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Upper GI Bleeding
Protocols:4B Ri
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Epidemiology:
Upper: Lower GI bleeding = 5:1
Incidence: 50-100 per 100,000 pts. 100 per
100,000 hospital admission.
30% pts are older than 65 years.
80% are self-limited.
20% of pts who have recurrent bleeding(within 48-72 hrs) have poor prognosis.
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Why upper GI bleeding?
More than 75% of ICU patient will have
gastroduodenal lesions by endoscopy.
Highest risk are: intubated patients; multi-
organ failure, coagulopathy, sepsis, or
extensive burns; head trauma or neurosurgery.
Decreased mucosal blood flow mucosa to
develop erosions or ulcerations.
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Prophylaxis to stress ulcer:
Frequency declined over the past 20 years. (but
not because of prophylaxis)
Prophylaxis:-- H2 receptor antagonist: (Zantac, Gaster)
-- Sucralfate (Ulsanic): lower incidence of
nosocomial pneumonia.-- Proton Pump Inhibitor: (Losec, Pantoloc)
higher incidence of nosocomial pneumonia.
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Acute GI bleeding:
Immediate Assessment
Stabilization of hemodynamic status
Identify the source of bleeding
Stopping the active bleeding
Treat the underlying
Prevent recurrent blee
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Initial assessment:
1. Orthostatic changes of BP and HR.
2. History: Drugs history (NSAID, anti-
thrombotic agents, Calcium channel blocker)
3. P.E.:heart, lung, and abdominal examinations,
skin and mucus membranes.
4. Lab: CBC, Plt, coagulation profile.5. Significant of GI blood loss: hematemesis,
melena, or hematochezia.
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Initial resuscitation + stabilization:
1. IV route in unstable patient for colloid
solution.
2. Oxygen support.
3. Monitor urine output.
4. Blood transfusion. (maintain Hct at 30% in the
elderly, 20-25% in younger pt, 25-28% inportal HTN.)
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Identify bleeding source:
1. N-G tube differentiate between upper/lower
GI bleeding.
2. Lavage color and rapidity of clearing; clear
the field for esophagogastroduodenoscopy
(EGD).
3. Initial EGD: within 24 hrs of bleeding.
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Stopping the active bleeding:
Most effective method: endoscopic therapy
Laser therapy: requires significant training.
Thermal contact: mono- (greater tissue injury)and bipolar electrocautery, heater probes.Widely available and require minimal training.
Injection therapy: epinephrine (1:10,000
dilution) with or without various sclerosantsolutions. ( or + thermal contact).
Rubber band ligation, metal clips.
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Treating the underlying
Causes of acute Upper GI bleedingUlcers: duodenal, gastric, esophageal
Varices: esophageal, gastric, duodenal
Mallory-Weiss tear
Dieulafoy's lesionsArteriovenous malformations
Portal hypertensive gastropathy
Gastric antral vascular ectasias (watermelon stomach)
ErosionsAorto-enteric fistula
Crohn's disease Malignancy Hemobilia Pancreaticsource Foreign body ingestion or bezoar Causticingestion No site found
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Ulcers:
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Ulcers:
High Risks:
1. active bleeding
2. visible vessels
3. recent bleeding
(overlying clot)
Lower Risks:
1. flat red or black spot
2. clean based ulcer
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Ulcers:
1. Two separate EGD.
2. Angiography with embolization: empirical
embolization can be done.
3. Surgical therapy: oversewing and resection of thebleeding site.
4. Medications to heal ulcers:
PPI-- decrease recurrent bleeding rate.H2 receptor antagonist not beneficial..
H. pylori present antibiotics, prevent rebleeding.
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Varices:
Hepatic venous pressuregradient > 12 mmHg.
In esophageal variceal ,
prefer variceal ligation (withmultiband ligator) overendoscopic sclerotherapy.
In gastric varices, injectionwith a sclerosing agent willbe more beneficial thanband ligation.
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Varices:
Medical therapy (could combine endoscopy):
1. Vasopressin: side effect-- Myocardial
infarction 25%. Combine with NTG.
2. Octreotide (somatostatin analog)
3. Nonselective -blockers, (haldolol or
propranolol) decreased rebleeding rate.4. -blockers with nitrates in stable pt.
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Varices:
TIPS (transjugular intrahepatic porto-systemic shunt):
transjugular approach connect portal v. and hepatic
v. reduce portal v. pressure gradient to < 12-15
mmHg. Patent a repeat endoscopy should be done to
evaluate for an alternative source of bleeding.
Complications include: bleeding, dye-induced renal
failure, hemolysis, stent migration, and puncture of
the gallbladder or other organs adjacent to the liver.
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Varices:
Balloon tamponade:
1. Intubation
2. Gastric balloon
3. Esophageal balloon Balloon should be inflated for less than 24 hrs.
75% rebleeding rate after balloon deflation.
Antibiotic prophylaxis for cirrhosis pt: norfloxacin,ciprofloxacin.
Maintain Hct at 25-28 %.
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Preventing recurrent bleeding:
Predictors of Rebleeding:1. Older age
2. Shock/hemodynamic instability/orthostasis
3. Comorbid disease states (e.g., coronary artery
disease, congestive heart failure, renal and hepaticdiseases, cancer)
4. Specific endoscopic diagnosis (e.g., GI malignancy)
5. Use of anticoagulants/coagulopathy
6. Presence of a high-risk lesion (e.g., arterialbleeding, nonbleeding, visible vessel and clot)
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References:
Critical issues in digestive diseases
Clinics in Chest Medicine
Volume 24 Number 4 December 2003
An annotated algorithmic approach to upper gastrointestinal bleeding
Gastrointestinal Endoscopy Volume 53 Number 7 June 2001
Management principles of gastrointestinal bleeding
Primary Care; Clinics in Office Practice
Volume 28 Number 3 September 2001
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Thank you for your
attention!!