1. This lecture was conducted during the Nephrology Unit Grand Ground by Medical Student under Nephrology Division under the supervision and administration of Prof. Jamal Al Wakeel, Head of Nephrology Unit, Department of Medicine and Dr. Abdulkareem Al Suwaida, Chairman of Department of Medicine and Nephrology Consultant. Nephrology Division is not responsible for the content of the presentation for it is intended for learning and /or education purpose only.

2. Presented By: Dr. Mohammed Al Harbi Medical Student 2009

3. Introduction  Upper gastrointestinal (GI) bleeding commonly presents with hematemesis (vomiting of blood or coffee-ground like material) and/or melena and Hematochezia (usually indicate severe bleeding).  A nasogastric tube lavage that yields blood or coffee-ground like material confirms the diagnosis and predicts whether bleeding is caused by a high-risk lesion.

4. Introduction  Upper GI bleeds are considered medical emergency, and require admission to hospital for urgent diagnosis and management.  Proxiamal bleeding to Ligament of Treits.

6. Epidemiology  Incidence 150/100,000 population per year.  Overall mortality 10% in those admitted to hospital.  Mortality 30 % in the elderly.

7.  A prospective series of 1000 cases of severe UGI bleeding at the UCLA and West Los Angeles Veterans Administration Medical Centers published in 1996 found the following distribution of causes:  Peptic ulcer disease 55 %  Esophagogastric varices 14 %  Arteriovenous malformations 6 %  Mallory-Weiss tears 5 %  Tumors and erosions 4 %each  Dieulafoy's lesion 1 %  Other 11 %  Management of upper gastrointestinal bleeding in the patient with chronic liver disease. Jutabha R; Jensen DM Med Clin North Am 1996

8. Etiology

10. How to approach?

11. Patient assessment Patient resuscitation Risk assessment Upper Endoscopy Low risk lesionHigh risk lesion SurgeryEndoscopic RxMedical Rx Rebleed

12. Initial patient assessment Initial approach to the patient with acute upper gastrointestinal bleeding should include near simultaneous completion of the following:  Patient resuscitation and stabilization.  Brief clinical history.  Limited physical examination.  Both a gastroenterologist and a surgeon should be promptly notified of all patients with severe acute UGI bleeding.

13. Patient resuscitation and stabilization  Check vital signs  Assess airway and breathing  Assess circulatory status (postural hypotension)  Obtain intravenous access  Replace volume  Transfuse blood (if necessary)  Measure urine output

14. Cont.  Inspect airway  Clear airway  Check ventilation  Supplemental oxygen  Endotracheal intubation: Intubation and mechanical ventilation should be considered for the following patients:  in shock from massive bleeding.  on going hematemesis, especially if the bleeding is torrential.  severe agitation.  depressed sensorium.  depressed respiratory status.

15.  A quick assessment of the circulatory status should be made by:  pulse rate.  measuring the supine blood pressure  checking for pallor and agitation  patients with normal supine blood pressure should be checked for postural hypotension.

16.  Intravenous access  At least two large bore (14 to 18 gauge) peripheral intravenous lines should be inserted for access and volume replacement.  Central Venous Catheter (CVC)  A CVC is usually not indicated because volume can easily be replaced with large bore peripheral IV lines. However a CVC may be useful in the following conditions:  failure to establish peripheral IV access  patients who have an unstable cardiac disease or cirrhosis, in whom measurement of left ventricular filling pressure is necessary to accurately assess volume status.

17.  Volume replacement: Volume should be replaced using crystalloids, such as 0.9% NaCl solution (normal saline) or Ringer's lactate, as rapidly as the patient's cardiopulmonary status will allow, to stabilize vital signs

18. Guidelines for transfusion of blood and blood products in Upper GI Bleed  Symptoms related to poor tissue oxygenation (e.g. angina).  If there is continued acute bleeding despite therapy.  If the patient is clinically shocked despite crystalloids.  If the hematocrit is low (in elderly, high risk patient Hct <30%, and in young, otherwise healthy patients <20%).  If there is coagulopathy (INR>1.5) or thrombocytopenia (<50,000/microL), then fresh frozen plasma and platelets transfusion should be given, respectively.

19. Nasogastric tube  Patients with definite or suspected acute upper gastrointestinal bleeding should have a nasogastric (NG) tube inserted. There is no contraindication to NG tube placement in patients suspected to have esophageal or gastric varices.  Once the NG tube has been placed, the stomach should be lavarged with tap water or normal saline at room temperature and then the tube should be connected to a gravity bag

20. Brief History  Previous history of an upper gastrointestinal bleeding, if so what was the cause.  Symptoms or previous history of peptic ulcer disease.  Use of NSAID's, aspirin or anticoagulants.  Previous history of liver disease.  Risk factors for liver disease (e.g. alcohol consumption, h/o blood transfusion, h/o hepatitis or jaundice).  Recent history of vomiting or retching.

21. Brief History  History of heartburn.  Abdominal pain.  Any previous surgeries, especially recently.  Any co morbid illnesses (e.g. cardiac, pulmonary or neurological illness, bleeding disorders, etc).  abdominal aortic aneurysm (AAA), or abdominal aortic vascular graft → aortoenteric fistula  Melena.  Hematochezia.

