UPPER GASTROINTESTINAL BLEEDING What Undergraduates should know ? Prof SM Chandramohan Prof and HOD Department of Surgical Gastroenterology and Center of Excellence for Upper GI Surgery Madras Medical College and Rajiv Gandhi Government General Hospital Chennai
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UPPER GASTROINTESTINAL BLEEDING What Undergraduates should know ?
UPPER GASTROINTESTINAL BLEEDING What Undergraduates should know ?. Prof SM Chandramohan Prof and HOD Department of Surgical Gastroenterology and Center of Excellence for Upper GI Surgery Madras Medical College and Rajiv Gandhi Government General Hospital Chennai. - PowerPoint PPT Presentation
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UPPER GASTROINTESTINAL BLEEDING
What Undergraduates should know ?
Prof SM ChandramohanProf and HOD
Department of Surgical Gastroenterology andCenter of Excellence for Upper GI Surgery
Madras Medical College andRajiv Gandhi Government General Hospital
Chennai
Can download this presentation from www.esoindia.org
Prof SM ChandramohanProf and HOD
Department of Surgical Gastroenterology andCenter of Excellence for Upper GI Surgery
Madras Medical College andRajiv Gandhi Government General Hospital
Any bleeding from The gastrointestinalTract above theLevel of ligament of Treitzis upper GI Bleeding
DEFINITIONS
• Acute GI bleed– < 3 days duration– hemodynamic instability– requires blood transfusion
• Overt vs. occult– overt = visible blood (melena, bright red
blood, coffee grounds)– occult = only detected by lab tests
COMMON CAUSES OF UGI BLEEDCAUSE % Peptic Ulcer 38%
Varix 16% Tumor 7% MW Tear 4%
Erosions 4%
Esophagitis 13%
NSAID (1) the risk of gastric ulceration is
increased to a greater extent than that of duodenal ulceration
(2) the risk of bleeding varies with the individual NSAID; for example, the relative risk of bleeding is greatest with piroxicam and less with ibuprofen
(3) the risk of bleeding is dose dependent
-age greater than 75 years, -history of heart disease, -history of peptic ulcer- history of previous gastrointestinal bleeding
Group Relative Risk Control[*] 1.0 Aspirin[†] 1.5-2.5 Other NSAIDs[†] 4-7 COX-2 Inhibitors 1.3-1.5
RISK FACTORS
AIRWAY
BREATHING
CIRCULATION
A
B
C
Examination
Tell tale signs…Chronic Liver DiseasePortal Hypertension
Examination
Not to miss……..Haemodynamic stabilitySigns of coagulation dysfunctionSigns of Liver cell failurePR
Bleeding PR
As he comes………….
Resuscitate and Examine Simultaneously…….
Form a team……….
Wide bore IV line…… preferably central line(take samples at the same time)Naso gastric tubeUrinary Catheter
ALERT OTHERS IN TEAM…….
Blood Sample for
Blood GroupHaemogram including plateletsCoagulation profileLiver function testRenal functionMarkers
Blood Sample
TRY NOT TO TAKE SAMPLES FREQUENTLYExcept for serial evaluation
WHICH TUBE AND WHY?
Naso Gastric Tube orSenstaken tube?
ROLE OF NASOGASTRIC TUBE
10 % of UGIB presents as LGIB
Red blood vs coffee grounds
NGT clears the gastric field for endoscopic visualization
prevent aspiration of gastric content
Endoscopy
When to do?What is Possible?
When not to do???
Endoscopy
One stop ShopDiagnose AssessTreatReassess
ENDOSCOPIC EVALUATION
If Hemodynamically stable
Identify Bleeding site
Delineate cause
Allow endotherapy
ENDOSCOPIC MANAGEMENT
VARICEAL
NONVARICEAL
ENDOSCOPIC VARICEAL LIGATIONA rubber band is placed over the varix which then undergoes thrombosis,sloughing,fibrosis.
ENDOSCOPIC SCLEROTHERAPYInvolves injecting a sclerosant Intravariceal/perivariceal
• Endoscopic therapy - successful in up to 90% of patients
• Failure of endoscopic therapy - antrectomy
SEVERE PORTAL HYPERTENSIVEGASTROPATHY
May present with acute orchronic bleed.
No role for endoscopic management.
Managed with B Blockers, TIPS, Surgical Porto Caval shunt, Liver transplantation.
HEMOBILIAThe diagnosis can be confirmedBy Side viewing Scopy
Ongoing or Recurrent bleed isTreated with angioembolization
CAUSES-HEMOBILIA
Liver trauma
Liver biopsy
ERCP/PTC/TIPS
HCC, CHOLANGIOCARCINOMA
Biliary parasite infestations
HEMOSUCCUS PANCREATICUSThe diagnosis can be made by Side viewing scopy
Management is by angioembolization
CAUSES-HEMOSUCCUS PANCREATICUS
Acute pancreatitis/chronic pancreatitis
Pancreatic pseudocyst
Pancreatic cancer
ERCP manipulation of PD
Rupture of splenic artery pseudoaneurysm into PD
ANGIOEMBOLIZATION
STRESS GASTRITIS
• Surgery - rarely indicated
• Vagotomy and pyloroplasty, with oversewing of the hemorrhage, or near-total gastrectomy - mortality rates as high as 60%
Malignancy
• Endoscopic therapy - successful in controlling hemorrhage, the rebleeding rate is high
• Standard cancer operations - indicated when possible
• Palliative wedge resections – to control bleed
Aortoenteric Fistula
• Ligation of the aorta proximal to the graft• Removal of the infected prosthesis• Extra-anatomic bypass• Defect in the duodenum - small and can be
repaired primarily• Typically, patients with bleeding from an
aortoenteric fistula will present first with a “sentinel bleed.”
MORTALITY
7% to 10%.
• The mortality has decreased only minimally during the last 30 years, despite the introduction of endoscopic therapy that reduces the rate of rebleeding.
– increasing percentage of UGIB occurring in the elderly– frequent use of antiplatelet medications or anticoagulants– frequent comorbid conditions.