UPPER GASTROINTESTINAL BLEEDING What Undergraduates should know ? Prof SM Chandramohan Prof and HOD Department of Surgical Gastroenterology and Center of Excellence for Upper GI Surgery Madras Medical College and Rajiv Gandhi Government General Hospital Chennai

Can download this presentation from www.esoindia.org Prof SM Chandramohan Prof and HOD Department of Surgical Gastroenterology and Center of Excellence for Upper GI Surgery Madras Medical College and Rajiv Gandhi Government General Hospital Chennai

DEFINITION CAUSES EVALUATION TREATMENT PLAN OF THE TALK CAUSES EVALUATION TREATMENT

DEFINITION CAUSES EVALUATION TREATMENT PLAN OF THE TALK CAUSES MEDICAL ENDOSCOPIC SURGICAL EVALUATION TREATMENT

DEFINITION Any bleeding from The gastrointestinal Tract above the Level of ligament of Treitz is upper GI Bleeding

DEFINITIONS Acute GI bleed Overt vs. occult < 3 days duration hemodynamic instability requires blood transfusion Overt vs. occult overt = visible blood (melena, bright red blood, coffee grounds) occult = only detected by lab tests

COMMON CAUSES OF UGI BLEED % Peptic Ulcer 38% Varix 16% Tumor 7% MW Tear 4% Erosions Esophagitis 13%

NSAID (1) the risk of gastric ulceration is increased to a greater extent than that of duodenal ulceration (2) the risk of bleeding varies with the individual NSAID; for example, the relative risk of bleeding is greatest with piroxicam and less with ibuprofen (3) the risk of bleeding is dose dependent -age greater than 75 years, -history of heart disease, -history of peptic ulcer - history of previous gastrointestinal bleeding RISK FACTORS

A AIRWAY B BREATHING C CIRCULATION

Examination Tell tale signs… Chronic Liver Disease Portal Hypertension

Not to miss…….. Examination Haemodynamic stability Signs of coagulation dysfunction Signs of Liver cell failure PR

Bleeding PR

Resuscitate and Examine Simultaneously……. As he comes…………. Resuscitate and Examine Simultaneously…….

Form a team………. Wide bore IV line…… preferably central line (take samples at the same time) Naso gastric tube Urinary Catheter ALERT OTHERS IN TEAM…….

Blood Sample for Blood Group Haemogram including platelets Coagulation profile Liver function test Renal function Markers

Blood Sample TRY NOT TO TAKE SAMPLES FREQUENTLY Except for serial evaluation

WHICH TUBE AND WHY?

Naso Gastric Tube or Senstaken tube?

ROLE OF NASOGASTRIC TUBE 10 % of UGIB presents as LGIB Red blood vs coffee grounds NGT clears the gastric field for endoscopic visualization prevent aspiration of gastric content

Endoscopy When to do? What is Possible? When not to do???

Endoscopy One stop Shop Diagnose Assess Treat Reassess

ENDOSCOPIC EVALUATION If Hemodynamically stable Identify Bleeding site Delineate cause Allow endotherapy

ENDOSCOPIC MANAGEMENT VARICEAL NONVARICEAL

ENDOSCOPIC VARICEAL LIGATION A rubber band is placed over the varix which then undergoes thrombosis,sloughing,fibrosis.

ENDOSCOPIC SCLEROTHERAPY Involves injecting a sclerosant Intravariceal/perivariceal Common sclerosants Ethanolamine oleate Absolute alcohol Sodium morrhuate Sodium tetradecyl Hypertonic saline Polidocanol

GLUE THERAPY Cyanoacrylate is a glue that is injected into Gastric varices Acts by forming a Cast over the varix on contact with blood

Endoclip

DEFINITIVE MANAGEMENT OF NON VARICEAL BLEED ULCERS IN POSTERIOR WALL BULB-GDA HIGH RISK ULCER FOR BLEED ULCERS IN THE HIGH LESSER CURVE - LGA SRH/LARGE ULCER >2 cm

Non-Variceal - Modalities Injection Therapy (a) Adrenaline (b) Sclerosants Thermal Therapy (a) Monopolar (b) Bicap (c) Heater Probe (d) Argon Plasma Coagulation (e) Laser Mechanical Therapy (a) Haemoclips Endoscopic Management

Bleeding Peptic Ulcer - Stigmata Forrest Classification 1a – Spurting vessel 1b – Oozing from a vessel 2 – Clot in the ulcer base 3 – Ulcer without bleed Endoscopic Management

SECOND LOOK ENDOSCOPY It is repeat endoscopy 24 hours after initial Endoscopic hemostasis INDICATIONS 1 Incomplete first endoscopic examination due to blood obscuring the field 2 Patients with clinically significant rebleeding

WHEN TO CALL IT AS FAILED ENDOTHERAPY?

