UGI Bleeding

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    Upper Gastrointestinal Bleeding

    (UGIB)

    No.1 Hospital of Zhengzhou University

    Fei-fei Li

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    Definitions

    the blood is coming from above the

    ligament of Treitz( esophagus, stomach,

    or first part of the small intestine).

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    A common medical condition 250,000 500,000 admissions/year US

    UGI bleeding incidence 100/100,000 adults

    Incidence increases 20-30 fold from third to

    ninth decade of life

    GI bleeding stops spontaneously in 80 %

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    Morbidity DataMajority will receive blood transfusions

    2 10 % require urgent surgery to arrest

    bleeding

    Mortality rates for UGI bleeding 2 15 %

    Mortality for patients who develop bleeding

    after admission to hospital for another

    reason is 20 30 %

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    Clinical presentation :Clinical

    manifestations of GI bleeding

    depends upon extent & rate Hematemesis 25 %,250-300 cc of blood in

    stomach will render Red blood hematemesis

    andCoffee ground

    emesis

    Melena alone 25 %, 50 100 cc of blood /day willrender stool melenic

    Hematochezia 15 %, seen in massive UGI

    hemorrhage Occult bleeding, 5-10 cc of blood/day will render

    stool occult bleeding

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    Clinical presentation : other General abdominal discomfort

    Classic signs and symptoms of shock

    Fatigue & exertional dyspnea typical

    symptoms with slow, chronic blood loss

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    Causes

    Peptic UlcerDisease

    Gastritis

    Varix Rupture

    Mallory-Weiss Tear

    Esophagitis

    Duodenitis

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    Causes

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    Peptic Ulcer

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    Esophageal Varices

    CausesChronic alcohol

    abuse and livercirrhosis

    Ingestion of caustic

    substances

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    History Epigastric or right upper quadrant discomfort,

    often described as gnawing orburning, may

    be reported in patients with peptic ulcerationinvolving either the stomach and distal esophagusor the duodenum .The history may reveal thatdiscomfort is relieved with food or antacid intakeand that it often recurs several hours after eating.

    Recent or chronic ingestion of steroids, aspirin,orother nonsteroidal antiinflammatory agents maypredispose to gastrointestinal bleeding.

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    History Hematemesis beginning after an initial bout

    of retching is often due to the development

    of a Mallory-Weiss mucosal laceration; ahistory of dietary and alcohol indiscretion is

    also frequently obtained.

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    Physical examination A. Abdominal pain elicited by palpation is

    often noted in patients with esophagitis ,

    peptic ulcer, diverticulitis, inflammatorybowel disease,colorectal carcinoma, and

    infectious diarrhea.

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    Physical examinationB. Signs of hyperestrogenism secondary to

    liver disease, including jaundice, palmar

    erythema, gynaecomastia, spider angioma,and testicular atrophy ,all support the

    diagnosis of significant liver damage, which

    may be associated with portal hypertensionand esophageal varices.

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    Laboratorial examination

    fecal occult blood test (FOBT)

    Blood rule test

    electrolytes/renal function

    liver function tests

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    Prognosis

    Despite a decreased incidence of ulcer

    disease and improvements in the

    management of acute upper GI bleeding,

    mortality remains at 6-7 % in most seriesin the literature for the past 30 years.

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    Scoring System for Predicting Rebleeding and

    Mortality

    A simplified scoringsystem based onendoscopic and clinical

    variables has beendeveloped

    Rockhall TA et al.:Selection of patients forearly discharge or

    outpatient care after acuteupper gastrointestinalhaemorrhage. Lancet1996:347: 1138-1140

    Variable Score

    Age

    79 2

    ShockNone 0

    Tachycardia 1

    Hypotension 2

    Comorbidity

    None 0

    CAD, CHF, other major comorbidity 1

    Renal failure, liver failure, malignancy 2

    DiagnosisMallory Weiss tear or no lesion observed 0

    All other diagnoses 1

    Malignant lesion 2

    Stigmas of recent hemorrhage

    None or spot in ulcer base 0

    Blood in the GI tract, clot, visible vessel

    in ulcer base

    2

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    Scoring is not Boring

    Score Rebleeding

    %

    Mortality %

    1 3 0

    2 5 0

    3 12 2

    4 13 4

    5 17 86 30 15

    7 40 20

    8 48 39

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    Upper Gastrointestinal Bleeding

    Severe UGIB is a commonand

    serious medico-surgical problem

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    Therapy:

