Upload
mahendra-perumal
View
225
Download
0
Embed Size (px)
Citation preview
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 1/81
PRESENTER- PRASANNAKUMAR KAMBLE
MODARATOR- DR H M VIJAYKUMAR
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 2/81
` A common ,potentially DEADLY condition .
` Accounts for 170 cases/100000
` 1-2% of all admissions
` Men > women .3:1
` Mortality 10%.
Sabiston
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 3/81
` Bleeding from a source proximal to the ligament of
Trietz .
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 4/81
` Upper: Lower GI bleeding = 5:1
` Incidence: 50-100 per 100,000 pts.
` 100 per 100,000 hospital admission.
` 30% pts are older than 65 years 80% are self-limited.
20% of pts who have recurrent bleeding (within
48-72 hrs) have poor prognosis.
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 5/81
1) Peptic ulcer disease - most common
cause
A) duodenal ulcers 29%
will rebleed in 10% of cases within24-48h
B) gastric ulcers 16%
more likely to rebleed
C) stomal ulcers <5%
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 6/81
` 2) Erosive gastritis, esophagitis, duodenitis
some causes are ETOH, ASA, NSAID¶s
` 3) PORTAL HYPERTENSION RELATED
esophageal varices gastric varices
portal hypertensive gastropathy
` 4) Mallory-Weiss syndrome ± longitudinal
mucosal tear in the cardioesophageal
region
caused by repeated retching
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 7/81
` WATER MELON STOMACH
` ESOPHAGITIS ±INFECTION
` DIEULAFOY S LESION
` AORTODUODENAL FISTULA
` ANGIODYSPLASIAS
` CROHN S DISEASE
` HEMOBILIA
` HEMORRHAGE FROM PANCREATIC SOURCE.
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 8/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 9/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 10/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 11/81
` Get to patient¶s bedside, assess ABC` Can the patient protect his airway?
Does he need to be intubated?
` Is the patient hemodynamically unstable?
Is he in hemorrhagic shock?` 2 large bore IV, Bolus 2L fluids, Type & Cross
blood, send CBC & Coags
` Place patient on O2 & continuous monitor
`
Place an NGT and lavage with NS To confirm if the bleeding source is upper GI
look for need for blood transfusion
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 12/81
Estimated Fluid and Blood Losses in Shock
Class 1 Class 2 Class 3 Class 4
Blood Loss,mL
Up to 750 750-1500 1500-2000 >2000
Blood Loss,%blood volume
Up to 15% 15-30% 30-40% >40%
Pulse Rate,bpm
<100 >100 >120 >140
BloodPressure
Normal Normal Decreased Decreased
RespiratoryRate
Normal orIncreased
Decreased Decreased Decreased
UrineOutput,mL/h
14-20 20-30 30-40 >35
CNS/MentalStatus
Slightlyanxious
Mildlyanxious
Anxious,confused
Confused,lethargic
Fluid
Replacement,3-for-1 rule
Crystalloid CrystalloidCrystalloidand blood
Crystalloidand blood
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 13/81
Criterion Score` Age <60 years 0
60-79 yrs 1
>80 years 2
` Shock None 0Pulse & sBP >100 1
sBP <100 2
` Co-morbidity None 0
Cardiac/any major 2Renal/liver/malig. 3
` Total initial score (max = 7)
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 14/81
Initial risk score (pre-endoscopy)Score Mortality
0 0.2%
1 2.4%
2 5.6%
3 11.0%
4 24.6%
5 39.6%
6 48.9%
7 50.0%
R ockall TA et al Gut 1996; 38: 316-21
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 15/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 16/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 17/81
Signs of shock Cold clammy extremitiesPoor mentation
Rectal examinationOccult bloodGross bloodBright red blood per rectumMelena
Blood coating stools versus within stoolsBloody diarrhea
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 18/81
` CBC; BUN, Cr; LFT, PT, PTT in all cases
` Others as indicated: Type and crossmatch
AST, ALT, GGTP, bilirubin Albumin, total protein
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 19/81
Packed cells are the preferred
Aim -restore lood volume and pressure and to
correct anaemia to maintain the oxygencarrying capacity.
Fresh frozen plasma given prothrom in time is
at least 1.5 times higher than the control value.
