management of acute ugi bleed.pptx

7/27/2019 MANAGEMENT OF ACUTE UGI bleed.pptx

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Upper gastrointestinal bleeding (UGIB) is defined as a

potentially life threatening abdominal emergency due to

hemorrhage that emanates proximal to the ligament of

Treitz.

Cerulli MA et al, Upper Gastrointestinal Bleeding, Medscape, Nov 2011
http://emedicine.medscape.com/article/187857-overviewhttp://emedicine.medscape.com/article/187857-overview


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Epidemiology

The incidence of UGIB is approximately 100 cases per 100,000

population per year.

The incidence of UGIB is 2-fold greater in males than in females, in

all age groups, however, the death rate is similar in both sexes.

The population with UGIB has become progressively older, with a

concurrent increase in significant comorbidities that increase

mortality. Mortality increases with older age (>60 y) in males and

females.

Cerulli MA et al, Upper Gastrointestinal Bleeding, Medscape, Nov 2011
http://emedicine.medscape.com/article/187857-overviewhttp://emedicine.medscape.com/article/187857-overview


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Peptic ulcerdisease

Esophageal and

gastric varices

Hemorrhagic

gastritis

Esophagitis

Duodenitis

Mallory-Weiss tear

Angiodysplasia

Upper gastrointestinal

malignancy

Anastomotic ulcers

(after PUD surgery or

bariatric surgery)Dieulafoy lesion

Med Clin N Am 92 (2008) 491509


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Prior history of GI bleeding

GI symptoms - weakness, dizziness, syncope associatedwith hematemesis (coffee ground vomitus), and melena.

Character of GI bleeding

GI medications

Gastrotoxic medications

Anticoagulants

Social habits

Medical comorbidities

Other relevant history

Med Clin N Am 92 (2008) 491

509


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Hemodynamic stability / signs of shock Sensorium- decreased conscious level

Cold clammy extremities

Tachycardia- Pulse >100bpm

Hypotension- Systolic BP 20mmhg on standing)

Hypoxia

JVP


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Abdominal examination

Signs of chronic liver disease or

portal hypertension

Hepatomegaly

Splenomegaly

Ascites - shifting dullness /fluid thrill

Palmar erythema Caput medusa

Spider angiomata

Peripheral edema

Rectal examination

Occult blood

Gross blood

Bright red blood per

rectum

Melena

Burgundy stools Blood coating stools

versus within stools

Bloody diarrhea

Med Clin N Am 92 (2008) 491509


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CBC: haemoglobin is measured serially (4-6 hourly in the first day)

to help assess trend. The requirement for transfusion is based on

initial haemoglobin and a clinical assessment of shock.

Crossmatch blood (usually between 2 and 6 units according to rate

of active bleeding).

Liver Function Tests - liver disease

Coagulation profile:

PT with APTT and (INR), fibrinogen level

Renal function tests and electrolytes;

BUN-to-Creatinine ratio (greater than 36 in renal insufficiencysuggests UGIB).

INVESTIGATIONS

Acute upper GI bleeding, NICE Clinical Guideline (June 2012)
http://guidance.nice.org.uk/CG141http://guidance.nice.org.uk/CG141


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Imaging

CXR: may identify aspiration pneumonia, pleural effusion, perforatedoesophagus.

Erect and supine abdominal X ray to exclude perforated viscus andileus.

CT scan and ultrasound can identify:o Liver disease.

o Cholecystitis with haemorrhage.

o Pancreatitis with haemorrhage and pseudocyst.

o Aortoenteric fistulae.

Nuclear medicine scans = active haemorrhage.

Angiography - useful if endoscopy fails to identify site of bleeding.



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Endoscopy

The primary diagnostic investigation in patients with acute UGIB:

Endoscopy should be undertaken immediately after resuscitation for

unstable patients with severe acute UGIB.

Endoscopy should be undertaken within 24 hours of admission for

all other patients with UGIB.



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Risk assessment

The following formal risk assessment scores are used for

all patients with acute upper gastrointestinal bleeding:

the Blatchford score at first assessment

the full Rockall score after endoscopy


MANAGEMENT


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Admission risk marker ScoreBlood Urea mmol/L

>/=6.5 -7.98-9.9

10-24.9

>/=2523

4

6Haemoglobin g/dL (men) >/=12 -1310-11.9

/=10-12


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ScoreVariable 0 1 2 3

Age, y < 60 6079 >/= 80

ShockNo shock

Systolic BP >

100 mm Hg

Pulse < 100

beats/min

Tachycardia

Systolic BP >

100 mm Hg

Pulse > 100

beats/min

Hypotension

Systolic BP

< 100 mm Hg

Comorbidity Nil majorCardiacfailure,

ischemic heart

disease, any

major

comorbidity

Renal failure,

liver

failure,dissemi

nated

malignancy

Diagnosis MalloryWeiss

tear, no lesion,and no SRHAll other

diagnosesMalignancy of

upper-GI tract

Major SRH None, or darkspot

Blood in

upper-GI tract,

adherent clot,

visible or

spurting vesselAcute upper GI bleeding, NICE Clinical Guideline (June 2012)


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Assess ABCs:

1. Ensure airway is patent and clear.

2. Ensure adequate respiratory effort.

3. Ensure adequate circulation.

4. Administer 2 large IV canulas withdrawing blood for investigation.

5. Transfuse patients with massive bleeding with blood (packed red

cells), platelets and clotting factors in line with local protocols formanaging massive bleeding.



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For the endoscopic treatment of non-variceal uppergastrointestinal bleeding, use one of the following:

a mechanical method (for example, clips) with or without

adrenaline. thermal coagulation with adrenaline.

fibrin or thrombin with adrenaline.



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Proton Pump Inhibitors

Do not offer acid-suppression drugs (proton pump

inhibitors or H2-receptor antagonists) before endoscopyto patients with suspected non-variceal upper

gastrointestinal bleeding.

Offer proton pump inhibitors to patients with non-variceal upper gastrointestinal bleeding and stigmata of

recent haemorrhage shown at endoscopy.



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Repeat endoscopy, with treatment as appropriate.

Offer interventional radiology to unstable patients who

re-bleed after endoscopic treatment.

Refer urgently for surgery if interventional radiology is

not promptly available.



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Offer terlipressin to patients with suspected variceal bleeding at

presentation.

Offer prophylactic antibiotic therapy at presentation to patients with

suspected or confirmed variceal bleeding.

Esophageal varices:

Use band ligation in patients with upper gastrointestinal bleeding

from oesophageal varices.

Consider transjugular intrahepatic portosystemic shunts (TIPS) if

bleeding from oesophageal varices is not controlled by band

ligation.



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Gastric varices:

Offer endoscopic injection ofN-butyl-2-cyanoacrylate to

patients with upper gastrointestinal bleeding from gastricvarices.

Offer TIPS if bleeding from gastric varices is not

controlled by endoscopic injection ofN-butyl-2-cyanoacrylate.



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Summary


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management of acute ugi bleed.pptx

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