prezentare hemoragie digestiva superioara

HDS

1. Upper gastrointestinal bleeding – success of hemostasis

2. Causes The most common causes of UGIB include the following (in approximate descending order of frequency) [1,4-6,9,10]: Gastric and/or duodenal ulcers Severe or erosive gastritis/duodenitis Severe or erosive esophagitis Esophagogastric varices Portal hypertensive gastropathy Angiodysplasia (also known as vascular ectasia) Mallory-Weiss syndrome Mass lesions (polyps/cancers) No lesion identified (10 to 15 percent of patients) Other less common causes of UGIB include: Dieulafoy's lesion Gastric antral vascular ectasia Hemobilia Hemosuccus pancreaticus Aortoenteric fistula Cameron lesions Ectopic varices Iatrogenic bleeding after endoscopic interventions Causes of upper gastrointestinal bleeding in adults - UpToDate . (n.d.). UpToDate. https://www.uptodate.com/contents/causes-of-upper-gastrointestinal-bleeding-in adults?search = upper+gi+bleeding&source = search_result&selectedTitle =3%7E150&usage_type= default&display_rank =3

3. Initial presentation Bleeding manifestations: Hematemesis – proximal of ligament of Treitz Melena – proximal of ligament of Treitz but also from oro /nasopharynx, small bowel or colon Hematochezia (large volume upper GI bleeding)

4. Past medical history Peptic ulcer disease History of Helicobacter pylori (H. pylori) infection, Nonsteroidal anti-inflammatory drug (NSAID) use, Antithrombotic use; Smoking Varices or portal hypertensive gastropathy History of liver disease; Excess alcohol use Gastrointestinal angiodysplasia: Kidney disease; Aortic stenosis; Hereditary hemorrhagic telangiectasia Aorto-enteric fistula Abdominal aortic aneurysm; Aortic graft Malignancy History of smoking; Excess alcohol use; H. pylori infection Marginal ulcer (ulcer at an anastomotic site) Gastroenteric anastomosis Medication history: NSAID, antiplatelet agents, anticoagulants.

5. Symptoms Peptic ulcer – Upper abdominal pain Esophageal ulcer – Odynophagia, gastroesophageal reflux, dysphagia Variceal hemorrhage or portal hypertensive gastropathy: jaundice, abdominal distention (ascites) Mallory-Weiss tear – Emesis, retching, or coughing prior to hematemesis Malignancy – Dysphagia, early satiety, unintentional weight loss, cachexia

6. Physical examination Mild to moderate hypovolemia (less than 15 percent of blood volume lost) – Resting tachycardia . Blood volume loss of at least 15 percent – Orthostatic hypotension (a decrease in the systolic blood pressure of more than 20 mmHg and/or an increase in heart rate of 20 beats per minute when moving from recumbency to standing). Blood volume loss of at least 40 percent – Supine hypotension . Cappell , M. S., & Friedel, D. (2008). Initial management of acute upper gastrointestinal bleeding: from initial evaluation up to gastrointestinal endoscopy.  Medical Clinics of North America ,  92 (3), 491–509. https://doi.org/10.1016/j.mcna.2008.01.005 Jensen, D. M., & Machicado , G. A. (1988). Diagnosis and treatment of severe hematochezia.  Gastroenterology ,  95 (6), 1569–1574. https://doi.org/10.1016/s0016-5085(88)80079-9

7. Laboratory data Complete blood count, serum chemistries, liver tests, and coagulation studies. In addition, serial electrocardiograms and cardiac enzymes in patients at risk. What do we look for? In acute upper GI bleeding: low Hgb with normal MCV Elevated blood urea nitrogen (BUN)-to-creatinine (>30:1) or urea-to-creatinine ratio (>100:1) Srygley , F. D., Gerardo, C. J., Tran, T., & Fisher, D. A. (2012). Does this patient have a severe upper gastrointestinal bleed?  JAMA ,  307 (10), 1072. https://doi.org/10.1001/jama.2012.253 Ernst, A. A., Haynes, M. L., Nick, T. G., & Weiss, S. J. (1999). Usefulness of the blood urea nitrogen/creatinine ratio in gastrointestinal bleeding.  The American Journal of Emergency Medicine ,  17 (1), 70–72. https://doi.org/10.1016/s0735-6757(99)90021-9