    Pharmacological Therapy

    Endoscopic Therapy

    Surgical therapy

    Angiography and transcatheter embolization

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    Pharmacological Therapyj Vasopressin

    lowers splanchnic blood pressure

    induces vasoconstriction

    high rate of complications

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    Pharmacological Therapyj Somatostatin and Octreotide

    Lower toxicity

    additional effects of decreasing

    gastric acid secretion and increasing

    duodenal bicarbonate secretion decreased risk of re-bleeding

    compared to H2RAs(H2 ReceptorAntagonists)

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    Pharmacological Therapy

    At intragastric pH < 7, coagulation is deficient

    due to ineffective function of clotting factors

    and platelets

    j Acid suppressing agents - H2 ReceptorAntagonists

    - Proton Pump Inhibitors

    (Omeprazole PantoprazolePantoprazole))

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    Endoscopic Therapy

    Endoscopic hemostatic therapy

    has been demonstrated to be the

    mainstay of management.

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    Acute U.G.I. BleedingAcute U.G.I. Bleeding**General management:

    y Drug therapy

    1. Somatostatin and Octreotide2. Proton pump inhibitors or H 2 receptor

    antagonists

    y Factors in reassessment

    1. age: 60 + greater mortality

    2. recurrent hemorrhage: +++ mortality

    3. re-bleeding: mostly within the 1st48 hrs

    4. surgical procedures in case of severe

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    Thanks

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    Proton Pump Inhibitors NEJM 1997: high dose oral omeprazole effective in

    reducing rebleeding rates. No endoscopic therapyperformed in this study from India

    Two multicenter trials from Scandinavia showed benefit ofhigh dose I.V. omeprazole (1997)

    Taiwanese study of 100 patients randomized between IVomeprazole and cimetidine. Intragastric pH was around 6.0for first 24 hours in omeprazole group but only between 4.5to 5.5 for cimetidine group. 12 pts in the cimetidine groupand 2 pts in the omeprazole group rebled. No change inLOS, number of procedures, or mortality (1998)

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    PROTONIXPROTONIX(Pantoprazole Sodium)(Pantoprazole Sodium)

    Formulations

    Formulations

    40-mg Delayed

    -Release Tablet

    40-mg Lyophilized Powder for Injection

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    PROTONIXPROTONIX(Pantoprazole(Pantoprazole

    Sodium)Sodium)

    Specific Cysteine Binding SitesSpecific Cysteine Binding Sites

    Modlin IM, Sachs G. Acid RelatedDiseases, Biology and Treatment. Schnetztor-Verlag. 1998:126-145.

    Binds two cysteine residues critical for theinhibition of gastric acid secretion

    (Cys 813 and 822)

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    PROTONIXPROTONIXI.V. (Pantoprazole Sodium)I.V. (Pantoprazole Sodium)

    for Injectionfor Injection in Inhibition of Acid Output

    40 mg I.V. vs. Placebo40 mg I.V. vs. Placebo

    Data on file, Wyeth-Ayerst Laboratories. Study 100-US.

    Pisegna JR et al.Am J Gastroenterol. 1999;94:2874-2880.

    -40

    -20

    0

    20

    40

    60

    80

    100

    Hours

    %I

    nhibition PROTONIX I.V. 40 mg (n=8)

    Placebo (n=4)

    8am 10am Noon 2pm 4pm 6pm 8pm 10pm 12pm 2am 4am 6am 8am

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    PROTONIXPROTONIXI.V. (Pantoprazole Sodium)I.V. (Pantoprazole Sodium)

    for Injectionfor Injection

    Dosage and AdministrationDosage and Administration

    DosageThe recommended dose is one

    vial (the equivalent of 40 mg

    pantoprazole) given once daily

    by intravenous infusion for 7 to

    10 days.

    AdministrationPROTONIX I.V. for Injection

    should be administered

    intravenously over a period of

    approximately 15 minutes at a

    rate not greater than 3 mg/min (7

    mL/min). PROTONIX I.V. for

    Injection should be administered

    using the in-line filter provided.

    The filter must be used to

    remove the precipitates that may

    form when the reconstituted drug

    product is mixed with I.V.

    solutions

    PROTONIX I.V. for Injection Prescribing Information. Wyeth-Ayerst Laboratories, Philadelphia, Pa

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    PROTONIXPROTONIXI.V. (Pantoprazole Sodium)I.V. (Pantoprazole Sodium)

    for Injectionfor Injection

    SummarySummary

    Impressive acid suppression

    No evidence of tolerance in a clinical study (oral

    10 days; I.V. 7days)

    Fast onset (within 15-30 minutes) and long acting

    Generally well tolerated

    No known clinically relevant drug interactions

    Data on file, Wyeth-Ayerst Laboratories.