Transcript UPPER GI BLEEDING - Liaquat University of Medical and

UPPER GI BLEEDING
Professor Altaf Talpur
Surgical unit -3
Outline
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Introduction
Aetiology
Presentation
Resuscitation
Diagnosis
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2.
History
Clinical
examination
investigations
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Treatment
Complications
Follow up
Prognosis
conclusion
Introduction
• Bleeding of GIT proximal to ligament of
treitz.
• Ligament of treitz- a fibromuscular band
which extends from right crus of
diaphragm to duodenojejunal flexure.
Presents as:
• Haematemesis,, malena, hematochezia or
occult blood.
• Malena can present with loss of 50-60ml
of blood.
• May be acute or chronic
• 100 cases per 100,000 person per year.
• Accounts for 3-5% of all hospitalizations
• The incidence is 2- fold greater in males
but death rate is similar in both sexes.
• Overall mortality from acute bleeding is
20% .
• Mortality & morbidity increases as age
advances (>60 yrs)
Etiology of upper GI bleeding
Aetiology (Common causes)
1. Peptic ulcer disease
≥ 50% of cases
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Duodenal ulcer
Gastric ulcer
Stomal ulcer
Aetiology (Common causes)
2. Erosive gastritis,
esophagitis, duodenitis
15-30% of cases
Common causative factors are:
ETOH [alcohol], ASA, NSAID’S,STEROIDS.
Erosive gastritis
Aetiology (Common causes)
3. Esophageal and gastric varices
10-20% of cases
caused by portal hypertension
Esophageal varices
Aetiology (Common causes)
4. Mallory- Weiss syndrome
• 5% of cases
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Characterized by longitudinal mucosal tear in the
cardioesophageal region.
Result from repeated vomitting or retching.
Common in male alcoholic patients
Mallory Weis Syndrome
Aetiology
Less common
Rare
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Oesophagitis
Malignant gastric tumor
Benign gastric tumors
Oesophageal ulcer
Oesophageal tumors
A-V malformations
Duodenal tumous
Pancreatic tumors
Arterial aneurysm
Blood dyscrasia
Hereditary telangiectasia
Haemobilia
Malignancy
• In 3% of cases presentation is with upper
GI bleeding
• Gastric cancer
• Oesophageal cancer
ESOPHAGEAL TUMORS
GASTRIC TUMORS
Clinical presentation
A. Chronic upper GI bleeding
• Anemia.
• Weakness.
• Fatigueness.
• Pt :looks pale.
• Malena.
• Occult blood positive.
B. Acute upper GI bleeding
• Presents as emergency with hemetemesis or
malena.
• Hypovolaemia:
i. Mild: no significant hypovolaemia.
ii. Moderate: hypovolaemia which responds to volume
replacement.
iii. Severe: hypovolaemia with continued active major
bleeding making resuscitation difficult even with
blood transfusions.
These patients are difficult to manage.
Patients will show all signs of shock.
Note: all patients should be examined for
stigmata of CLD.
• H/O drugs (NSAIDS).
• H/O ulcers.
• H/O alcohol abuse.
Resuscitation
Initial management has 4 primary goals:
1. Quick assessment with attention to
hemodynamic status
2. Appropriate resuscitation (ABC) &
monitoring
3. Identify major source of bleeding
4. Specific therapeutic intervention.
Resuscitation (General measures)
• Airway cleared of clot.
• Oxygen inhalation.
• Maintain IV line with at least 2 wide bore
cannulae
• Sample to blood bank for cross matching.
• Class I + II hemorrhage replace with crystalloid.
• Class III + IV hemorrhage replace with
crystalloid & blood.
• Pass NG tube for diagnostic & therapeutic
purpose.
• Catheterize the patient.
• Sedation may be needed.
SEVERITY
Estimated Fluid and Blood Losses in Shock
Class 1
Class 2
Class 3
Class 4
Blood Loss,
mL
Up to 750
750-1500
1500-2000
>2000
Blood Loss,%
blood volume
Up to 15%
15-30%
30-40%
>40%
<100
>100
>120
>140
Normal
Normal
Decreased
Decreased
Normal or
Increased
Decreased
Decreased
Decreased
14-20
20-30
30-40
Slightly
anxious
Mildly
anxious
Anxious,
confused
Confused,
lethargic
Crystalloid
Crystalloid
Crystalloid
and blood
Crystalloid
and blood
Pulse Rate,
bpm
Blood
Pressure
Respiratory
Rate
Urine
Output,
mL/h
CNS/Mental
Status
Fluid
Replacement,
3-for-1 rule
>35
Specific measures
• If stable following resuscitation, proceed
for upper GI endoscopy.
• Endoscopy ideally done within 4-24 hrs.
• If patient could not be stabilized, an
emergency laparatomy may be necessary.
Diagnosis
History of:
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Epigastric pain or retrosternal burning
hematemesis, melena, or hematochezia.
Vomiting, weight loss, alteration of bowel habits.
Aortic graft surgery
Use of ASA, NSAID’S, steroids, alcohol addiction
Diagnosis
Physical examination
• Vital signs may show hypotension & tachycardia.
• Cool, clammy skin.
