Role of emergency endoscopy in saving lives dr ravi gupta

• 1.DR RAVI GUPTACONSULTATNT G I ENDOSCOPIST LILAVATI HOSPITAL

2. UPPER G I ENDOSCOPY FOREIGN BODIES IN UPPER G I TRACT UPPER G I BLEED 3. Acute Upper GI bleed The annual rate of hospitalization for acute UGIB in theUnited States is 160 hospital admissions per 100,000population, which translates into more than 400,000 peryear In most settings, the vast majority of acute episodes ofupper gastrointestinal bleeding (80 to 90%) have non-variceal causes, with gastroduodenal peptic ulceraccounting for the majority of lesions Mortality associated with peptic ulcer bleeding remainshigh at 5 to 10% N Engl J Med 2008;359:928-37. 4. F B IN UPPER G I TRACT F B IN ESOPHAGUS SHARP FBS WITH RISK OF PERFORATION 5. Indian scenarioLimited studies on the prevalence of peptic ulcer bleeding in IndiaPeptic ulcer is widely prevalent in India, more common among thepopulation of South India than North IndiaConflicting data exist from different studies on the MC type ofpresentationLifetime prevalence of PU in India Delhi 0.61% Chandigarh 0.69 Chennai 0.75%These studies have limitations in diagnostic method and not consideringasymptomatic populationKhuroo et al Gut 1989;30;930-934 6. ROLE OF PRIMARY PHYSICIAN PAEDIATRIC AGE GROUP LOOK FOR BREATHING DIFFICULTY OR COUGH SALIVATION ABDOMENAL SIGNS IF ANY ASK FOR X RAY NECK CHEST & ABDOMEN SOS REFER TO HOSPITAL KEEP THE CHILD NBM 7. A: Resuscitation, riskassessment & pre- D: Non-endoscopic, endoscopyC: Pharmacological non-meds in- E: Post discharge,management B: Endoscopic management managementhospital RxASA, NSAIDsA1: Immediately evaluate andB1: Develop institution-B7: Endoscopic C1: Histamine2-receptorD1: Patients at low-riskE1: In patients with a prior initiate appropriate specific protocols forhemostaticafter endoscopyulcer bleed who antagonists are resuscitation* multidisciplinary therapy iscan be fed withinrequire an NSAID,management*not recommendedA2: Prognostic scales are indicated for 24 hours*it should be- Include access to an for patients with recommended for earlyendoscopist trained inpatients with D2: Most patients having recognized that acute ulcer stratification of patients endoscopichigh-risk undergonetreatment with a into low-and high-risk stigmata (active bleeding*endoscopic traditional NSAIDhemostasis* categories for rebleedingB2: Have available on anbleeding or aC2: Somatostatin and hemostasis for plus PPI or a COX- and mortality urgent basis, support visible vessel inoctreotide are not high-risk stigmata 2 (-) alone is stillA3: Consider placement of a staff trained to assist an ulcer bed)* routinelyshould beassociated with a naso-gastric tube in in endoscopy* B8: Epinephrine alone hospitalized for atclinically important recommended forB3: Early endoscopy (within selected patients becauseprovides patients withleast 72 hours risk of recurrent24 hours of the findings may havepresentation) issuboptimal acute ulcerthereafter ulcer bleeding prognostic value*recommended in most efficacy andD3: Seek surgical E2: In patients with prior bleeding*A4: Blood transfusions should patients with acute should be usedconsultation for ulcer bleeding who C3. An intravenous be administered to a upper gastrointestinalin combinationpatients who haverequire an NSAID patient with a bleeding with another bolus followed byfailed endoscopicthe combination of hemoglobin level 70 g/L B4: Endoscopic hemostatic modalitycontinuous-therapy* a proton pumpA5: In patients ontherapy is notB9: No single method infusion proton- D4: Where availableinhibitor and aindicated for patients anticoagulants,of endoscopicpump inhibitor percutaneous COX-2 (-) iswith low-risk stigmata