UPPER GI Bleed BY DR DENNIS PRABHU DAYAL.

Slides:



Advertisements
Similar presentations
Management of acute upper GI haemorrhage
Advertisements

Management of a Pt with Hematemesis
Lower GI Bleeding.
CIRRHOSIS. Use of nonspecific has been studied extensively in randomized, controlled trials of the primary prophylaxis of variceal bleeding. β-adrenergic.
Upper GI Bleeding Dr M. Ghanem.
Upper GI Bleed James Peerless April 2011.
Mohammad Mobasheri SpR General Surgery
PR BLEEDING BY HELEN BERMINGHAM. MESENTERIC BLOOD VESSELS Coeliac trunk T12 foregut left gastric common heptic splenic SMA L1 midgut inferiorpancreaticoduodenal.
Acute Upper Gastrointestinal Hemorrhage “Surgical Perspective”
Teaching Liver cirrhosis with varices. Discussion  Approximately half of patients with cirrhosis have esophageal varices  One-third of all patients.
Tad Kim, M.D. Connie Lee, M.D. Michael Hong, M.D.
Peptic ulcer disease Hannah Vawda FY1.
Peptic Ulcer & its Complications Prof. Dr. Faisal Ghani Siddiqui FCPS; MCPS-HPE; PGDip-bioethics.
Upper GI Bleeding Tad Kim, M.D. UF Surgery (c) ; (p)
UPPER GASTROINTESTINAL BLEEDING Bernard M. Jaffe, MD Professor of Surgery Emeritus.
Upper GI Bleeding Tad Kim, M.D. Connie Lee, M.D..
Haematemesis Lent The case: Mr J O’F 48 year old jockey (divorced, no recent wins). Presents at 2am with a big haematemesis Unable to give a history.
Upper Gastrointestinal Bleeding. Gastrointestinal (GI) bleeding refers to any bleeding that starts in the gastrointestinal tract. Bleeding may come from.
Complications of Liver Cirrhosis Ayman Abdo MD, AmBIM, FRCPC.
Liver pathology: CIRRHOSIS
Gastrointestinal Bleeding PCOM Internal Medicine Residents 2004.
- Definition: - Causes: 1.Liver cirrhosis (Com.). 2.Extra hepatic portal v. occlusion. 3.Intra hepatic veno occlusive Dis. 4.Occlusion of hepatic vein.
Upper GI Bleeds AMU Nurse Teaching Dr Clare Pollard ST6 AIM & GIM.
Gastrointestinal Bleeding G Muthukumarasamy Specialist Registrar in General Surgery.
GASTROINTESTINAL (G.I) BLEEDING
Core Topic UCI Internal Medicine Residency Learning Objectives Review the major causes of upper GI bleeding and important elements of the history.
NYU Medical Grand Rounds Clinical Vignette Jeffrey Mayne, MD Third Year Resident Internal Medicine 1/17/2012 U NITED S TATES D EPARTMENT OF V ETERANS A.
Gastro Intestinal Bleeding By: Abdulrahman Sindi ED Resident.
GASTROINTESTINAL BLEEDING
Abdominal and Gastrointestinal Emergencies-3
Bleeding from the Gut Clinical approach Severity Vital signs Haematocrit Beware ongoing losses Acute onset or chronic blood loss Fe deficiency Stigmata.
Gastric Emergencies Principles of Critical Care Module Session length 1hour.
From Mouth to Rectum and Everywhere in Between
Portal Hypertension portal venous pressure > 5 mmHg
Clinical Case: Mr Veri Pushi: 45 year old married self-employed property developer You are present in casualty when this gentleman is brought in by ambulance.
Portal Hypertension Mazen Hassanain.
Complications of liver cirrhosis
PROF. IBRAHIM A. AL-MOFLEH Professor of Medicine, College of Medicine & University Hospitals, KSU PROF. IBRAHIM A. AL-MOFLEH Professor of Medicine, College.
Complications of liver cirrhosis
Complications of Liver Cirrhosis
Diagnosis of Gastrointestinal Bleeding Liu Zhenhua.
Lec 10 Upper Gastrointestinal Bleeding Dr;Basim Rassam Al-Madena copy1.
Peptic ulcer Presented by د. قصي العبيدي بورد ( دكتوراه ) جراحه عامه جامعة الكوفة - كلية طب.
Medical Grand Round - Disease review
Complications of liver cirrhosis. Recognize the major complications of cirrhosis. Understand the pathological mechanisms underlying the occurrence of.
Doreen Benary 3rd Year Medical Student NY Medical Programme, TAU Sheba MC, Internal Medicine 6 Head: Prof Avi Livne.
Upper Gastrointestinal Cancers Top ⑩ Tips
Approach to gastrointestinal bleeding
GASTRO INTESTINAL BLEED
GIT Bleeding.
Matt Warren. Gastroenterology North Tyneside Hospital
Acute Upper GIT bleeding
Portal Hypertension.
Portal Hypertension.
PROF. IBRAHIM A. AL-MOFLEH
Upper Gastrointestinal Bleeding Dr;Basim Rassam
Acute upper gastrointestinal Bleeding
Qassim J. odda Master in adult nursing
GASTROENTEROLOGY 2009;137:892–901 R2. 정 회 훈.
Approach to Upper GI Bleeding
Mark McAlindon Gastroenterology
Nelson Essential of pedaitrics
Gastrointestinal Haemorrhage
Upper GI bleeding University of Jordan.
GASTROINESTINAL BLEEDING
Proposed new acute variceal bleeding (AVB) management algorithm.
Dilemma.
Management of Acute Bleeding from a Peptic Ulcer
Presentation transcript:

