Upper Gastro Intestinal Bleeding and its managements.pptx

The presentatin is about Upper Gastro Intestinal Bleeding, its causes, approach to the patients with GI Haemorrhage, initial assessment, resuscitation, history and physical examination, localisation, specific causes of GI Haemorrhage, investigations and managements.

1. Upper g.i. bleeding Dr. Manotosh Biswas SR, General Surgery AIIMSK

2. Introduction Acute G.I. hemorrhage is a common clinical problem with diverse manifestations. Trivial to massive/from virtually any region Classified by the location relative to the ligament of Treitz Obscure bleeding : hemorrhage that persists/recurs after negative evaluation with endoscopy Occult bleeding : not apparent to the patient until symptoms related to the anemia are manifested Management of these patients is frequently multidisciplinary

3. approach to the patient with GI hemorrhage

4. Initial Assessment Patient’s airway and breathing take first priority Patient’s hemodynamic status becomes the dominant concern The preexisting deficits and ongoing hemorrhage Continuous reassessment of the patient’s circulatory status  aggressiveness of subsequent evaluation and intervention Determination of severity >40% loss : Obtundation, agitation, & hypotension (SBP <90 mm Hg in the supine position) associated with cool, clammy extremities 20% to 40% loss : resting HR >100 beats/min with a decreased pulse pressure 20% at least : postural changes - ↓ in BP of >10 mm Hg or ↑ of the pulse of >20 beats/min

5. Resuscitation More severe the bleeding, the more aggressive the resuscitation two large-bore IV lines , preferably in the antecubital fossae Unstable patients  2-liter bolus of crystalloid solution, usually RL Blood typing & cross matching, CBC, Coagulation profile, LFT Foley catheter Administering supplemental oxygen Blood transfusion  packed RBCs are the preferred form high-volume transfusion  empirically receive both FFP & platelets & calcium

6. History and Physical Examination Preliminary assessment of the site & cause of bleeding & comorbidities Characteristics of the bleeding: Hematemesis : vomiting of blood Melena : passage of black, tarry, and foul-smelling stool Hematochezia : bright red blood from the rectum Demographic data Elderly – angiodysplasias, diverticula, ischemic colitis, and cancer Younger – peptic ulcers, varices, and Meckel’s diverticula

7. History and Physical Examination Medical history Antecedent epigastric distress – peptic ulcer Antecedent vomiting – Mallory-Weiss tear Weight loss – malignant disease Liver disease – variceal bleeding Previous aortic surgery – aortoenteric fistula Medication (NSAIDs, SSRIs, warfarin, LMWH) - GI mucosal erosions Physical examination Oropharynx and nose – Local source Abdominal examination – to exclude masses, splenomegaly, and adenopathy Epigastric tenderness – gastritis or peptic ulceration Stigmata of liver disease - jaundice, ascites, palmar erythema, and caput medusae

8. Localization

9. Risk Stratification

10. ACUTE UPPER GASTROINTESTINAL HEMORRHAGE Bleeding that arises from the GI tract proximal to the ligament of Treitz Accounts for nearly 80% of significant GI hemorrhage The foundation for the diagnosis and management: EGD Angiography Operative intervention Tagged RBC scan is seldom necessary contrast studies usually contraindicated

11. Specific Causes of Upper Gastrointestinal Hemorrhage Nonvariceal Bleeding

12. Peptic ulcer disease Most frequent cause of upper GI hemorrhage (~40% of all) 10% to 15% of patients with peptic ulcer disease develop bleeding at some point Bleeding develops as a consequence of acid-peptic erosion of the mucosal surface Chronic blood loss is common Significant bleeding typically results when there is involvement of an vessel Gastroduodenal artery or left gastric arteries

13. Peptic ulcer disease Medical management PPI The association between H. pylori infection & bleeding is less strong Ulcerogenic medications should be stopped Endoscopic management Epinephrine injection (usually addition of thermal therapy to the injection) Heater probes Coagulation Application of clips Surgical management 10% of patients with bleeding ulcers still require surgical intervention Indications ( traditionally): blood transfusion requirements, excess of 6 units

14. Mallory-Weiss tears mucosal and submucosal tears that occur near the gastroesophageal junction alcoholic patients after a intense retching & vomiting following binge drinking forceful contraction of the abdominal wall against an unrelaxed cardia 5% to 10% of cases of upper GI Bleeding diagnosed on the basis of history Endoscopy  retroflexion maneuver and to view the area just below the gastroesophageal junction Most tears occur along the lesser curvature Supportive therapy  90% of bleeding episodes are self-limited severe ongoing bleeding  endoscopic, embolization, gastrotomy and suturing

