upper gi bleed james peerless april 2011. introduction incidence of 100/100 000 population per year...
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Upper GI Bleed
James PeerlessApril 2011
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Introduction
• Incidence of 100/100 000 population per year (UK & USA)
• >80% occur as acute admissions• ‘Hospital-acquired’– Critically ill patients– Prolonged NG tube– Drug Rx
• Associated with high rate of mortality and long ICU stay
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Objectives
• Definitions• Anatomy• Sources of Bleeding• Presentation• Assessment• Management
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DefinitionsUpper GI TractThe oral cavity, pharynx, oesophagus, stomach & proximal duodenum
HaematemesisThe act of vomitting blood; swallowed or that arisen from the bleeding within the upper GI tract
MelaenaBlack discoloured faeces due to the presence of partly-digested blood from the upper GI tract
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Anatomy
Hepatic a.
Left gastric a.
Right gastric a.Left gastro-epiploic a.
Right gastro-epiploic a.
Splenic a.
Coeliac trunk
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Azygous v.
L + R gastric vv.
Portal v.
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Causes
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Varices
• Secondary to portal hypertension
• Dilated collateral veins formed at G-Oe junction
• These portosystemic anastomoses are superficial and prone to rupture
• High pressure veins in a hyperdynamic circulation
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Presentation
• Active bleeding• History of haematemesis• Melaena• Shock/hypotension/collapse• Anaemia
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Acute Management
Supportive
• Resuscitation– A B C
• History & Examination• Recruit help• Investigations• Continuous monitoring• Blood products• Correction of coagulopathy
Corrective
• Medical• Balloon tamponade• Endoscopy• Surgical
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Assessment
• Acute Assessment• History & Examination• Is the airway safe?• Is the patient at risk of further events?
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Identifying Risk
• Rockall Score
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Rockall Criteria
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Rockall Score0 1 2 3
Age <60 60-79 >80
Shock No shock HR >100 HR >100, SBP <100
Comorbidity Cardiac failure, ischaemic heart disease
Renal failure, liver failure, disseminated malignancy
Diagnosis Mallory Weiss, no lesion, no stigmata of recent haemorrhage
All other diagnoses
Malignancy of upper gastrointestinal tract
SRH (Endoscopy)
None, or dark spot
Fresh blood, adherent clot, visible or spurting vessel
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Mortality Rates0 1 2 3 4 5 6 7 8+
Total (%) 4.9 9.5 11.4 15.0 17.9 15.3 10.6 9.0 6.4
Re-bleed (%)
4.9 3.4 5.3 11.2 14.1 24.1 32.9 43.8 41.8
Death (non re-bleed) (%)
0 0 0.3 2.0 3.5 8.1 9.5 14.9 28.1
Death (re-bleed) (%)
0 0 0 10.0 15.8 22.9 33.3 43.4 52.5
Death (total) (%)
0 0 0.2 2.9 5.3 10.8 17.3 27.0 41.1
Rockall TA, Logan RF, Devlin HB, Northfield TC (1996) Risk assessment after acute upper gastrointestinal haemorrhage. Gut 38:316 – 21
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Scoring Systems
• Rockall Score• Forrest Classification– Active haemorrhage– Signs of recent haemorrhage– Lesions without active bleeding
• Glasgow-Blatchford Score– Scored on Hb, urea, BP,
presentation/comorbidities (no endoscopy)
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Management Pathway
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Oesophagogastroduodenoscopy
• Offers diagnostic information and opportunity for therapeutic intervention
• Scoping within 24 hours has a proven reduction in rebleed, mortality and length of admission
• For ulcers:– Adrenaline injection (temporary efect)– Diathermy/haemocoagulation– Endocscopic clips
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Variceal Bleeding
• Endoscopy is the definitive treatment of choice for variceal bleed
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Drugs & Secondary MX
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Sengstaken-Blakemore Tube
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Sengstaken-Blakemore Tube
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Linton-Nachlas Tube
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TIPSS
• Transjugular Intrahepatic Portosystemic Shunt• Radiologically guided stent– Drilled through the liver and connects the portal
and hepatic vein• Available in specialised units• Complications– Thrombosis (10%)– Bleeding– Infarction
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Summary
• Hidden clinical picture• Supportive and Corrective Management• Endoscopic therapy mainstay of treatment• Risk of rebleeding remains high – keep
monitoring the patient!
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The End