UPPER GI Bleed BY DR DENNIS PRABHU DAYAL

GI Bleeding Maybe classified into: Upper GI bleeding (proximal to DJ flexure) Variceal bleeding Non-variceal bleeding Lower GI bleeding (distal to DJ flexure) Upper GI bleeding 4x more common than lower GI bleeding Emergency resuscitation same for upper and lower GI bleeds

Emergency Resuscitation Takes priority over determining the diagnosis/cause ABC (main focus is ‘C’) Oxygen: 15L Non-rebreath mask 2 large bore cannulae into both ante-cubital fossae Take bloods at same time for FBC, U&E, LFT, Clotting, X match 6Units Catheterise IVF initially then blood as soon as available (depending on urgency: O-, Group specific, fully X-matched) Monitor response to resuscitation frequently (HR, BP, urine output, level of consciousness, peripheral temperature, CRT) Stop anti-coagulants and correct any clotting derrangement NG tube and aspiration (will help differentiate upper from lower GI bleed) Organise definitive treatment (endoscopic/radiological/surgical)

Estimating Degree of Blood Loss RR, HR, and BP can be used to estimate degree of blood loss/hypovolaemia

History and Examination Aim of history and examination is 3 fold 1. Identify likely source – upper vs lower – and potential cause 2. Determine severity of bleeding 3. Identify precipitants (e.g. Drugs)

History in patients with GI bleeding PC/HPC Duration, frequency, and volume of bleeding (indicate severity of bleeding) Nature of bleeding: will point to source Haematemesis (fresh or coffee ground)/melaena suggest upper GI bleed. (Note a very brisk upper GI bleed can present with dark or bright red blood PR). PR Dark red blood suggests colon PR Bright red blood suggests rectum, anus If PR bleeding, is blood being passed alone or with bowel opening (if alone suggests heavier bleeding) If with bowel opening is blood mixed with the stool (colonic), coating the stool (colonic/rectal), in the toilet water (anal), on wiping (anal) Ask about associated upper or lower GI symptoms that may point to underlying cause E.g. Upper abdominal pain/dyspeptic symptoms suggest upper GI cause such as peptic ulcer E.g. 2. lower abdo pain, bowel symptoms such as diarrhoea or a background of change in bowel habit suggest lower GI cause e.g. Colitis, cancer Previous episodes of bleeding and cause PMH History of any diseases that can result in GI bleeding, e.g. Peptic ulcer disease, diverticular disease, liver disease/cirrhosis Bleeding disorders e.g. haemophilia DH Anti-platelets or anti-coagulants can exacerbate bleeding NSAIDs and steroids may point to PUD SH Alcoholics at risk of liver disease and possible variceal bleeding as a result Smokers at risk of peptic ulcer disease

