Approach to acute upper gastrointestinal bleeding(1) (1)-5(3).pptx

Elaborate the approach and management of patients presenting with upper gastrointestinal bleeding

1. Approach to acute upper gastrointestinal bleeding Dr. m. usman ahmad pgr gastr0enterology

2. Definition It is defined as a bleeding derived from a source proximal to the ligament of Treitz. The anatomic landmark that separates upper and lower bleed is the ligament of Treitz, also known as the suspensory ligament of the duodenum.

3. Causes of UGIB: Non Variceal Erosive or inflammatory causes : Peptic ulcer disease Esophagitis Erosive gastritis or duodenitis Vascula r causes: Gastric antral vascular ectasia Dieulafoy lesion Angiodysplasia Variceal Esophageal varices Gastric varices

4. Causes of UGIB Non variceal Tumors: Gastric or esophageal cancer Traumatic or iatrogenic: Hiatal hernias Mallory-Weiss syndrome Boerhaave syndrome Others: Portal hypertensive gastropathy Coagulopathy Following open or endoscopic surgery

5. manifestations of UGIB Hematemesis is defined as vomiting of blood. Bright red color suggests recent or ongoing bleeding while coffee ground emesis suggests bleeding that has stopped some time ago. Melena is defined as black tarry stool that results from degradation of blood to hematin by intestinal bacteria. It is being seen with as little as 50 mL of blood and appears 4 to 20 hours after ingestion Hematochezia refers to bright red blood per rectum which is usually due to lower GI bleeding, can occur with massive upper GI bleeding(>1L)

6. Brain storming A 38 year old man comes to the emergency department because of epigastric pain and multiple episodes of vomiting for 4 hours. Initially, the vomit was yellowish in color, but after the first couple of episodes it was streaked with blood. He had 2 episodes of vomiting that contained streaks of frank blood on the way to the hospital. He drinks 2 pints of vodka daily but had over 4 pints during the past 12 hours. He takes naproxen for his “hangovers”. He appears uncomfortable. His temperature is 37’C (99.1’F), pulse is 105/min, and blood pressure is 110/68 mm of Hg. Examination shows dry mucous membranes and a tremor of his hands. The abdomen is soft and shows tenderness to palpation in the epigastric region; there is no organomegaly. Cardiopulmonary examination shows no abnormalities. Rectal examination is unremarkable. His hemoglobin concentration is 13.9 g/dl and hematocrit concentration is 40%. Which of the following is the most likely cause of this patient’s findings?

7. . A) superficial ectatic artery in the gastric cardia B) dilated submucosal veins in the lower esophagus c) transmural tear of the lower esophagus D) pseudoaneurysm of the gastroduodenal artery E) ulcerative damage to the posterior wall of the duodenum F) inflammation of the esophageal wall G) mucosal tear at the gastroesophageal junction H) abnormal connection between gastric arteries and veins I) neoplastic growth at the gastroesophageal junction

8. . A) superficial ectatic artery in the gastric cardia B) dilated submucosal veins in the lower esophagus c) transmural tear of the lower esophagus D) pseudoaneurysm of the gastroduodenal artery E) ulcerative damage to the posterior wall of the duodenum F) inflammation of the esophageal wall G) mucosal tear at the gastroesophageal junction H) abnormal connection between gastric arteries and veins I) neoplastic growth at the gastroesophageal junction

9. Initial assessment and management Goal of the evaluation Assess the severity of the bleed Identify potential sources of the bleed Determine if there are conditions present that may affect subsequent management

10. INITIAL EVALUATION Clinically significant UGIB evaluation includes: Detailed History Physical examination Laboratory tests

11. Detailed history Focused history should include a history of associated symptoms (e.g., upper/lower abdominal pain), past history of GI bleeding, medical history (e.g., PUD, cirrhosis), and medication history (especially the use of NSAIDs, corticosteroids, and antithrombotic agents) Medical history can help in identifying potential bleeding sources and comorbidities Potential bleeding sources suggested by a patient’s past medical history include: Varices or portal hypertensive gastropathy in a patient with a history of liver disease or excess alcohol use Aorto-enteric fistula in a patient with a history of an abdominal aortic aneurysm or an aortic graft

12. To be cont… Angiodysplasia in a patient with renal disease, aortic stenosis, or hereditary hemorrhagic telangiectasia Peptic ulcer disease in a patient with a history of helicobacter pylori (H. pylori), infection, nonsteroidal anti-inflammatory drugs(NSAIDS)) use, antithrombotic use or smoking. Malignancy in a patient with a history of smoking, excess alcohol use, or H. pylori infection. Marginal ulcers (ulcers at an anastomotic site) in a patient with a gastroenteric anastomosis

13. Physical examination The physical examination is a key component of the assessment of hemodynamic stability. Signs of hypovolemia include: Tachycardia Hypotension orthostasis

14. Physical examination Assessment of hemodynamic status Mild to moderate hypovolemia< 15% loss - resting tachycardia. Blood volume loss of at least 15 percent - Orthostatic hypotension Blood volume loss of at least 40 percent – Supine hypotension. PR examination It is very important part of evaluation of UGIB (Usually skipped on examination) as it can differentiate normal dark brown color stool from melena having tarry black appearance.