8. Management General support: oxygen by nasal cannula, two large caliber peripheral intravenous catheters or a central venous line. Endotracheal intubation for patients deemed high-risk for aspiration and massive upper GI bleeding Fluid resuscitation (+/- vasopressor drugs) Blood product transfusions ( Treshold Hgb 7 g/dL or 8 g/dL CV comorbidities) Managing anticoagulants, antiplatelet agents and coagulopathies (administration of prothrombin complex concentrate, frozen plasma, reversal agents for various anticoagulants)

9. Medication Medication PPI: IV every 12 hours or starting a continuous infusion. Prokinetics: erythromycin and metoclopramide Vasoactive medications: Somatostatin, its analog octreotide, and terlipressin are used in the treatment of variceal bleeding Antibiotics for patients with cirrhosis Upper Endoscopy: Early еոԁοѕϲοpy (within 24 h) is recommended for most patients. If variceal bleеdiոg is suspected – endoscopy within 12 h is also possible Approach to acute upper gastrointestinal bleeding in adults - UpToDate. (n.d.). UpToDate. https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults?search=upper%20gi%20bleed&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1

10. Approach to acute upper gastrointestinal bleeding in adults - UpToDate. (n.d.). UpToDate. https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults?search=upper%20gi%20bleed&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1

11. Risk scores The full Rockall score is calculated after endoscopy and is based upon age, the presence of shock, comorbidity, diagnosis, and endoscopic stigmata of recent hemorrhage The GBS, unlike the Rockall score, does not take endoscopic data into account and thus can be calculated when the patient first presents. The score is based upon the blood urea nitrogen, hemoglobin, systolic blood pressure, pulse, and the presence of melena, syncope, hepatic disease, and/or cardiac failure. AIMS65 is another scoring system that uses data available prior to endoscopy (serum albumin, INR, presence of altered mental status, systolic blood pressure, and age), but it is less sensitive than the Blatchford and preendoscopic Rockall scores for identifying low-risk patients the Age, Blood tests and Comorbidities (ABC) score, was developed to predict mortality in patients with upper GI bleeding and lower GI bleeding Risk scores - Approach to acute upper gastrointestinal bleeding in adults - UpToDate. (n.d.). UpToDate. https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults?search=upper%20gi%20bleed&source=search_result&selectedTitle=1%7E150&usage_type=default&display_rank=1#

12. Treatment in peptic ulcer disease Pharmacologic therapy: PPI IV every 12h or continuous infusion (standard of care) or orally if IV is not available in case of active bleeding or high risk stigmata. Otherwise, standard dose once a day Somatostatin and its long-acting analogue octreotide: reduce splanchnic blood flow, inhibit gastric acid secretion, and may have gastric cytoprotective effects Prokinetic agents: erythromicin Endoscopic therapy: Standard approaches to treatment include thermal coagulation (also APC) and endoscopic clip placement. In addition, both of these modalities can be combined with injection therapy, (epinephrine) an approach known as combination therapy Alternatives to standard endoscopic therapy that are being studied include the use of tissue adhesives and agents that promote hemostasis. Overview of the treatment of bleeding peptic ulcers - UpToDate. (n.d.). UpToDate. https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?search=upper+gi+bleeding&source=search_result&selectedTitle=4%7E150&usage_type=default&display_rank=4

13. Forrest classification Dhahab, H. A., & Barkun, A. (2012). The acute management of nonvariceal upper gastrointestinal bleeding. Ulcers, 2012, 1–8. https://doi.org/10.1155/2012/361425