Upper GI bleed Upper GI bleeding refers to bleeding from oesophagus, stomach, duodenum (i.e. Proximal to ligmanet of treitz) Bleeding from jejunum/ileum is not common

Presentation Acute Upper GI bleeding presents as: Haematemesis (vomiting of fresh blood) Coffee ground vomit (partially digested blood) Melaena (black tarry stools PR) If bleeding very brisk and severe then can present with red blood PR! If bleeding very slow and occult then can present with iron deficiency anaemia

Risk Stratification: Rockall Score Identifies patients at risk of adverse outcome following acute upper GI bleed Score <3 carries good prognosis Score >8 carries high risk of mortality

Management (Non-variceal) Emergency resuscitation as already described Endoscopy Urgent OGD (within 24hrs) – diagnostic and therepeutic Treatment administered if active bleeding, visible vessel, adherent blood clot Treatment options include injection (adrenaline), coagulation, clipping If re-bleeds then arrange urgent repeat OGD Pharmacology PPI (infusion) – pH >6 stabilises clots and reduces risk of re-bleeding following endoscopic haemostasis Tranexamic acid (anti-fibrinolytic) – maybe of benefit (more studies needed) If H pylori positive then for eradication therapy Stop NSAIDs/aspirin/clopidogrel/warfarin/steroids if safe to do so (risk:benefit analysis)

Variceal Bleeds Suspect if upper GI bleed in patient with history of chronic liver disease/cirrhosis or stigmata on clinical examination Liver Cirrhosis results in portal hypertension and development of porto-systemic anastamosis (opening or dilatation of pre-existing vascular channels connecting portal and systemic circulations) Sites of porto-systemic anastamosis include: Oesophagus (P= eosophageal branch of L gastric v, S= oesophageal branch of azygous v) Umbilicus (P= para-umbilical v, S= infeior epigastric v) Retroperitoneal (P= right/middle/left colic v, S= renal/supra-renal/gonadal v) Rectal (P= superior rectal v, S= middle/inferior rectal v) Furthermore, clotting derrangement in those with chronic liver disease can worsen bleeding

Management of Variceal bleeds Emergency resuscitation as already described Drugs Somatostatin/octreotide – vasoconstricts splanchnic circulation and reduces pressure in portal system Terlipressin – vasoconstricts splanchnic circulation and reduces pressure in portal system Propanolol – used only in context of primary prevention (in those found to have varices to reduce risk of first bleed) Endoscopy Band ligation Injection sclerotherapy Balloon tamponade – sengstaken-blakemore tube Rarely used now and usually only as temporary measure if failed endoscopic management Radiological procedure – used if failed medical/endoscopic Mx Selective catheterisation and embolisation of vessels feeding the varices TIPSS procedure: transjugular intrahepatic porto-systemic shunt shunt between hepatic vein and portal vein branch to reduce portal pressure and bleeding from varices): performed if failed medical and endoscopic management Can worsen hepatic encephalopathy Surgical Surgical porto-systemic shunts (often spleno-renal) Liver transplantation (patients often given TIPP/surgical shunt whilst awaiting this)

TIPSS Sengstaken-Blakemore Tube

Surgical porto-systemic shunt (spleno-renal shunt)

Variceal Bleed: Prognosis Prognosis closely related to severity of underlying chronic liver disease (Childs-Pugh grading) Child-Pugh classification grades severity of liver disease into A,B,C based on degree of ascites, encephalopathy, bilirubin, albumin, INR Mortality 32% Childs A, 46% Childs B, 79% Childs C

THANK YOU