • Surgical Shunts: • Goal: decompression of the high-pressure portal venous system into a low-pressure systemic venous system and devascularization of the distal esophagus and proximal stomach • Portacaval shunt (end-to-side, side to side, interposition graft) • Mesocaval shunt (Large- or small diameter interposition graft) • Distal splenorenal (Warren) shunt • Esophagogastric devascularization, • Esophageal transsection, & reanastomosis • Orthotopic liver transplantation • Splenectomy (for splenic vein thrombosis) 10/13/2014 56
  57. 57. VARICES • Surgical Shunts: • bleeding control rate >90% • No differences in survival rates: ~5%. • Complications; – Re-bleeding – Encephalopathy – Ascites 10/13/2014 57
  58. 58. • Stress ulcers – Numerous ulcers- vagotomy + hemi-gastrectomy – Few - oversewn • Mallory-Weiss syndrome – Mucosal laceration is sutured • Aorto-enteric fistula – Fistula disconnected and closed – Aorta grafted with antibiotic primed graft and covered with omentum – Antibiotic cover 10/13/2014 58
  59. 59. NEGATIVE LAPAROTOMY • No lesion may be found in the eosophagus, stomach or duodenum • The small and larged intestined are carefully examined for possible source of bleeding • If negative, the abdomen is closed 10/13/2014 59
  60. 60. COMPLICATION OF UPPER GI BLEEDING • Anaemia • Sepsis • DIC • MODS 10/13/2014 60
  61. 61. PROGNOSIS • Overall mortality is 10-15% • 33% in patient over 70years • 70-80% of bleeding peptic ulcer stop bleeding sponteneously • Predictors of mortality: – Age – Shock – Co-morbidities – Delay in diagnosis – Re-bleeding 10/13/2014 61
  62. 62. PROGNOSIS • 20% re-bleed in 5-10years when treated conservatively • When treated surgically, 4.5% re-bleed in 5- 10years • With H.pylori eradication, the re-bleeding rate is likely to go down. 10/13/2014 62
  63. 63. CHALLANGES • ICU space limited – Hemodynamic instability – Massive • Delayed definitive diagnosis 10/13/2014 63
  64. 64. CONCLUSION • Even though 70-80% stops spontaneously, • Bleeding frighten the patient it requires expeditious work-up ,prompt diagnosis and treatment. • Accurate patient evaluation and early resuscitation before esophagogastroduodenoscopy (EGD) is critical to decrease the morbidity and mortality. 10/13/2014 64
  65. 65. REFERENCES • E.A. Badoe, E.Q. Arcampompong, J.T Rocha; “Principles and Practice of surgery including pathology in the tropics”. 4th edition, Assembly of God Literature Center ltd, 2009. P 637-641 • Souba, Wiley et al; “ACS Surgery principles and practice” 6th edition, WebMD Inc. (Professional Publishing), 2007. • Sriram Bhat M; “SRB’s Manual of surgery” . 4th edition, Jaypee brothers medical publishers ltd, 2013. • Mitchell S. Cappell, David Friedel,; Initial Management of Acute Upper Gastrointestinal Bleeding: From Initial Evaluation up to Gastrointestinal Endoscopy. Med Clin N Am 92 (2008) 491–509 • Ingrid Lisanne Holster, Ernst Johan Kuipers; Management of acute nonvariceal upper gastrointestinal bleeding: Current policies and future perspectives. World J Gastroenterol 2012 March 21; 18(11): 1202-1207 • Jiwon Kim; management and prevention of upper GI bleeding: Gastroenterology and Nutrition. PSAP -VII 10/13/2014 65
  66. 66. »THANK YOU 10/13/2014 66

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