Management of Non-Variceal Upper

8/2/2019 Management of Non-Variceal Upper

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Introduction

UGIB is a common medical emergencyassociated with significant morbidity andmortality.

The commonest cause of UGIB is peptic ulcer disease

NSAIDS

H. pylori

Oesophatigis

Malignancy

Mallory weiss tear


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Bleeding peptic ulcer most commoncourse.

80% stop spontaneously

20% persistent/ recurrent bleeding.


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> men than women Increasing age Mortality rate from UGIB was 10.2% but increased substantially

with age and did not differ between the sexes.Inpatients that were admitted for otherdiagnosis but developed UGIB had the highestmortality; at almost 5 times higher than thosewith emergency admissions or transfers from

other hospitals for UGIB. 64% of thoseadmitted in this series had peptic ulcer diseaseas a cause of bleeding


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Assessment of OngoingBleeding Continuous haemetemesis or persistent

hypovolaemia despite aggressive resuscitationbleeding is still active.

Passage of fresh melaena, which is marooncoloured or passage of bright red visible clots

suggest active bleeding. The insertion of a nasogastric tube may be helpful in

demonstrating active bleeding.

However,it may be poorly tolerated.

The caveat is when there is a bleeding ulcer with the

pylorus in spasm. Aspirate without evidence of bloodor coffeee-grounds material is seen in about 15% ofpatients with UGIB.


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Risk Assessment

Risk Factors For Death After Hospital AdmissionFor Acute Upper Gastrointestinal Bleeding

1. Advanced age2. Shock on admission(pulse rate >100 beats/min;

systolic blood pressure < 100mmHg)

3. Comorbidity (particularly hepatic or renal failure anddisseminated malignancy)

4. Diagnosis (worst prognosis for advanced uppergastrointestinal malignancy)

5. Endoscopic findings (active, spurting haemorrhagefrom peptic ulcer; non-bleeding visible vessel)

6. Rebleeding (increases mortality 10 fold)


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Endoscopy For RiskAssessment

Early upper gastrointestinal endoscopy(within 12-24 hours) is the cornerstoneof management of UGIB.

Early endoscopy has 3 major roles viz.diagnosis, treatmentandriskstratification.

It is the most accurate method availablefor identifying the source of bleeding.


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Endoscopic therapy


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PHARMACOLOGICALTHERAPY

H2-Receptor Antagonists

A recent meta-analysis concluded that there wasno evidence to support the use of H2- receptor

antagonists in the treatment of bleedingduodenal ulcers but there is evidence of amoderate benefit in gastric ulcers

Proton Pump Inhibitors (PPIs)

High dose intravenous PPI (eg IV Omeprazole80mg stat followed by an infusion of 8mg hourlyfor 72 hours) be commenced (Grade B)


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MANAGEMENT ofREBLEEDING

Recurrent bleeding remains the singlemost important adverse prognosticfactor.

Morbidity and mortality are higher inthose with rebleeding and 95% ofrebleeding occurs within the first 72

hours of hospitalisation

R bl di Aft I iti l


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Rebleeding After InitialEndoscopic Control of

Bleeding Ulcers haemostasis is not permanent and re-bleeding occurs in about 15-20% of thecases.

In patients with peptic ulcers andrecurrent bleeding after initialendoscopic control of bleeding,endoscopic retreatment reduces the

need for surgery without increasing therisk of death and is associated withfewer complications than is surgery


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Surgery if decided upon should beperformed early rather than late to avoidan unfavorable outcome especially in

the hypotensive elderly patient. In some patients, endoscopic

appearances (eg. a giant posterior

duodenal ulcer) may suggest thatsurgery be the preferred option


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ROLE OF SURGERY

changed with wider use of endoscopichemostasis in bleeding ulcers, no longeraiming to cure the disease but primarily

to stop the hemorrhage. Mortality after urgent surgery correlates

with the preoperative Apache 2 score.


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Indications for Surgery as thePrimary Mode of Treatment Massive bleeding

Ulcer inaccessible to endoscopic control

Type of Surgery for Bleeding PepticUlcer

under-running/ over-sewing or excision

of ulcer radical surgery (gastric resection or

vagotomy)


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While under-running or over-sewing forbleeding ulcers is advisable in a largeproportion of cases, ulcer excision or evenmore radical surgery (e.g. gastric resection

for large, chronic, penetrating gastriculcers) may be performed in selectedcases.

The rebleeding rate was lowest in patientshaving a gastrectomy to include the ulcereither with Billroth I or Billroth IIreconstruction when compared with moreconservative surgery.


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However, the bile leak was followinggastrectomy was much higher and the overallmortality was similar in the two randomizedgroups.

The same study suggested that when ableeding duodenal ulcer is under-run, ligationof the gastroduodenal and right gastroepiploicarteries reduced the rebleeding rate to asimilar level as gastrectomy.

The magnitude of surgery should be tailored tothe type of ulcer, severity of illness in thepatient and experience of the surgeon


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INTERVENTIONALRADIOLOGY In the critical or unstable patient who is not

amenable to immediate surgical interventionradiological intervention appears increasinglyas a very effective option.

In a recent retrospective evaluation ofinterventional embolization therapy over an 8year period, bleeding was stopped in 83% ofcases.

The rate of complications was 14%. Sodium diatrizoate, metal coils, tissue

adhesives and Gelfoam particles were used


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FOLLOW UP

should be discharged with oral proton pumpinhibitors.

Those with gastric ulcers should be re-endoscoped in 6 weeks to assess healing and

rule out malignancy. Attention should be paid to Helicobacter pylori

eradication forall H. pylori positive ulcers. The latter is also recommended for those on

long-termaspirin. Those who need to continue

on NSAIDs should consider COX-2 inhibitors,or the least damaging NSAID with a protonpump inhibitor.


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Management of Non-Variceal Upper