Upper GI bleeding University of Jordan
University of Jordan
University of Jordan
UPPER GI BLEEDING Signs and Symptoms Hematemesis Melena Dizziness Abd. Pain and symptoms of Peptic ulcer disease Hx of NSAID’s use Pallor Hypotension Orthostasis Jaundice and other stigmatas of chronic liver diseases University of Jordan
UPPER GI BLEEDING CAUSES RARE CAUSES Neoplasms AVM/Ectasia Dieulafoy’s Stoma ulcers Esophageal ulcers Deodenitis Hemobilia Aorto-enteric fistulas Unknown 5% Rare 5% GU GU 20% Varices DU 15% Erosions Mallory Weiss Mallory Weiss DU Varices 5% 25% Rare Unknown Erosions 25% University of Jordan
UPPER GI BLEEDING Peptic Ulcer Disease Defect in the GI mucosa extending through the muscularis mucosa. Decreasing incidence. Caused by imbalance between the aggressive and defensive factors. University of Jordan
UPPER GI BLEEDING Peptic Ulcer Disease Helicobacter Pylori NSAID’s Acid Hypersecretory state. Antral G cell Hyperplasia University of Jordan
UPPER GI BLEEDING Peptic Ulcer Disease University of Jordan
UPPER GI BLEEDING Gastric Ulcers University of Jordan
UPPER GI BLEEDING Duodenal Ulcers University of Jordan
UPPER GI BLEEDING Mallory - Weiss Laceration around the GE junction Classical presentation as bleeding after episode of vomiting Classical presentation found in 50% only Self- limiting University of Jordan
UPPER GI BLEEDING Dieulafoy’s Massive And recurrent bleeding Extramural artery present in the Submucosa. Most commonly in the gastric Cardia, 6 cm from GE junction High Mortality Difficult to diagnose University of Jordan
UPPER GI BLEEDING Hemobilia University of Jordan
UPPER GI BLEEDING Hemobilia University of Jordan
UPPER GI BLEEDING Vascular abnormalities Portal HTN Gastropathy Mosiac / Snake skin Body or fundus Antral Vascular Ectesia Multiple punctuated lesions PBC and CREST University of Jordan
UPPER GI BLEEDING stress ulcers Caused by Vagal hyperstimulation and vascular hypoperfusion. Body and fundus more affected Multiple Prophylaxis is indicated in critically ill ICU patients Curling Extensive burn Cushing Head Injury University of Jordan
UPPER GI BLEEDING ADVERSE PROGNOSTIC FACTORS Diagnosis Varices Malignancy Older age Severe initial bleeding Recurrence during hospitalization Coincidental diseases Endoscopic stigmata of recent bleeding Need for emergency surgery University of Jordan
UPPER GI BLEEDING MANAGEMENT Resuscitation Assessment Endoscopy Bleeding Stops Bleeding continues Surgery or angiogram/ embolization History Physical NG Tube Labs University of Jordan
UPPER GI BLEEDING MANAGEMENT Most Have NG Tube Rectal Exam Endoscopy University of Jordan
UPPER GI BLEEDING MANAGEMENT Most Have NG Tube Rectal Exam Endoscopy University of Jordan
UPPER GI BLEEDING IMPLICATIONS OF NG ASPIRATE Active bleeding by endoscopy Requires Surgery Death Clear 16 % 10 % 6 % Coffee ground 30 % 13 % Red blood 48 % 23 % 18 % University of Jordan
UPPER GI BLEEDING IMPLICATION OF A CLEAR NG ASPIRATE Endoscopic finding Incidence ( % ) Duodenal Ulcers 30 Gastric Erosions 25 Gastric Ulcers 20 Doudenitis 7 Varices 4 Mallory Wiess 3 Others/ None 11 University of Jordan
UPPER GI BLEEDING MANAGEMENT Most Have NG Tube Rectal Exam Endoscopy University of Jordan
UPPER GI BLEEDING MORTALITY: CORRELATION WITH STOOL AND NG COLOR Stool color Black Red Clear 5 % 7 % Coffee ground 9 % 20 % 12 % 30 % NG Aspirate University of Jordan
UPPER GI BLEEDING MANAGEMENT Most Have NG Tube Rectal Exam Endoscopy University of Jordan
