2010.10.14. 1 Gastrointestinal bleeding definitions (I) • Acute bleeding : vomiting blood or profuse rectal bleeding within 3 days, leading to hemodynamically unstable condition of the patient. Problems arising from blood loss must be treated often before proceeding to diagnosis • Chronic bleeding : repeated episodes of presence of occult blood in stool Gastrointestinal bleeding definitions (II) • Hematemesis : - fresh, red vomitus, containing hemoglobin (above lig. Treitz) suggesting acute bleeding - brown, containing digested blood (previous bleeding) • Melena : (min. 100 ml) digested blood in faeces • Hematochesia: fresh blood in the stool
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2010.10.14.
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Gastrointestinal bleedingdefinitions (I)
• Acute bleeding: vomiting blood or profuse rectal bleeding within 3 days, leading to hemodynamically unstable condition of the patient. Problems arising from blood loss must be treated often before proceeding to diagnosis
• Chronic bleeding: repeated episodes of presence of occult blood in stool
• SEVERE BLOOD LOSS: signs of perturbed organ perfusion, hepatic encephalopathy, altered mental status, hepatorenal/ or renal insufficiency, metabolic acidosis, ischemic heart attack
Gastrointestinal bleedingmanagement of diagnosis (I)
• HISTORY- previous GI bleeding episodes, abdominal
surgery, known bleeding tendency, hematologic disorders, known severe liver, kidney or heart diseases
- current medication - aspirin, NSAIDs coumarol, habits of alcohol consumption
- onset, duration of present complains - form os bleeding, characteristics of stool
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Gastrointestinal bleedingmanagement of diagnosis (II)
• Physical examination:pulse and RR in both supine and upright position, signs of hypovolemia, anemia and coagulopathy, abdominal status, ascites, bowel sounds, tongue, rectal digital examination etc.
• Initial laboratory studies: Hb, htc, WBC, platelet count, PT (INR), PTT, serum BUN and creatinine, liver function
Gastrointestinal bleedingmanagement of diagnosis (III)
• Stabilization of the patient´s condition:monitoring of ECG, RR, oxygen saturation, volume replacement (~300 ml/h saline), nasal oxygen, if necessary blood transfusion, FFP
Gastrointestinal bleedingstrategy of treatment (III)
• MEDICAL THERAPY- acid suppression (PPI or H2RA infusion i.v.) - vasoactive drugs for the reduction of portal pressure: 1. octreotid (somatostatin) infusion: 100 µg i.v. bolus, 25 µg/h infusion for 48-96 h. 2. terlipressin (triglycil-lysin vasopressin) - lactulose, 3 x 20-40 ml/day, sucralphate, - Helicobacter pylori eradication therapy - propranolol, neomycin, ISMN, DDAVP etc.
Algorithm for treatment of acute variceal bleeding (J.Bosch, J.G. Abraldes, Semin.Hemat.41, Suppl.1.
8-12,2004)Suspection of variceal bleeding
Endoscopy:ligature, or sclerotherapy, in extreme: ballon tamponade, and continuation of drug therapy for about 5 days
Further bleeding/early rebleeding
Further bleeding(failure to control)
Early starting of vasoactiv drug administration: 1. Terlipressin 2. Somatostatin or octreotid
Antibiotics, volume replacement
Repeated endoscopic treatment trial
Rescue TIPS / Surgery
rFVIIa?
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Further treatment options
human albumin infusion,
in case of severe haemostatic disturbance fresh frozen plasma, eventually platelet suspension, especially of hugh amount of transfusions was given, - consider dilution and Ca supplementation!
Decomtamination of the intestine: lactulose, neomycin, rifaximin (Normix), SBP (spontaneous bacterial peritonitis) profilaxis: norfloxacin
adequat diet (low in fat, rich in carbohydrate and vitamines, less protein)
Gastrointestinal bleedingstrategy of treatment (IV)
• OTHER THERAPEUTIC POSSIBILITIES -balloon tamponade (Sengstaken-Blakemore,
Surgical treatment of acute gastrointestinal bleeding
• Primary acute operation: if acute bleeding could not been stopped (e.g. Forrest I/A ulcer)Early elective surgery: within 48 hours following successful primary hemostasis, because of high risk of rebleeding or other conditions (predominantly resection is carried out)Secondary acute operation: in case of rebleedingElective surgery: giant ulcer in elderly, malignancy
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Further perspectives in GI bleeding
• SPONTANEOUSLY STOPS up to 80 % of all cases, if varix rupture is excluded
• SEVERE REBLEEDING (within 48 hours) upper GI tract: 15-20 % lower GI tract: < 10 %
• SURGICAL INTERVENTION : along with modern, GI intensive care unit 3-10 %