Platelet transfusion platelet count is elow
50 000/mm3.
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 20/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 21/81
` Age >60 yr
` Comorbid disease
` Renal failure
` Liver disease
` Respiratory insufficiency
` Cardiac disease
` Magnitude of the hemorrhage
` Systolic blood pressure <100 mm Hg on
presentation
` Transfusion requirement >4 units
` Persistent or recurrent hemorrhage
` Onset of hemorrhage during hospitalization
` Need for surgery
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 22/81
` History
` NG Tube
` EGD
` Colonoscopy` Tagged RBC Scan
` Angiography
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 23/81
Probable Source of GI Bleeding Within the Gut
ClinicalIndicator
Probability of Upper GI
Source
Probability of Lower GISource
HematemesisAlmostcertain
Rare
Melena Probable Possible
Hematochezia Possible Probable
Blood-
streaked stoolRare
Almost
certain
Occult bloodin stool
Possible Possible
HISTORY
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 24/81
Effect of the Color of the Nasogastric Aspirate and of the Stool onUGIB Mortality Rate
Nasogastric
Aspirate Color
Stool
Color
Mortality
Rate, %
Clear Brownor red
6
Coffee-groundBrown
or black8.2
Red 19.1
Red blood Black 12.3
Brown 19.4
Red 28.
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 25/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 26/81
` PHARMACOLOGICAL
` ENDOSCOPIC
` Topical treatment
` Injection treatment` Mechanical treatment
` Thermal treatment
` ANGIOGRAPHIC
` SURGICAL
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 27/81
` Most common cause ~ 25 %
` Mortality rates slight declining !
` 5 % initial manifestation.
` 20 % at least once.
` Hemorrhage lethal ; 80 % deaths due to acuteepisode..
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 28/81
` H.PYLORI INFECTION
` NSAID¶S
` ANTICOAGULANTS
` CHONIC SYSTEMIC DISEASES` HOSPITALISED PATIENTS
` ETHANOL
` GLUCOCORTICOIDS
` COX-2 INHIBITORS
` ZOLLINGER SYNDROME
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 29/81
` Ongoing leed
` Low systolic pressure ( i. e.,<100 mmhg excludingothostatic measures)
` Elevated prothrom in time (i.e.,>1.2 times the control)
` Altered mental status
` Presence of co mor id disease ( define)
Presence of any one 3 fold risk ,independent of endoscopy findings
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 30/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 31/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 32/81
Bleeding vessel (re leed 80%)Visi le vessel (re leed 50%)Fresh clot (re leed 30%)
Black spots ulcer ase (re leed 5%)Clean ulcer ase (re leed <1%)
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 33/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 34/81
Nuclear Medicine Techniques in the
Diagnosis of Gastrointestinal Bleeding
After the intravenous injection of either sulfur colloid
or
la eled red lood cells, images are made over theupper and lower a domen
.Bleeding rates as low as 0.1 ml per minute may e
detected.
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 35/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 36/81
H. pylori eradication
1st line
x PPI + clarithromycin (500mg OD) +
amoxicillin (1000mg BID) or metronidazole(500mg) if patient has a penicillin allergy
2nd linex PPI + ismuth + metronidazole + tetracycline
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 37/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 38/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 39/81
INJECTION THERAPY
Adrenaline
The ethanol is injected slowly, in amounts of
0.1 to 0.2 ml per injection, at three or four sites
surrounding the leeding vessel and 1 or 2 mm
from the vessel .
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 40/81
Sclerosants
1% polidocanol, alcohol and ethanolamine .
Polidocanol causes haemostasis y inducing
owel wall spasm and early oedema with
su sequent inflammation and throm osis of
the vessel.
A solute alcohol stops leeding y causing
rapid dehydration and fixation of the tissue,
thus o literating the leeding vessel.
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 41/81
Procoagulants (Throm ogenic Agents)
Human throm in and fi rin sealant
Technique
video-gastroscope (3.7 or 4.2mm workingchannel) with a disposa le 23 or
25 gauge sclerotherapy needle is
recommended.