22. Laboratory investigations  CBC  PT (INR), aPTT  Type and cross match blood  Creatinine, urea,  Liver function tests  HBSag and anti-HCV if liver disease is suspected  ECG in patients over 50 years of age or h/o cardiac disease (boz they are more pron to develop M.I.)

23. Risk assessment Mild to Moderate Upper GI Bleeding  The patient is < 60 years of age, and has no chronic medical illness.  There is no sign of hemodynamic instability.  Hematocrit is > 30%.

24. Risk assessment Severe Upper GI Bleeding  The patient is > 60 years old.  There are signs of hemodynamic instability (Pulse >100/min, SBP < 100 or postural hypotension).  There is active bleeding (bright red hematemesis, bright red blood in NG tube or hematochezia with hypotension).  Drop in hematocrit of 6% or more.  There is severe co morbid disease (liver, cardiac, pulmonary or renal)

25. Endoscopic diagnosis & treatment  Upper Endoscopy is the procedure of choice in majority of patients with an acute upper gastrointestinal bleeding, for the following reasons:  It can define the source of bleeding in the majority of patients with an upper gastrointestinal bleeding.  It can stratify the patients risk of rebleeding.  It can provide endoscopic therapy for esophageal and gastric varices, peptic ulcer disease and vascular malformations.

26. Other diagnostic tests  For acute UGI bleeding include angiography and a tagged red blood cell scan, which can detect active bleeding.  UGI barium studies are contraindicated in the setting of acute UGI bleeding because they will interfere with subsequent endoscopy, angiography, or surgery.

27. Balloon Tamponade  Sengstaken-Blakemore tube can control variceal hemorrhage in 40 – 80% patients  Inflate gastric balloon first, the esophageal balloon if no improvement

28. Medication  Somatostatin:or its analog octreotide, which have been best studied in the treatment of variceal bleeding, may also reduce the risk of bleeding due to nonvariceal causes. It can be used as adjunctive therapy before endoscopy, or when endoscopy is unsuccessful, contraindicated, or unavailable.  Somatostatin or octreotide compared with H2 antagonists and placebo in the management of acute nonvariceal upper gastrointestinal hemorrhage: a meta-analysis. Imperiale TF; Birgisson S Ann Intern Med 1997  Failures of endoscopic therapy for bleeding peptic ulcer: an analysis of risk factors. Choudari CP; Rajgopal C; Elton RA; Palmer KR Am J Gastroenterol

29. Medication  Erythromycin — two randomized controlled trials (one involving 105 patients and the other involving 41 patients), which have suggested that a single dose of intravenous Erythromycin given 20 to 120 minutes before endoscopy can significantly improve visibility, shorten endoscopy time, and reduce the need for a second-look endoscopy. Erythromycin promotes gastric emptying based upon its ability to be an agonist of motilin receptors. Treatment appeared to be safe in both studies. Thus, this approach can be considered in patients who are likely to have a stomach full of blood such as those with severe bleeding. A reasonable dose would be to give 3 mg/kg intravenously over 20 to 30 minutes, 30 to 90 minutes prior to endoscopy.  Erythromycin intravenous bolus infusion in acute upper gastrointestinal bleeding: a randomized, controlled, double-blind trial. AFrossard JL; Spahr L; Queneau PE; Giostra E; Burckhardt B; Ory G; De Saussure P; Armenian B; De Peyer R; Hadengue A. Gastroenterology 2002  Erythromycin improves the quality of EGD in patients with acute upper GI bleeding: a randomized controlled study. Coffin B; Pocard M; Panis Y; Riche F; Laine MJ; Bitoun A; Lemann M; Bouhnik Y; Valleur P Gastrointest Endosc 2002

30. Medication  Acid suppression — Several studies have examined the role of acid suppression given before or after endoscopy (with or without therapeutic intervention). In the setting of active UGI bleeding, acid suppressive therapy with H2 receptor antagonists has not been shown to significantly lower the rate of ulcer rebleeding.  By contrast, high dose antisecretory therapy with an intravenous infusion of proton pump inhibitor (IV PPI with pantoprazole or omeprazole) significantly reduced the rate of rebleeding as compared to standard treatment in patients with bleeding ulcers. Oral and intravenous PPI therapy also decreases the hospital stay, rebleeding rate, and the need for blood transfusion in high-risk ulcer bleeders treated with endoscopic therapy.  Proton pump inhibitor treatment initiated prior to endoscopic diagnosis in upper gastrointestinal bleeding. Dorward S; Sreedharan A; Leontiadis GI; Howden CW; Moayyedi P; Forman D Cochrane Database Syst Rev. 2006  Proton pump inhibitors versus H2-antagonists: a meta-analysis of their efficacy in treating bleeding peptic ulcer. Gisbert JP; Gonzalez L; Calvet X; Roque M; Gabriel R; Pajares JM Aliment Pharmacol Ther 2001  Estrogen/progesterone treatment of diffuse antral vascular ectasia. Manning RJ Am J Gastroenterol 1995

31. Surgiacl  If all the previous trearment fail consider the surgiacl treatment

32. Than you