Upper GI Bleeding Dr Iqbal

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					Upper Gastrointestinal Bleeding
Dr. Iqbal Siddique
Associate Professor Department of Medicine Faculty of Medicine, Kuwait University
Consultant Gastroenterologist Thuniyan Al-Ghanim Gastroenterology Center Al-Amiri Hospital

Gastrointestinal Bleeding
Upper Gastrointestinal bleeding

Gastrointestinal Bleeding
Gastrointestinal bleeding presents in one of four ways:

Gastrointestinal Bleeding
Gastrointestinal bleeding presents in one of four ways:     Hematemesis Melena Hematochezia Chronic (occult) gastrointestinal bleeding

Upper GI Bleeding - Epidemiology

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Incidence 150/100,000 population per year. Overall mortality 10% in those admitted to hospital.

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Mortality 30 % in the elderly.

Upper GI Bleeding – Common Causes Causes
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U.S.
55% 14%

U.K.
50% 10%

Peptic Ulcers (DU & GU) Gastro-esophageal varices

Mallory-Weiss tear Gastric erosions Esophagitis Gastric cancers Angiodysplasia Doudenal erosions Miscellaneous

5% 4% 4% 6% 12%

7% 20% 5% 3% 5%

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Upper GI Bleeding – Common Causes
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Doudenal Ulcer

Doudenal Ulcer

Bleeding doudenal ulcer

Upper GI Bleeding – Common Causes
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Gastric Ulcer

Gastric ulcer

Bleeding gastric ulcers

Upper GI Bleeding – Common Causes
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Esophageal Varices

Esophageal Varices

Bleeding esophageal varices

Upper GI Bleeding – Common Causes

Gastric varices

Mallory Weiss Tear

Esophagitis

Upper GI Bleeding – Common Causes
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Angiodysplasia of the stomach

Upper GI Bleeding – Initial Management
Initial patient assessment

Upper GI Bleeding – Initial Management
Initial patient assessment Initial approach to the patient with acute upper gastrointestinal bleeding should include near simultaneous completion of the following:
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Patient resuscitation and stabilization Brief clinical history Limited physical examination

Upper GI Bleeding – Initial Management
Patient resuscitation and stabilization

Upper GI Bleeding – Initial Management
Patient resuscitation and stabilization
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Check vital signs Assess airway and breathing Assess circulatory status (postural hypotension) Obtain intravenous access Replace volume Transfuse blood (if necessary) Measure urine output

Initial Management – Airway & Breathing

Initial Management – Airway & Breathing
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Inspect airway Clear airway Check ventilation Supplemental oxygen Endotracheal intubation: Intubation and mechanical ventilation should be considered for the following patients:

Initial Management – Airway & Breathing
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Inspect airway Clear airway Check ventilation Supplemental oxygen Endotracheal intubation: Intubation and mechanical ventilation should be considered for the following patients:
– – – – – in shock from massive bleeding. on going hematemesis, especially if the bleeding is torrential. severe agitation. depressed sensorium. depressed respiratory status.

Initial Management – Circulatory Assessment
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A quick assessment of the circulatory status should be made by:

Initial Management – Circulatory Assessment
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A quick assessment of the circulatory status should be made by:
– – – – pulse rate measuring the supine blood pressure checking for pallor and agitation patients with normal supine blood pressure should be checked for postural hypotension.

Initial Management – Circulatory Resuscitation
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Intravenous access
– At least two large bore (14 to 18 gauge) peripheral intravenous lines should be inserted for access and volume replacement.

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Central Venous Catheter (CVC)
– A CVC is usually not indicated because volume can easily be replaced with large bore peripheral IV lines. However a CVC may be useful in the following conditions:
• failure to establish peripheral IV access • patients who have an unstable cardiac disease or cirrhosis, in whom measurement of left ventricular filling pressure is necessary to accurately assess volume status.

Initial Management – Circulatory Resuscitation
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Volume replacement: Volume should be replaced using crystalloids, such as 0.9% NaCl solution (normal saline) or Ringer's lactate, as rapidly as the patient's cardiopulmonary status will allow, to stabilize vital signs.

Upper GI Bleeding – Initial Management
Guidelines for transfusion of blood and blood products in Upper GI Bleed
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Symptoms related to poor tissue oxygenation (e.g. angina). If there is continued acute bleeding despite therapy. If the patient is clinically shocked despite crystalloids.
If the hematocrit is low (in elderly, high risk patient Hct <30%, and in young, otherwise healthy patients <20%). If there is coagulopathy or thrombocytopenia, then fresh frozen plasma and platelets transfusion should be given, respectively.

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Initial Management – Circulatory Resuscitation
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Vasopressor
– Vasopressors are generally not required because the problem is typically one of volume depletion. However if shock is refractory to volume replacement then vasopressors may be indicated.

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Measurement of urinary output
– This is necessary to follow the status of volume replacement and renal perfusion.

Upper GI Bleeding – Initial Management
Laboratory investigations

Upper GI Bleeding – Initial Management
Laboratory investigations
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CBC PT (INR), aPTT Type and cross match blood Creatinine, urea, Liver function tests HBSag and anti-HCV if liver disease is suspected ECG in patients over 50 years of age or h/o cardiac disease

Upper GI Bleeding – Initial Management Nasogastric tube

Upper GI Bleeding – Initial Management Nasogastric tube
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Patients with definite or suspected acute upper gastrointestinal bleeding should have a nasogastric (NG) tube inserted. There is no contraindication to NG tube placement in patients suspected to have esophageal or gastric varices.

