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

2. ACUTE GI – BLEEDING (AGIB)

4. Forms Upper Lower Obscure AGIB

5. 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% AGIB

6. 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 What are your plans (objectives) ? How would you approach him ? Mention the adverse prognostic factors ? AGIB

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

8. How to approach the patient ? 1.Initial assessment 2.Resuscitation 3.History and exam 4.Lab evaluation 5.Localization 6.Treatment AGIB

9. 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 ? ( 1 ) AGIB

10. Initial assessment – B What are the features of shock ? Agitation Pallor Hypotension Tachycardia ( 1 ) AGIB

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

12. How to approach the patient ? 1.Initial assessment 2.Resuscitation 3.History and exam 4.Lab evaluation 5.Localization 6.Treatment AGIB

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

15. Resuscitation Indications for blood transfusion Unstable VS Continuous bleeding Bright blood Age > 60 Concomitant CPD ( 2 ) AGIB

16. How to approach a patient with AGIB? 1.Initial assessment 2.Resuscitation 3.History and exam 4.Lab evaluation 5.Localization 6.Treatment AGIB

17. History and examination History Exam AgeStigmata of CLD DyspepsiaHereditary vascular anomalies Previous bleeding Scars Previous PUDPalpable organs / masses Previous endoscopy Lymphadenopathy Previous surgery PR (PUD aortic graft etc..) Drugs CLD Weight loss, Anorexia Changing bowel habits ( 3 ) AGIB

18. How to approach a patient with AGIB? 1.Initial assessment 2.Resuscitation 3.History and exam 4.Lab evaluation 5.Localization 6.Treatment AGIB

19. Laboratory parameters Type and crossmatchingType and crossmatching CBC, PT, PTT,CBC, PT, PTT, BUN, BUN / Creatinin ratioBUN, BUN / Creatinin ratio LFTLFT ABGABG ( 4 ) AGIB

20. How to approach a patient with AGIB? 1.Initial assessment 2.Resuscitation 3.History and exam 4.Lab evaluation 5.Localization 6.Treatment AGIB

21. Localization Clinical Endoscopy RBC scan Angiography ( 5 ) AGIB

22. How to approach a patient with AGIB? 1.Initial assessment 2.Resuscitation 3.History and exam 4.Lab evaluation 5.Localization 6.Treatment AGIB

23. Treatment Medical Endoscopic Angiographic Surgical ( 6 ) AGIB

24. 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 AGIB

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

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

28. Role of endoscopy Site of bleeding Source of bleeding Stigmata of bleeding PUD −Active bleeding −Visible vessel −Clot −Black spot Endoscopic therapy AGIB

29. Endoscopic hemostatic methods Variceal bleeding Injection Banding Non-variceal bleeding Injection Thermal Clips

30. Bleeding Esophageal Varices

31. EVL

32. Gastric Varices

33. GU – Visible Vessel

34. Sentinel Clot

35. Gastric Angiodysplasia

36. Bleeding Angiodysplasia

37. DU – Bleeding Control

38. DU – Bleeding

39. GU Clips

40. Bleeding GU

41. Bleeding Diverticulum

42. Diverticulum Visible Vessel

43. Bleeding hemorrhoids

44. Dieulafoy - Colon

45. Thank you !