15. Laboratory Investigations CBC, serum chemistries, liver function tests, coagulation profile, blood typing and cross match ECG and cardiac evaluation in old/ischemic patients Hb may be normal at baseline- repeat after 2 to 8hrs(based on severity) Urea-to-creatinine ratio  >100:1, suggest upper GI bleeding Anemia, low hematocrit, coagulopathy, and elevated BUN at presentation are signs of severe GI bleeding

16. General management and resuscitation Hemodynamically unstable patient: Patient should be managed following ABCD survey. Protection of airway : Endotracheal intubation should be considered in patients with ongoing hematemesis or altered respiratory or mental status to decrease the risk of aspiration Patients should receive supplemental oxygen by nasal cannula and should receive nothing per mouth. Maintenance of circulation : Intravenous access should be attained with two 18 gauge or more intravenous catheters Fluid resuscitation : Normal saline is infused at a rate needed to keep patient Sbp above 100mm of hg and pulse less than 100 bpm

17. To be cont… Blood products Transfusion : patient should be transfused with packed RBCs, platelets and FFPS as necessary to keep hemoglobin level greater than 7g/dl , platelet count higher than 50000/mm3 and PT< 15 seconds Restrictive Transfusion strategy should be followed in hemodynamically stable patients as it is associated with higher survival rates along with lower rebleeding rate. Liberal transfusion strategy: In patients with massive bleeding and hemorrhagic shock despite an apparently normal hemoglobin level.

18. Initial medical therapy High dose PPI : Omeprazole 80 mg IV once, then 8 mg/hour continuous IV infusion for 3 days. Administration of PPI is useful for reducing rebleeding rates in patients with PUD. Patient with strong suspicion of portal hypertension and variceal bleeding should be started empirically on IV vasoactive drugs (Terlipressin or octreotide) as they reduce the risk of rebleeding along with empirical iv antibiotics .

19. Risk stratification Pre-endoscopy risk stratification : All patients with GI bleeding should be risk-stratified to guide the diagnostic and therapeutic approach, timing of endoscopy, and patient disposition Pre endoscopy scoring systems have been developed to identify the patients with nonvariceal bleeding at greatest risk for mortality and rebleeding These scoring systems include Blatchford score, clinical Rockall score, artificial neural network score and AIMS65 score

20. Blatchford score Interpretation Score 0-1: low-likelihood of rebleeding or need for urgent intervention Score > 1: higher likelihood of rebleeding and/or need for urgent intervention

21. Patient with Rockall score 0 to 2 are considered ;ow risk and should be considered for early discharge

22. Post endoscopy risk stratification The Forrest classification is commonly used to determine the need for hemostatic interventions during the procedure and can help guide disposition by predicting the risk of rebleeding Low risk (Forrest IIc–III): can usually be managed as outpatients with PPI therapy Higher risk (Forrest I–IIb): Typically require inpatient care

23. Forrest classification IA

24. Forrest classification IIb

25. Forrest classification IIc, III

26. Diagnostic studies Upper endoscopy is the diagnostic modality of choice for acute upper GI bleeding Colonoscopy is generally required for patients with hematochezia or melena and a negative upper endoscopy CT Angiography for further workup of patients with ongoing bleeding and negative endoscopy EVALUATION OF SMALL BOWEL if both upper endoscopy and colonoscopy are negative: Advanced endoscopic evaluation : push enteroscopy, push- and-pull enteroscopy, video capsule endoscopy (VCE) Radiographic evaluation : CT enterography, tagged RBC scintigraphy, Meckel scan

27. Evaluation of suspected upper gastrointestinal bleeding

28. Treatment Endoscopic measures for the control of nonvariceal bleed Endoscopic modalities include Bipolar probe Unipolar probe Thermal probe Argon plasma coagulation Hemostatic clips Injection sclerotherapy

29. Timing of endoscopy Patients admitted to or under observation in hospital for UGIB should undergo endoscopy within 24 hours of presentation

30. Endoscopic management based on Forrest classification

31. Treatment according to book Treatment is discussed according to forrest classification Class 1A combination therapy is recommended whether use inj epinephrine with thermal probe or injection epinephrine with Haemostatic clips along with iv omeprazole for 3 days. Class 1B monotherapy with inj epinephrine or heater probe along with iv omeprazole for 3 days .