15. Stress gastritis Appearance of multiple superficial erosions of the entire stomach Result from the combination of acid and pepsin injury in the context of ischemia Acid suppressive therapy is often successful in controlling the hemorrhage When this fails, consideration should be given to administration of octreotide or vasopressin, endoscopic therapy, or even angiographic embolization The surgical choices included vagotomy and pyloroplasty with oversewing of the hemorrhage or near-total gastrectomy

16. Esophagitis infrequently the source for significant hemorrhage GERD  Esophageal inflammation  chronic blood loss Other causes  medications, Crohn’s disease, and radiation suppressive therapy, Endoscopic control Surgery is seldom necessary

17. Dieulafoy lesion vascular malformations , primarily along the lesser curve of the stomach within 6 cm of the gastroesophageal junction rupture of unusually large vessels (1 to 3 mm) Erosion of the gastric mucosa overlying these vessels mucosal defect is usually small (2 to 5 mm)  difficult to identify endoscopic control, embolization, surgical intervention

18. Gastric antral vascular ectasia(gave)/watermelon stomach collection of dilated venules appearing as linear red streaks converging on the antrum Acute severe hemorrhage is rare persistent, iron deficiency anemia from continued occult blood loss Endoscopic therapy is indicated for persistent, transfusion-dependent bleeding antrectomy.

19. Malignancy Associated with chronic anemia Hemoccult-positive stool rather than episodes of significant hemorrhage Ulcerative lesions that may bleed persistently GIST, leiomyomas, lymphomas. Surgical resection is indicated rather than endoscopic therapy

20. Aortoenteric fistula Primary aortoduodenal fistulas are rare The more common entity seen clinically is a graft-enteric erosion the median interval is about 3 years pseudoaneurysm at the proximal anastomotic suture line in the setting of an infection  subsequent fistulization often massive and fatal present first with a “ sentinel bleed .” Any evidence of bleeding in the distal duodenum (3 rd /4 th portion) on EGD should be considered diagnostic Therapy includes ligation of the aorta proximal to the graft, removal of the infected prosthesis, and extra-anatomic bypass

21. Hemobilia typically associated with trauma, recent instrumentation of the biliary tree, or hepatic neoplasms suspected in anyone who presents with hemorrhage , right upper quadrant pain , and jaundice ( Quincke's triad ) Endoscopy can be helpful by demonstrating blood at the ampulla Angiography is the diagnostic procedure of choice. If diagnosis is confirmed, angiographic embolization is the preferred treatment

22. others Hemosuccus pancreaticus Bleeding is bleeding from the pancreatic duct Erosion of a pancreatic pseudocyst into the splenic artery Abdominal pain and hematochezia Angiography is diagnostic and permits embolization , which is often therapeutic Iatrogenic bleeding follow therapeutic or diagnostic procedures percutaneous transhepatic procedures Endoscopic sphincterotomy upper GI surgery resection and anastomosis

23. Specific Causes of Upper Gastrointestinal Hemorrhage Bleeding Related to Portal Hypertension

24. Portal Hypertension Most often in the setting of cirrhosis Result of bleeding from varices Collateral pathway for decompression of the portal system into the systemic venous circulation Most common in the distal esophagus

25. Management Fluid resuscitation in patients with cirrhosis is a delicate balance Early admission to an ICU setting Low threshold for intubation Defects in coagulation are common Underlying sepsis

26. Management Medical management Pharmacologic therapy to reduce portal hypertension Vasopressin produces splanchnic vasoconstriction (cardiac vasoconstriction) somatostatin or its synthetic analogue, octreotide Terlipressin is a newer vasopressin Temporary control of bleeding and allows time for resuscitation Endoscopic management varices are identified, sclerotherapy and variceal banding Banding seems to have a lower complication rate and, when expertise is available, should be the therapy of choice

27. management Other management Balloon tamponade – sengstaken-blakemore tube, the minnesota tube Self-expanding esophageal stents Emergent portal decompression – TIPS and surgical shunting Isolated gastric varices  due to left sided hypertension  splenectomy Prevention of rebleeding Nonselective beta blocker , such as nadolol, and an antiulcer agent , such as a PPI or sucralfate Endoscopic band ligation repeated every 10 to 14 days until all varices have been eradicated Elective portal decompression The preferred elective shunt is a selective distal splenorenal shunt

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