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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
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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
Chennai
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DEFINITION
CAUSES
EVALUATION
TREATMENT
PLAN
OF
THE
TAL
K
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DEFINITION
CAUSES
EVALUATION
TREATMENT
PLAN
OF
THE
TAL
K
MEDICALENDOSCOPIC
SURGICAL
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DEFINITION
Any bleeding from The gastrointestinalTract above theLevel of ligament of Treitzis upper GI Bleeding
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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
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COMMON CAUSES OF UGI BLEEDCAUSE % Peptic Ulcer 38%
Varix 16% Tumor 7% MW Tear 4%
Erosions 4%
Esophagitis 13%
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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
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AIRWAY
BREATHING
CIRCULATION
A
B
C
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Examination
Tell tale signs…Chronic Liver DiseasePortal Hypertension
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Examination
Not to miss……..Haemodynamic stabilitySigns of coagulation dysfunctionSigns of Liver cell failurePR
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Bleeding PR
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As he comes………….
Resuscitate and Examine Simultaneously…….
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Form a team……….
Wide bore IV line…… preferably central line(take samples at the same time)Naso gastric tubeUrinary Catheter
ALERT OTHERS IN TEAM…….
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Blood Sample for
Blood GroupHaemogram including plateletsCoagulation profileLiver function testRenal functionMarkers
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Blood Sample
TRY NOT TO TAKE SAMPLES FREQUENTLYExcept for serial evaluation
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WHICH TUBE AND WHY?
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Naso Gastric Tube orSenstaken tube?
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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
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Endoscopy
When to do?What is Possible?
When not to do???
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Endoscopy
One stop ShopDiagnose AssessTreatReassess
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ENDOSCOPIC EVALUATION
If Hemodynamically stable
Identify Bleeding site
Delineate cause
Allow endotherapy
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ENDOSCOPIC MANAGEMENT
VARICEAL
NONVARICEAL
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ENDOSCOPIC VARICEAL LIGATIONA rubber band is placed over the varix which then undergoes thrombosis,sloughing,fibrosis.
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ENDOSCOPIC SCLEROTHERAPYInvolves injecting a sclerosant Intravariceal/perivariceal
Common sclerosants Ethanolamine oleate Absolute alcohol Sodium morrhuate Sodium tetradecyl Hypertonic saline Polidocanol
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GLUE THERAPYCyanoacrylate is a glue that is injected intoGastric varicesActs by forming a Cast over the varix on contactwith blood
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Endoclip
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DEFINITIVE MANAGEMENT OF NON VARICEAL BLEED
HIGH RISKULCERFORBLEED
SRH/LARGE ULCER >2 cm
ULCERS IN POSTERIOR WALL
BULB-GDA
ULCERS IN THE HIGH LESSER CURVE - LGA
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Endoscopic Management
Non-Variceal - Modalities Injection Therapy (a) Adrenaline (b) Sclerosants Thermal Therapy (a) Monopolar (b) Bicap (c) Heater Probe (d) Argon Plasma Coagulation (e) Laser Mechanical Therapy (a) Haemoclips
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Endoscopic Management
Bleeding Peptic Ulcer - Stigmata
1a – Spurting vessel 1b – Oozing from a vessel
2 – Clot in the ulcer base 3 – Ulcer without bleed
ForrestClassification
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SECOND LOOK ENDOSCOPYIt is repeat endoscopy 24 hours after initial Endoscopic hemostasis
INDICATIONS1 Incomplete first endoscopic examination due to blood obscuring the field2 Patients with clinically significant rebleeding
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WHEN TO CALL IT AS
FAILED ENDOTHERAPY?
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SURGICAL MANAGEMENT OF UGI BLEEDING
The NeedOnly in Select Situations
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Role of Surgery
5-10% of UGI Bleed
Mortality
3% to 14%
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TV Vs H.PYLORI Eradication
40% to 70% of patients with a bleeding duodenal ulcers- positive for H. pylori
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Bleeding Gastric Ulcer
Simple excision alone -rebleed in 20% of patients
10% incidence of malignancy
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Surgical options- Variceal bleeding
ShuntOr Devascularisation
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Less Common Causes of UGIB
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MALLORY WEISS TEARS
Managed with1 Hemoclips2 MPEC Probes3 PPI
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DIEULAFOY’S LESIONlarge submucosal artery that protrudes through mucosaat the gastric fundus.
bleeding can be massive
Endoscopic Doppler USG canhelp localize
Endoscopic hemostasis -injection therapy , Thermal probe, clips.
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Dieulafouy’s lesion
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PPPRE APC PPPOST APC
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Gastric Antral Vascular Ectasia
• Endoscopic therapy - successful in up to 90% of patients
• Failure of endoscopic therapy - antrectomy
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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.
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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
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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
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ANGIOEMBOLIZATION
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STRESS GASTRITIS
• Surgery - rarely indicated
• Vagotomy and pyloroplasty, with oversewing of the hemorrhage, or near-total gastrectomy - mortality rates as high as 60%
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Malignancy
• Endoscopic therapy - successful in controlling hemorrhage, the rebleeding rate is high
• Standard cancer operations - indicated when possible
• Palliative wedge resections – to control bleed
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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.”
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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.
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Conclusion