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Once the NG tube has been placed, the stomach should be lavarged with tap water or normal saline at room temperature and then the tube should be connected to a gravity bag.

Upper GI Bleeding – Initial Management
Brief History
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Previous history of an upper gastrointestinal bleeding, if so what was the cause.
Symptoms or previous history of peptic ulcer disease. Use of NSAID's, aspirin or anticoagulants. Previous history of liver disease. Risk factors for liver disease (e.g. alcohol consumption, h/o blood transfusion, h/o hepatitis or jaundice).

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Recent history of vomiting or retching. History of heartburn. Any previous surgeries, especially recently.
Any co morbid illnesses (e.g. cardiac, pulmonary or neurological illness, bleeding disorders, etc).

Upper GI Bleeding – Initial Management

Brief Physical Examination
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A physical examination should be done to look for  stigmata of chronic liver disease.  surgical scars on the thorax and abdomen.

Upper GI Bleeding – Risk Assessment

Upper GI Bleeding – Risk Assessment Mild to Moderate Upper GI Bleeding
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The patient is < 60 years of age, and has no chronic medical illness. There is no sign of hemodynamic instability. Hematocrit is > 30%.

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Upper GI Bleeding – Risk Assessment Severe Upper GI Bleeding
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The patient is > 60 years old.

There are signs of hemodynamic instability (Pulse >100/min, SBP < 100 or postural hypotension). There is active bleeding (bright red hematemesis, bright red blood in NG tube or hematochezia with hypotension).
Drop in hematocrit of 6% or more.

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There is severe co morbid disease (liver, cardiac, pulmonary or renal)

Upper GI Bleeding - Decisions
Mild to Moderate Upper Gastrointestinal Bleeding:
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Admit to general medical ward. Observe for continued bleeding or rebleeding.
Arrange for upper endoscopy on the next routine list. Discharge patient from hospital in 5 days if there is no evidence or continued or recurrent bleeding and if there are no other contraindications.

Upper GI Bleeding - Decisions
Severe Upper Gastrointestinal Bleeding
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Admit to a high dependency ward with close monitoring. Observe for continued bleeding or recurrent bleeding (signs of overt bleeding, drop in blood pressure, rise in pulse rate, or fall in CVP).

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Restore blood volume with blood products and crystalloids as needed. Keep patient fasting (except for sips of water). Arrange for endoscopy as soon as the patient has been stabilized, preferably within 12 hours of presentation. If there is any suspicion of portal hypertension, then start Somatostatin or Octreotide infusion after giving a bolus dose.

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Upper GI Bleeding – Endoscopic Treatment

Upper GI Bleeding – Endoscopic Treatment
Endoscopic diagnosis & treatment
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Upper Endoscopy is the procedure of choice in majority of patients with an acute upper gastrointestinal bleeding, for the following reasons:
– It can define the source of bleeding in the majority of patients with an upper gastrointestinal bleeding. – It can stratify the patients risk of rebleeding. – It can provide endoscopic therapy for esophageal and gastric varices, peptic ulcer disease, Dieulafoy's lesion, vascular malformations and tumors.

Upper GI Bleeding – Endoscopic Treatment

Endoscopic modalities of therapy:
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Thermal therapy Injection therapy Mechanical therapy

Upper GI Bleeding – Endoscopic Treatment

Endoscopic modalities of therapy:
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Thermal therapy Injection therapy Mechanical therapy Plus IV PPI

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Upper GI Bleeding – Endoscopic Treatment
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Doudenal Ulcer (Thermal therapy)

Endoscopic therapy of bleeding doudenal ulcer

Upper GI Bleeding – Endoscopic Treatment
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Gastric Ulcer (Injection therapy)

Endoscopic therapy of bleeding gastric ulcers

Upper GI Bleeding – Endoscopic Treatment
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Esophageal Varices (Band ligation)

Band ligation of esophageal varices

Upper GI Bleeding – Endoscopic Treatment
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Duodenal ulcer (Clipping)

Band ligation of esophageal varices

Upper GI Bleeding – Medical Rx & Follow-up

Upper GI Bleeding – Medical Rx & Follow-up
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Once the bleeding has been controlled the patient may need further medical or endoscopic therapy.

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This may have to be initiated either prior to discharge from the hospital or afterwards. It is the responsibility of the physician taking care of the patient to arrange for this prior to discharging the patient from the hospital.

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Upper GI Bleeding – Medical Rx & Follow-up
Esophageal or gastric varices
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Continue Somatostatin or Octreotide for 3 to 5 days after the control of bleeding. Consider starting a non-selective Beta blocker on a long term basis.

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Consider possible iron supplementation for anemia. Arrange for follow up endoscopy sessions for continued endoscopic therapy and eventual eradication of varices. Follow up of the underlying liver disease.

Upper GI Bleeding – Medical Rx & Follow-up
Peptic ulcer disease
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Consider iron supplementation for anemia. Evaluate Helicobacter pylori status and if positive give treatment for eradication.
If the ulcer is in the stomach then re-endoscopy in 4 to 6 weeks may be needed to confirm healing. Patients who were taking aspirin or NSAID's should be counseled about stopping these medications.

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Patients who do not have H. pylori or NSAID's as a cause of their ulcers may benefit from maintenance therapy with H2Blockers.

Upper GI Bleeding – Management
Patient assessment Patient resuscitation Risk assessment
Airway, Breathing, Circulation

IV access, blood transfusion, labs

Severe , moderate or mild bleeding

Upper Endoscopy Low risk lesion Medical Rx High risk lesion Surgery

Endoscopic Rx

Rebleed


				
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