SURGICAL MANAGEMENT OF UGI BLEEDING The Need Only in Select Situations

Role of Surgery 5-10% of UGI Bleed Mortality 3% to 14%

TV Vs H.PYLORI Eradication 40% to 70% of patients with a bleeding duodenal ulcers- positive for H. pylori

Bleeding Gastric Ulcer Simple excision alone -rebleed in 20% of patients 10% incidence of malignancy

Surgical options- Variceal bleeding Shunt Or Devascularisation

Less Common Causes of UGIB

Managed with 1 Hemoclips 2 MPEC Probes 3 PPI MALLORY WEISS TEARS Managed with 1 Hemoclips 2 MPEC Probes 3 PPI

Mallory-Weiss Tears Angiographic embolization – in cases of failed endoscopic therapy High gastrotomy and suturing of the mucosal tear – failure of all methodes

DIEULAFOY’S LESION large submucosal artery that protrudes through mucosa at the gastric fundus. bleeding can be massive Endoscopic Doppler USG can help localize Endoscopic hemostasis -injection therapy , Thermal probe, clips.

Dieulafouy’s lesion

DIEULAFOY'S LESION Failed endoscopic therapy - angiographic coil embolization Surgical intervention - prior endoscopic tattooing Gastrotomy - bleeding source can be oversewn Partial gastrectomy - the bleeding point not identified

GASTRIC ANTRAL VASCULAR ECTASIA-GAVE rows of ectatic mucosalVessels(WATERMELON STOMACH) most patients present with persistent, iron deficiency anemia from continued occult blood loss. It is managed with 1 APC-argon Plasma coagulation 2 MPEC Multiple sessions may be needed to eradicate the lesions.

PPPRE APC PPPOST APC

Gastric Antral Vascular Ectasia Endoscopic therapy - successful in up to 90% of patients Failure of endoscopic therapy - antrectomy

SEVERE PORTAL HYPERTENSIVE GASTROPATHY May present with acute or chronic bleed. No role for endoscopic management. Managed with B Blockers, TIPS, Surgical Porto Caval shunt, Liver transplantation.

HEMOBILIA The diagnosis can be confirmed By Side viewing Scopy Ongoing or Recurrent bleed is Treated with angioembolization CAUSES-HEMOBILIA Liver trauma Liver biopsy ERCP/PTC/TIPS HCC, CHOLANGIOCARCINOMA Biliary parasite infestations

HEMOSUCCUS PANCREATICUS The diagnosis can be made by Side viewing scopy Management is by angioembolization CAUSES-HEMOSUCCUS PANCREATICUS Acute pancreatitis/chronic pancreatitis Pancreatic pseudocyst Pancreatic cancer ERCP manipulation of PD Rupture of splenic artery pseudoaneurysm into PD

ANGIOEMBOLIZATION

STRESS GASTRITIS Surgery - rarely indicated Vagotomy and pyloroplasty, with oversewing of the hemorrhage, or near-total gastrectomy - mortality rates as high as 60%

Malignancy Endoscopic therapy - successful in controlling hemorrhage, the rebleeding rate is high Standard cancer operations - indicated when possible Palliative wedge resections – to control bleed

Aortoenteric Fistula Ligation of the aorta proximal to the graft Removal of the infected prosthesis Extra-anatomic bypass Defect in the duodenum - small and can be repaired primarily Typically, patients with bleeding from an aortoenteric fistula will present first with a “sentinel bleed.”

MORTALITY 7% to 10%. The mortality has decreased only minimally during the last 30 years, despite the introduction of endoscopic therapy that reduces the rate of rebleeding. increasing percentage of UGIB occurring in the elderly frequent use of antiplatelet medications or anticoagulants frequent comorbid conditions.

Conclusion