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

2. ACUTE GI – BLEEDING (AGIB)

4. 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 ?

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

6. 1- How to approach the patient ?
AGIB
1- How to approach the patient ?
Initial assessment
Resuscitation
History and exam
Lab evaluation
Localization
Treatment

7. 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 ?

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

9. 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 – 20% Moderate
Shock > 20% Severe

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

11. 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

12. AGIB

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

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

15. 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..)

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

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

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

19. 5. Localization Clinical Endoscopy Radiological AGIB RBC scan
Angiography

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

21. AGIB
6. Treatment
Pharmacological
Endoscopic
Angiographic
Surgical

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

23. 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

24. 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

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

26. ACUTE GI – BLEEDING

28. AGIB
Forms
Upper
Lower
Obscure

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

30. Bleeding Esophageal Varices

31. EVL

32. GU – Visible Vessel

33. Sentinel Clot

34. Gastric Angiodysplasia

35. Bleeding Angiodysplasia

36. DU – Bleeding Control

37. Gastric Varices

38. Bleeding GU

39. DU – Bleeding

40. GU Clips

41. Bleeding Diverticulum

42. Diverticulum Visible Vessel

43. Bleeding hemorrhoids

44. Dieulafoy - Colon

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

46. الحمد لله