32. To be cont… Class 2A monotherapy with heater probe or hemoclips along with iv omeprazole for 3 days. Class 2 B start with injection epinephrine then remove the clot with cold snare and treat accordingly. Class 2 C if DEP is available and blood flow is present hemoclips are recommended. Class 3 take ulcer edge biopsies and give oral ppis

33. Choice of endoscopic therapy for bleeding ulcer as per ACG 2021 recommendations

34. Antisecretary therapy after endoscopic hemostatic therapy High dose PPI therapy should be given continuously or intermittently for 3 days after successful endoscopic hemostatic therapy of a bleeding ulcer followed by twice daily PPI therapy until 2 weeks after index endoscopy

35. Recurrent bleeding after successful endoscopic hemostatic therapy Patient with recurrent bleeding after endoscopic therapy for a bleeding ulcer should undergo repeat endoscopy and endoscopic therapy rather than surgery or transcatheter arterial embolization Over the scope clips should be used as hemostatic therapy for patients with recurrent bleeding due to ulcers after successful endoscopic therapy.

36. Failure of endoscopic hemostatic therapy Patient with bleeding ulcers who have failed endoscopic therapy next be treated with transcatheter arterial embolization Patient who failed to respond to transcatheter arterial embolization should have surgery for hemostatic control

37. Treatment of the underlying cause Once hemostasis has been achieved, the underlying cause should be evaluated for and treated.

38. Bipolar Electrocoagulation In Bipolar mode current is transmitted from one electrode to other electrode on the probe and grounding plate is not required. Large probe is required 3.2mm(10 Fr) 15 watts 8-10 seconds Firm to maximal pressure Firm tamponade then coagulate around

39. Bipolar Electrocoagulation Apply coagulation directly on the vessel if vessel is less than 1mm in diameter. Apply coagulation circumferentially around the vessel if diameter of vessel is more than 1 mm. Probe should be removed slowly with gentle irrigation to prevent pulling of coagulation tissue. Therapeutic end point is when bleeding stops and visible vessel is flattened. Strong recommendation with moderate quality of evidence. Complications include perforations and pulling of soft tissue with probe.

40. Heater probe A Teflon coated hollow aluminium cylinder with an inner heating coil and a thermocoupling device at the tip of probe. Generates heat directly. 30 Joules of energy 8-10 seconds. Firm to maximal pressure. Firm tamponade then coagulate around bleeding point. Complications include displacement of tip and perforation. Strong recommendation moderate quality of evidence.

41. Sclerosant injection Ethanol injection is used. Polidocanol is under trial. Cause dehydration of mucosa, vasoconstriction and necrosis of vessel wall. 0.1 to 0.2 ml per injection at multiple sites 1-2 mm from bleeding site and maximum of 1-2 ml. Strong recommendation moderate quality of evidence. Acg did not recommend thermal contact therapy over ethanol injection.

42. Haemostatic powder spray Tc-325 used. Bleeding difficult to control by traditional measures or large lesion causing massive bleed. It is a bridge to definite therapy. Powder is sprayed in 1-2 sec burst. Keep catheter tip 1-2 cm from bleeding site. Continue spraying until bleeding stops. Sloughs within 24 hours. Conditional recommendation very low quality of evidence.

43. Argon plasma coagulation. Non contact electrocoagulation device that delivers high frequency monopolar current through ionized gas causing desiccation of target tissue. Gas flow 1-2 lit per minute. Power setting of 40- 70 watts. Probe should be 2-10 mm away. Conditional recommendation very low quality of evidence. Complications include pain, bloating, emphysema and perforation.

44. Haemostatic clips. Made of stainless steel. Bleeding site is clipped first then additional clips can be applied around the bleeding point. Clips dislodge spontaneously within 2-4 weeks and pass in stool. Ulcers present at proximal lesser curvature, gastric cardia and posterior wall of duodenal bulb are difficult to approach. Vessel larger than 2 mm is difficult to approach. If used with inj epinephrine clipping should be done first. Conditional recommendation very low quality of evidence. Complications include displacement of clips.

45. Over the scope clips. Mostly used in patients with rebleed. Lesion is approached, cap is placed over the lesion, lesion is sucked into the cup and clip is released. Larger clips and can capture deep tissue layer. Conditional recommendation , very low quality of evidence.

46. Injection epinephrine Epinephrine injection is diluted in ratio 1:10000 or 1:20000 0.5 to 2 ml is used per injection into four quadrant of ulcer. Needle size may range from 19 to 25 G Results in local tamponade and vasospasm. Use to control bleeding to improve visibility before some other procedure. Inexpensive and easy to use. Single use of injection epinephrine is not recommended. Strong recommendation very low quality of evidence. Complications include rebleeding , bowel ischemia, perforation and systemic side effects of drug.

47. . Thank you