peptic ulcer disease - mucosal immunology · 6 peptic ulcer disease bible class 08.23.2017,...
TRANSCRIPT
Peptic ulcer disease
Benjamin Heimgartner, OA Gastroenterologie
Universitätsklinik für Viszerale Chirurgie und Medizin, Inselspital
Bible class
08.23.2017
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Peptic ulcer disease
Bible class 08.23.2017, Gastroenterologie Inselspital
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Peptic ulcer disease
Bible class 08.23.2017, Gastroenterologie Inselspital
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Peptic ulcer disease
Bible class 08.23.2017, Gastroenterologie Inselspital
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Peptic ulcer disease
Bible class 08.23.2017, Gastroenterologie Inselspital
What is the initial most important
step in patients with suspected
GI-bleeding?
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Hemodynamic status should be assessed immediately upon
presentation and resuscitative measures begun as needed
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Bible class 08.23.2017, Gastroenterologie Inselspital
When do you prescribe blood
transfusions?
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Bible class 08.23.2017, Gastroenterologie Inselspital
When do you prescribe blood
transfusions?
Blood transfusions should target hemoglobin ≥ 7 g/ dl, with
higher hemoglobins targeted in patients with clinical evidence of
intravascular volume depletion or comorbidities such as
coronary artery disease
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Peptic ulcer disease
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6 weeks mortality
5% vrs 9%
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What are the limits of thrombocytes
and INR (NICE guidelines)?
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Bible class 08.23.2017, Gastroenterologie Inselspital
Thrombocyten > 50 G/L
What are the limits of thrombocytes
and INR (NICE guidelines)?
•INR < 1.5
• Thrombocyten > 50 G/L
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Peptic ulcer disease
Bible class 08.23.2017, Gastroenterologie Inselspital
Which scores of risk assessments
do you know and what are the
clinical implications?
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Peptic ulcer disease
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Peptic ulcer disease
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Peptic ulcer disease
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Peptic ulcer disease
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Peptic ulcer disease
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Which medication should be
considered before active bleeding?
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Peptic ulcer disease
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Which medication should be
considered before active bleeding?
-Erythromycin 250 mg i.v.
(NNT 9 patients => Diagnosis)
Barkun AN et al.: Prokinetics in acute upper GI bleeding: a meta-analysis.
Gastrointest Endosc 2010: 1138 – 45 .
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What about PPI before and after
endoscopy?
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PPI before endoscopy
Lau et al. NEJM 2008; 1631-40
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PPI-Therapie after endoscopy
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What about nasogastric tube?
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What about nasogastric tube?
-Up 18% to upper GI bleeding
missed
-To low negativ predictive value
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Peptic ulcer disease
Bible class 08.23.2017, Gastroenterologie Inselspital
Timing of the endoscopy?
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Timing of the endoscopy?
- first resuscitative efforts
- usually within 24 hours
- within 12 hours:- tachycardia, hypotension, bloody emesis or NG aspirate
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Peptic ulcer disease
Bible class 08.23.2017, Gastroenterologie Inselspital
•Is endotracheal intubation
recommended?
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Peptic ulcer disease
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•Is endotracheal intubation
recommended?
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Classification of peptic ulcers?
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Classification of peptic ulcers?
Forrest classification
- 1: Active bleeding
- 2: Evidence of recent hemorrhage
- 3: Clean base
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Why this is important?
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90%Spritzend Blutung Ia 10%
Sickernde Blutung Ib 10%
50%
25-30%
Gefässstumpf IIa 25%
Koagelbedeckt IIb 10%
Hämatinbelag IIc 10%
Fibrinbelag III 35%
Katschinski B et al. Dig Dis Sci. 1994; 706-12.
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Peptic ulcer disease
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90%Spritzend Blutung Ia 10%
Sickernde Blutung Ib 10% 10-20%
50%
25-30%
Gefässstumpf IIa 25%
Koagelbedeckt IIb 10%
Hämatinbelag IIc 10%
Fibrinbelag III 35%
Katschinski B et al. Dig Dis Sci. 1994; 706-12.
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Peptic ulcer disease
Bible class 08.23.2017, Gastroenterologie Inselspital
90%Spritzend Blutung Ia 10%
Sickernde Blutung Ib 10% 10-20%
50%
25-30%
Gefässstumpf IIa 25%
Koagelbedeckt IIb 10%
Hämatinbelag IIc 10% 7-10%
Fibrinbelag III 35% 3-5%
Katschinski B et al. Dig Dis Sci. 1994; 706-12.
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How do you use Adrenaline?
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How do you use Adrenaline?
-Adrenaline not used alone
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• What treatment options exists?
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• What treatment options exists?
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•Second look endoscopy?
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•Second look endoscopy?
-Not as a matter of routine
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•Second look endoscopy?
-Not as a matter of routine
•Rebleeding after second
endoscopic attempt?
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•Second look endoscopy?
-Not as a matter of routine
•Rebleeding after second
endoscopic attempt?
- Consider surgery or angiography
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Risk factors for rebleeding
Aliment Pharmacol Ther 2011; 888–900
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Peptic ulcer disease
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Risk factors for rebleeding
Aliment Pharmacol Ther 2011; 888–900
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Peptic ulcer disease
Bible class 08.23.2017, Gastroenterologie Inselspital
Risk factors for rebleeding
Aliment Pharmacol Ther 2011; 888–900
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•Nutrition after endoscopy?
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•Nutrition after endoscopy?
-Usually clear fluid immediatly
-If clean based regular diet
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•Nutrition after endoscopy?
-Usually clear fluid immediatly
-If clean based regular diet
•Duration of hospitalisation?
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•Nutrition after endoscopy?
-Usually clear fluid immediatly
-If clean based regular diet
•Duration of hospitalisation?
- Usually 3 days in high risk patients
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Prevention of rebleeding
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Prevention of rebleeding
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•Is every ulcer due to peptic
disease?
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•Is every ulcer due to peptic
disease?
-Cancer
- Infectious
- Ischemic
-Chronic inflammatory disease
-Acute inflammatory
Consider CT
Document healing!!!
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• Whats the problem with H. pylori
testing in bleeding patients?