14. Factors associated with rebleeding identified in a meta-analysis included: Hemodynamic instability (systolic blood pressure less than 100 mmHg, heart rate greater than 100 beats per minute) Hemoglobin less than 10 g/L Active bleeding at the time of endoscopy Large ulcer size (greater than 1 to 3 cm in various studies) Ulcer location (posterior duodenal bulb or high lesser gastric curvature) Increase in the blood urea nitrogen (BUN) level at 24 hours compared with baseline García-Iglesias, P., Villoria, A., Suarez, D., Brullet, E., Gallach, M., Feu, F., Gisbert, J. P., Barkun, A., & Calvet, X. (2011). Meta-analysis: predictors of rebleeding after endoscopic treatment for bleeding peptic ulcer. Alimentary Pharmacology & Therapeutics, 34(8), 888–900. https://doi.org/10.1111/j.1365-2036.2011.04830.x

15. Recurrent bleeding - one or more of the following: Hematemesis or bloody nasogastric aspirate more than six hours after endoscopy Melena after normalization of stool color Hematochezia after normalization of stool color or after melena Development of tachycardia (heart rate ≥110 beats per minute) or hypotension (systolic blood pressure ≤90 mmHg) after at least one hour of hemodynamic stability Hemoglobin drop of 2 g/dL or more after two consecutive stable hemoglobin values (less than a 0.5 g/dL decrease) obtained at least three hours apart. Tachycardia or hypotension that does not resolve within eight hours after index endoscopy despite appropriate resuscitation (in the absence of an alternative explanation), associated with persistent melena or hematochezia Persistently dropping hemoglobin of more than 3 g/dL in 24 hours, associated with persistent melena or hematochezia. Laine, L., Spiegel, B., Rostom, A., Moayyedi, P., Kuipers, E. J., Bardou, M., Sung, J., & Barkun, A. N. (2009). Methodology for randomized trials of patients with nonvariceal upper gastrointestinal bleeding: recommendations from an international consensus conference. The American Journal of Gastroenterology, 105(3), 540–550. https://doi.org/10.1038/ajg.2009.702

16. What to do in recurrent bleeding? Patients with one episode of recurrent bleeding following initially successful endoscopic therapy are typically treated with a second attempt at endoscopic therapy Angiography-guided intervention ( transarterial embolization (TAE)) or surgery may be indicated for patients who fail endoscopic therapy (persistent bleeding or recurrent bleeding after two therapeutic endoscopies). Overview of the treatment of bleeding peptic ulcers - UpToDate. (n.d.). UpToDate. https://www.uptodate.com/contents/overview-of-the-treatment-of-bleeding-peptic-ulcers?search=upper+gi+bleeding&source=search_result&selectedTitle=4%7E150&usage_type=default&display_rank=4

17. Variceal bleeding The first step in stopping variceal bleeding is the initiation of pharmacologic therapy (vasopressin, ѕοmаtоstаtin , and their analogs- ( terlipressin and octreotide). Bleeding esophageal varices are typically managed with endoscopic therapy: Endoscopic variceal ligation is generally preferred due to its high efficacy and low complication rate. Endoscopic sclerotherapy is an alternative that is also highly effective, but it is associated with higher complication rates than endoscopic variceal ligation. If endoscopic therapy fails, treatment options include transjugular intrahepatic portosystemic shunt (TIPS) placement or creation of a surgical shunt.

18. In 10 to 20 percent of patients, emergent endoscopic therapy fails to control bleeding or there is rebleeding following endoscopic therapy [1]. Patients in whom hemostasis cannot be achieved are at high risk for exsanguination and other complications related to active bleeding. If one endoscopic modality fails to control bleeding, it is reasonable to try using a different treatment modality ( eg , band ligation for failed sclerotherapy) (algorithm 1) [55,72]. In patients with rebleeding following initially successful endoscopic therapy, a second attempt at endoscopic therapy may be carried out, though data are lacking regarding the best approach for patients with early rebleeding [4]. For those with severe bleeding, proceeding with stabilization and TIPS may be more appropriate. If bleeding is not quickly and effectively stopped endoscopically, or if rebleeding occurs a second time, more definitive therapy (TIPS placement or surgery) is required [14]. Balloon tamponade or esophageal stent placement can be performed as a temporizing measure. TIPS is generally preferred as definitive therapy because it is associated with a high success rate (90 to 100 percent of patients will achieve hemostasis). While surgery is also highly effective, it is associated with a high mortality rate (up to 50 percent).