correction of(a clean based ulcer, thermalshould be used toembolization can recommended to coagulopathy isor a non-protuberantcoaptive therapy decrease be considered as reduce the risk of recommended butpigmented dot in an is superior to rebleeding and an alternative torecurrent bleeding should not delay ulcer bed)* another*surgery in patientsfrom that of COX-2 mortality in endoscopyB5: A finding of a clot in an B10: Clips, thermal orhaving failed(-) aloneulcer bed warrants patients with highA6: Promotility agents should sclerosantendoscopicE3: In patients receiving not be used routinelytargeted irrigation ininjection should risk stigmatatherapylow-dose ASA whoan attempt athaving undergone before endoscopy tobe used inD5: Patients withdevelop an acutedislodgement, with an increase the diagnosticpatients withsuccessful bleeding pepticulcer bleed, ASAappropriate treatment yieldof the underlying high risk lesions, endoscopic ulcer should beshould be restartedA7: Selected patients with acutelesion alone or intherapy tested for H. p andas soon as the risk ulcer bleeding at lowB6: The role of endoscopiccombinationC4: Patients should be receiveof cardiovascular risk for rebleeding basedtherapy for ulcers with witheradication if complication is discharged on a on clinical andadherent clots is epinephrine present, withthought to outweighcontroversial. single daily dose endoscopic criteria mayinjectionconfirmation ofthe risk of bleedingEndoscopic therapy oral PPI for a be discharged promptly B11: Routine second-eradicationE4: In patients with a priormay be considered, duration as after endoscopy although intensive PPIlook endoscopyD6: Negative H. p test ulcer bleed whoA8: Pre-endoscopic, PPI is not dictated by theresults obtained inrequire CVtherapy alone may be therapy may be sufficient recommended underlying the acute settingprophylaxis, it considered to downstageB12: A second attemptetiology should be repeated should be the endoscopic lesionat endoscopicrecognized that and decrease the needRx is generallyclopidogrel alone for endoscopic recommended in has a higher risk of intervention, but should cases of re- rebleeding vs ASA 8. Overall managementABCs and adequate resuscitation Early risk stratification pre-endoscopyat early endoscopyVery Low risk patients All other patients discharge home admit High-risk patientsLow-risk patients Endoscopic hemostasis Initiate daily dose PPI Initiate high-dose IV PPI Consider secondary prophylaxisH pylori testing and treatingNSAID/COX2 useASA use 9. ROLE OF PRIMARY PHYSICIAN ADULT AGE GROUP ALCOHOL INTOXICATION X RAY NECK CHEST & ABDOMEN PLEASE DO NOT TRY ANY BANANA DIET ETC IF FB IN THE ESOPHAGUS OR IF SHARP FB, IT DELAYS ENDOSCOPIC INTEVENTION. 10. So what to do?- subgroup selection Efficacy at best marginal, so PPI should NOT replace the role of adequate resuscitation and early endoscopy Can provide PPI before endoscopy or not; more likely to be cost-effective IF: Delay to endoscopy (over 16 hours) Patient more likely to be bleeding from a non variceal source high-risk lesion (hematemesis, bloody NGT) If you are going to use, high-dose preferred Barkun AN, GI Endosc 2008 11. F B ESOPHAGUS PAEDIATRIC AGE GROUP ADMISSION, DONE UNDER G A WITHTRACHEAL INTUBATION. SHARP OBJECTS USE OVERTUBE ORUMBRELLA ADULTS SUSPECT A STRICTURE BELOWTHE FB 12. UPPER G I BLEED VARICEAL NON VARICEAL 13. What about an elevated INR andendoscopy? A presenting INR >1.5 does not predict rebleeding, yet is anindependent predictor of subsequent death following anadmission due to NVUGIB Correction of INR to 1.8 as part of intensive resuscitativemeasures may improve mortality Endoscopic treatment may be safely performed in patientswith an INR of