PROF. IBRAHIM A. AL-MOFLEH Professor of Medicine, College of Medicine & University Hospitals, KSU

ACUTE GI – BLEEDING (AGIB)

a- What are your plans (objectives) ? AGIB A 60 yrs old patient was brought with the ambulance to the emergency room with acute GI-bleeding ; you are asked to care for this patient ; a- What are your plans (objectives) ? b- How would you approach him ? c- Mention the adverse prognostic factors ?

Maintain the hemodynamics Determine the level Determine the cause AGIB Objectives Maintain the hemodynamics Determine the level Determine the cause Treat and prevent rebleeding

1- How to approach the patient ? AGIB 1- How to approach the patient ? Initial assessment Resuscitation History and exam Lab evaluation Localization Treatment

1. Initial assessment A - How urgent is the situation ? stable AGIB 1. Initial assessment A - How urgent is the situation ? stable or in shock ? What are the features of shock ? What is the magnitude of blood loss ?

Initial assessment Agitation Pallor Hypotension Tachycardia AGIB Initial assessment B-What are the features of shock ? Agitation Pallor Hypotension Tachycardia

C- How to assess the magnitude of blood loss? AGIB C- How to assess the magnitude of blood loss? VS Blood loss (% of total volume) Severity of bleed Normal < 10% Mild Postural drop 10 – 20% Moderate Shock > 20% Severe

2. How to approach the patient ? AGIB 2. How to approach the patient ? Initial assessment Resuscitation History and exam Lab evaluation Localization Treatment

2. Resuscitation Hemodynamically unstable patient AGIB 2. Resuscitation Hemodynamically unstable patient Restore and maintain hemodynamics Oxygen Monitor VS and urinary output Admission to ICU Blood transfusion ? FFP

AGIB

Resuscitation Indications for blood transfusion AGIB Resuscitation Indications for blood transfusion Unstable VS Continuous bleeding Bright blood Age > 60 Concomitant CPD

3. How to approach a patient with AGIB? Initial assessment Resuscitation History and exam Lab evaluation Localization Treatment

3. History and examination AGIB 3. History and examination History Exam Age Stigmata of CLD Dyspepsia Hereditary vascular anomalies Previous endoscopy Scars Previous PUD Palpable organs / masses Previous bleeding Lymphadenopathy CLD PR Drugs Anorexia Weight loss Changing bowel habits Previous surgery (PUD, aortic graft etc..)

4. How to approach a patient with AGIB? Initial assessment Resuscitation History and exam Lab evaluation Localization Treatment

4. Laboratory parameters AGIB 4. Laboratory parameters CBC, PT, PTT, type and crossmatching BUN , BUN / Creatinin ratio Liver profile ABG

5. How to approach a patient with AGIB? Initial assessment Resuscitation History and exam Lab evaluation Localization Treatment

5. Localization Clinical Endoscopy Radiological AGIB RBC scan Angiography

6. How to approach a patient with AGIB? Initial assessment Resuscitation History and exam Lab evaluation Localization Treatment

AGIB 6. Treatment Pharmacological Endoscopic Angiographic Surgical

Indications for emergency endoscopy AGIB Indications for emergency endoscopy Cause Severity Age Cirrhosis Persistent bleeding Rebleeding

Role of endoscopy Site of bleeding Source of bleeding AGIB Role of endoscopy Site of bleeding Source of bleeding Stigmata of bleeding PU Endoscopic therapy

C- Adverse prognostic factors AGIB C- Adverse prognostic factors Clinical Old age Comorbid diseases Bright blood (NGA, vomitus, stool) Onset of bleeding in the hospital Amount of blood lost Shock or hypotension on presentation Emergency surgery

Adverse prognostic factors AGIB Adverse prognostic factors Endoscopic Vascular bleeding Active bleeding Visible vessel Clot Giant ulcer

ACUTE GI – BLEEDING

AGIB Forms Upper Lower Obscure

Epidemiology Common (e.g. 15000 deaths/yr in USA) AGIB Epidemiology Common (e.g. 15000 deaths/yr in USA) Upper is 5 x more than lower More frequent in men and elderly Spontaneous cessation in 80% Mortality in general 10% in elderly 20% cont. bl/rebleeding >30%

Bleeding Esophageal Varices

EVL

GU – Visible Vessel

Sentinel Clot

Gastric Angiodysplasia

Bleeding Angiodysplasia

DU – Bleeding Control

Gastric Varices

Bleeding GU

DU – Bleeding

GU Clips

Bleeding Diverticulum

Diverticulum Visible Vessel

Bleeding hemorrhoids

Dieulafoy - Colon

Summary 0f patients approach AGIB Summary 0f patients approach Initial assessment Resuscitation History and exam Lab evaluation Localization Treatment

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