4-16 ml of 1:10,000 adrenaline,
in 0.5ml aliquots is injected into and around
the leeding point until the leeding stops
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 42/81
Thermal Modalities
Contact and non-contact methods
. Monopolar elect rocoag ulationDue to an unpredicta le depth of coagulation,
monopolar electrocoagulation is no longer recommended
M ul ti polar elect rocoag ulation
Consists of 3 pairs of electrodes arranged in a linear array at the tip and connected to a power generator.
The flow of the electrical current is limited thus
avoiding pro lems with grounding and a errant current.
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 43/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 44/81
Thermal non-contact methods
Argon Plasma Coagulation
Argon plasma coagulation (APC) is a special
electrosurgical modality in which high
frequency electric current is conducted
µcontact-free¶ through ionized and thus
electrically conductive argon (argon plasma)into the tissue to e treated.
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 45/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 46/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 47/81
` FAILED E NDOSCOPY
` EVIDE NCE OF ER OSIO N OF MAJOR VESSEL
` BLOOD LOSS EXCEEDING HALF A BLOOD
VOLUME
` NO E NDOSCOPY.
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 48/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 49/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 50/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 51/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 52/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 53/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 54/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 55/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 56/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 57/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 58/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 59/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 60/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 61/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 62/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 63/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 64/81
` Vasopressin potent splanchnic vasoconstrictor.
I v olus 20 u over 20 mins and then continuous
infusion of 0.2 to 0.4 u/min ,then taper to 0.1u/min.
` Causes hypertension, radycardia decreased
cardiac output and coronary vasoconstriction. Nitroglycerin adminstered simultaneously
40 micro g / min .
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 65/81
` Somatostatin 250 micro g I v olus followed y
continuous infusion of 250 micro g / hr for 2-4 days.
` Now octreotide 50 micro g olus plus infusion is eing
used .
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 66/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 67/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 68/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 69/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 70/81
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 71/81
` Stress gastritis , acute mucosal ischemia, erosive
gastritis or stress ulcer
` Predominant in ody
` Distinct from
NSA
IDassoc mucosal erosion
` Sepsis, respiratory failure,coma following head injury
or intracranial operation
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 72/81
` 10 % UGIB
` Tear in proximal gastric mucosa near esophagogastric junction
` History vomiting, retching or coughing followed y
hemetemesis` Mean age >60 years ; 80 % men
` 90 % stop spontaneously
` Antisecretory drugs.
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 73/81
` Laporotomy for oversewing of the mucosal tear
through high gastrotomy
` Acid reducing procedure not required.
` Photo
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 74/81
Bleed from cancer of thegastrointestinal tract,esophageal cancer,gastric cancer gastriclymphoma,gastrointestinal stromaltumors, and metastatic
tumorsSource Only 15%
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 75/81
` These lesions are unusually large su mucosal or
mucosal vessels
` R are cause
`
Superficial erosion usually lesser curvature` Sclerotherapy ,electrocoagulation not effective
` Surgical excision
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 76/81
` R ecently recognised
` When arranged in linear pattern in antrum of the
stomach gastric antral vascular ectasia (GAVE)or
WATER MELO N stomach
` Pathogenesis unknown.
` Surgical excision.
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 77/81
` Uncommon` Inflammator tract e elops bet een aorta and IT
` Infectious aortitis,or inflammator aortic aneur sms or
f ollowing aortic re placements
` ndoscopy mandator y
` T ,ot ers emer gency angiogra phy
` Emer gency la por otomy,contr ol of pr oximal aorta.
`
Extra anatomic ascular bypass.
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 78/81
Protective role for nitric oxide no
Video capsule endoscopy
Endoloops detacha le nylon snares.
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 79/81
PillCam SB
± 11 mm x 26 mm
± 1 camera
± 2 frames per second
± Std optics / 1 lens
± Standard lighting control
± Standard angle of view (AOV)
140°
± Depth of field 0-30 mm
PillCam SB 2
± 11 mm x 26 mm
± 1 camera
± 2 frames per second
± New optics / 3 lenses
± Advanced Automatic Light Control
± Extra wide angle of view (AOV)
156°
± Depth of field 0-30 mm
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 80/81
Bleeding
Celiac DiseaseTumors
Suspected Crohn¶s
8/7/2019 UPPER GI BLEED-final - Copy
http://slidepdf.com/reader/full/upper-gi-bleed-final-copy 81/81