UPPER GI BLEEDING INFLUENCE OF DIAGNOSIS ON OUTCOME % Rebleeding % Dying Varices 60 30 Gastric Cancer 50 14 Gastric ulcers 28 6 Duodenal ulcers 24 4 Gastric erosions 15 7 Mallory Weiss 2 No diagnosis 2.5 0.4 University of Jordan
UPPER GI BLEEDING MANAGEMENT: Endoscopic Therapy Prevalance Mortality Rebleeding rate without endoscopic therapy Rebleeding rate with endoscopic therapy Clean base 34 2 3 <3 Flat spot(s) 16 5 7 Clot 15 9 22 Nonbleeding visible vessel 17 11 43 23 Active bleeding 18 12 55 25 University of Jordan
UPPER GI BLEEDING University of Jordan
UPPER GI BLEEDING University of Jordan
UPPER GI BLEEDING University of Jordan
UPPER GI BLEEDING University of Jordan
UPPER GI BLEEDING MANAGEMENT:H2 Blockers University of Jordan
UPPER GI BLEEDING MANAGEMENT: Proton Pump Inhibitors 10 studies had been published on the use of PPIs for upper GI bleeding since 1990. Proven benefit in controlling bleeding when 80 mg bolus of Omeprazole followed by infusion for total of 160 mg/day. Preventing rebleeding when Omeprazole orally at 40 mg twice daily. University of Jordan
UPPER GI BLEEDING BLEEDING ESOPHAGEAL VARICEAL Dilated tortuous veins of the lower and mid esophagus. Secondary to portal HTN 30% mortality after the first episode. 60% Rebleeding rate University of Jordan
UPPER GI BLEEDING Esophageal Varices: Predictors of severity High Hepatic Gradient >12 mmHg Degree of Cirrhosis (Child Classification ) Size of Varices Larger > smaller Endoscopic Appearance Cherry red spots Red wale University of Jordan
UPPER GI BLEEDING Esophageal Varices: Significance of hepatic gradient University of Jordan
UPPER GI BLEEDING Esophageal Varices: Influence of endoscopic appearance University of Jordan
UPPER GI BLEEDING Esophageal Varices: Influence of degree of Cirrhosis 1 2 3 Bilirubin ( mg/dl) <2.0 2-3 >3.0 INR <1.7 1.7-2.3 >2.3 Albumin (mg/dl) > 3.5 2.8-3.5 <2.8 Encephalopathy None I-II III-IV Ascites Slight Moderate Tense University of Jordan
UPPER GI BLEEDING Esophageal Varices: Influence of degree of Cirrhosis A < 7 points B 7-9 points C >10 points University of Jordan
UPPER GI BLEEDING Esophageal Varices: Relation of size to bleeding University of Jordan
UPPER GI BLEEDING Esophageal Varices: Active Bleeding University of Jordan
UPPER GI BLEEDING Esophageal Varices: Management Assessment / Resuscitation Pharmacological Therapy Somatostatin or Octreotide Vassopressin and Nitroglycerine Endoscopy for diagnosis and therapy Variceal Banding Sclerotherapy Balloon Temponade University of Jordan
UPPER GI BLEEDING Esophageal Varices: Vassopressin Splanchnic vasoconstriction and decrease portal blood flow Controls bleeding in 50%. High side effects profile with 50% develops chest pain while on treatment. Nitroglycerin decreases CP but cause hypotension. 0.2-0.4 U/min Infusion University of Jordan
UPPER GI BLEEDING Esophageal Varices: Somatostatin and Octreotide Decrease portal pressure and collateral blood flow. Equivalent to sclerotherpy in controlling bleeding. More effective than Vassopressin with less side effects. Used as initial therapy University of Jordan
UPPER GI BLEEDING Esophageal Varices: Endoscopic banding Bleeding control in 90%. Rebleeding rate reduced to 30%. Comparing to sclerotherapy Less rebleeding Lower mortality Less complications Fewer treatment sessions University of Jordan
UPPER GI BLEEDING Esophageal Varices: TIPS Technical success in 90% Control of bleeding in > 90% Immediate procedural complications around 10%. Late complications Encephalopathy 20-30% Heart failure 40% University of Jordan
University of Jordan
University of Jordan