• Petechiael hemorrhage & purpura seen in
coagulopathy.
• Signs of chronic liver disease.
• Proper abdominal & rectal examination.
Investigations
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Upper GI endoscopy.
Arteriography.
Barium swallow
Ultrasound
Lab investigations
Endoscopy
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Most important investigation
For diagnosis & intervention
Establishes diagnosis in 90% of patients
Can be repeated more than once.
Arteriography
• In pts who bleeds contineously & site can not be
identified.
• Has accuracy of 50-90%.
• Accuracy is increased if there is active bleeding
during investigation.
• Demonstrates bleeding of 0.5-1.0ml/min
• With technetium-labelled RBC, 0.1-0.5ml/min
• Embolisation may be done at same time
Barium swallow / meal
• Used when endoscopy is not available
• Double contrast study is ideal
• May show varices, esophagitis, peptic
ulcers, gastric tumors etc
Abdominal Ultrasound scan
• To assess both liver architecture and
portal circulation
• More widely available than Arteriography
• Should be performed before more invasive
procedures
Lab Investigations
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CBC
Electrolytes
Glucose
Coagulation studies
Liver function studies
Blood grouping and cross-match
Lab investigations
• CBC, urea/creatinine, S/Electrolytes,
ABGs.
• ed urea/ creatinine in upper GI bleeding.
• Normal Hb in pts with active bleeding.
• Iron deficiency anemia in chronic blood
loss.
Treatment ( peptic ulcer disease)
At endoscopy
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10ml epinephrine at ulcer base
Thermal treatment with bipolar diathermy
Laser photocoagulation
Rebleed is treated similarly
A second rebleed is treated by surgery
Post endoscopy treatment
• Continuous intravenous infusion of
Octretide (somatostatin analogue)
• Proton pump inhibitors
• H. pylori treatment may be required.
Surgery- PUD
Surgical options are:
• Truncal vagotomy & drainage
• Highly selective vagotomy
• Partial gastrectomy
Surgery - PUD
Indications for surgery are:
• Exsanguinating hemorrhage
• Visible spurting arterial bleed
• Concomitant perforation
• Pts >60 yrs, who rebleed once or need 4 units at
resuscitation or 8 units in 48 hrs
• Younger pts requiring 8 units at initial
resuscitation or 12 units in 48 hrs
• Rare blood group
Treatment
Gastric erosions / stress ulcers
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Treatment of underlying cause
Intraluminal antacids
IV proton pump inhibitors
Bleeding usually subsides in 24-48 hrs
Treatment
Esophageal varices
1. Endoscopic sclerotherapy
• Repeated at 3 weeks interval then 3
monthly until varices disappear
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Some sclerosing agents are ethanolamine
oleate, sodium morrhuate, 3% tetradecyl
sulphate, absolute alcohal
2. Rubber band ligation
3. Vasoconstriction therapy (octreotide,
vasopressin, propranolol)
Sclerotherapy of esophageal
varices
Esophageal variceal Banding
4. Balloon tamponade: if above measures fail
Modified Sengstaken- Blakemoore tube
Minnesota tube, Linton tube, Foley catheter
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Balloon tamponade applied for 12 hrs
Stop bleeding in 80% of cases
Must be followed by surgery as bleeding
is likely to recur after removal.
Balloon temponade
Surgery – esophageal varices
• TIPS: in refractory bleed
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Shunt established between portal vein & Rt
or middle hepatic vein
Stapling transection of esophagus at CEJ
Distal splenorenal shunt
Portosystemic shunts
Spleenectomy in hypersplenism
Liver transplantation
Transjuglar intrahepatic
portosystemic shunt [TIPS]_
Treatment
• Mallory- weiss
observe
if persist, suture mucosal tear
• Esophagitis
Observe
• Benign gastric tumors
Excise
• Dieulafoy’s lesion
Endoscopic electrocoagulation, sclerotherapy
Complications
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Of presenting problem
Of resuscitative measures
Of underlying disease
Of treatment
Complications of massive
hemorrhage
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Hemorrhagic shock
Acute renal shut down
MODS
Death
Complications of resuscitation
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Fluid overload
Pulmonary edema
CCF
Blood transfusion reaction
Cardiac arrest
Hypothermia
Esophageal perforation
Complications of underlying
diseases
• Rebleed in PUD & varices
• Gastric outlet obstruction in PUD
• Progressive CLD causing portal
hypertension, ascites & coagulopathies
Complications of definitive surgery
• PUD
Early & late dumping
gastric tumors
Iron deficiency anemia
• Bypass procedures for portal hypertension
mucosal ulceration
Hepatic encephalopathy
Follow-up
• To monitor progress of non- surgical
treatment
• To prepare pts for elective definitive
surgery
• To look out for, and treat complications of
surgery
Prognosis
Depends upon
ROCKALL scoring system
this includes :
• The state / time of presentation of pt
• energetic resuscitation
• underlying disease
• Co morbidities
ROCKALL SCORING SYSTEM
Adverse prognostic factors
Conclusion
• Upper GI bleeding is not uncommon &
may be life threatening.
• Prompt intervention could be life saving.
• It require multidisciplinary approach.
• Definitive treatment depends upon the
final diagnosis.
THANK YOU