Transcript SANGUINAMENTO delle PRIME VIE DIGESTIVE

UPPER
GASTROINTESTINAL
BLEEDING
G.C. Sturniolo
Nicoletta Merlini
Dipartimento di
Scienze Chirurgiche e Gastroenterologiche
Sezione di Gastroenterologia
ACUTE UPPER GI BLEEDING
INCIDENCE:
50 to 150 cases per 105 per year
In UK
25.000 hospital admission
each year
Palmer, PMJ 2004
AUGIB
ETIOLOGY
 Peptic ulcer disease
 Oesophageal/gastric varices
 Mallory-Weiss tear
 Oesophagitis
 Duodenitis/gastritis/erosions
 Vascular (Angiodysplasia, Dieulafoy)
 Tumours
Aortoenteric fistula
ACUTE UPPER GI BLEEDING
Vascular
Mallory Weiss
2,5%
Tumours
2,5%
3,5%
Aortoduodenal
fistula <1%
Varices
8,5%
Peptic ulcers
42,5%
Erosions
15%
Oesophagitis 25%
Adapted from
Palmer, PMJ 2004
MORTALITY
4153 upper GI bleeding
40%
30%
20%
10%
0%
Rockall, BMJ 1995
MORTALITY in UGIB
50%
Hospital mortality
and mortality related to the source of bleeding
in 362 UGIB
45,5%
40%
30%
29,4%
22,7%
20%
10%
Varices
20%
Peptic Ulcer
9,1%
3,8%
0%
Hospital Mortality
Erosion
5,9%
0%
Mallory Weiss Tear
Bleeding Mortality
Klebl, Int J Colorectal Dis 2005
MORTALITY in UGIB
60%
Mortality of patients
during hospitalization
50%
40%
30%
20%
10%
0%
40%
p < 0,05
11%
Bleeding
only before
admission
Bleeding
before + after
admission
Adapted from
Palmer, PMJ 2004
MORTALITY FOR UGIB:
Time Trend
1996
20%
15%
10%
5%
19,5%
1996
11,7%
p=0,03
2000
p=0,05
2000
11,1%
7,2%
0%
Cirrhosis+Non cirrhosis
Cirrhosis
Fiore, Eur J Gastr Hep 2005
UGIB:
Diagnostic Endoscopy
• Identifies the bleeding lesions
>95% of sensitivity and specificity
• Doesn’t alter patient outcome:
• Morbidity
• Mortality
• Transfusions
• Length of stay
• Surgery
Peterson, NEJM 1981
Cappell, Med Clin N Am 2002
UGIB:
Therapeutic Endoscopy
• Only patients with persisten or recurrent
bleeding
• 80% patients don’t have further bleeding
• Optimal utilization
IDENTIFY HIGH RISK PATIENTS
UGIB: ROCKALL SCORE
Developed in 1996
to assess risk of mortality and rebleeding
in UGIB patients Rockall, BMJ 1996
Rockall risk score
Variable
Score 0
Score 1
Score 2
AGE
< 60
60-79
> 80
SHOCK
None
Score 3
Pulse > 100 bpm Fc>100,PAOs <100
Renal,liver
CO-MORBID
None
Cardiac failure
failure
Mallory-Weiss
All
other
DIAGNOS
Malignancy upper GI
diagnoses
No lesions
MAJOR SRH
None or
dark spots
Blood in upper
GI tract, blood clot
UGIB:
ROCKALL SCORE
Retrospective study, 222 patients
Distribution of Rockall Score
% of patients
50%
7
40%
4
30%
3
20%
10%
0%
5
6
8
9
10
2
Bessa, DLD 2006
UGIB:
ROCKALL SCORE
Retrospective study, 222 patients
30%
25%
Rebleeding Risk
p = ns
30%
25%
20%
20%
15%
15%
10%
10%
5%
5%
0%
0%
Rockall < 5
Rockall > 6
Mortality Risk
p < 0,001
Rockall < 5
Rockall > 6
Bessa, DLD 2006
UGIB
WHICH PATIENTS
ARE MORE LIKELY
TO REBLEED?
UGIB:
Clinical Risk
• Large volume bleeding
• Shock
• Age > 60 years
• Bleeding onset after admission
• Comorbidity
• Variceal Bleeding
Scoring Systems for UGIB
• Baylor bleeding score (1993)
• Cedars-Sinai predictive index (1996)
• Rockall Score (1996)
• Blatchford Score (2000)
Das, Gastrointest Endosc 2004
UGIB: Blatchford Score
• Derived from clinical information at
presentation such as:
• Urea
• Hb
• Blood pressure
• Comorbidity (syncope, melena,
heart and/or liver disease)
Blatchford, Lancet 2000
BLATCHFORD vs ROCKALL
BETTER ROC FOR
“CLINICAL INTERVENTION”
Blatchford, Lancet 2000
PEPTIC ULCERS
CLASSIFICATION
FORREST CLASSIFICATION
ACUTE HEMORRHAGE
Forrest I a
Forrest I b
Arterial, spurting hemorrhage
Oozing hemorrhage
SIGNS OF RECENT HEMORRHAGE
Forrest II a
Visible vessel
Forrest II b
Adherent clot
Forrest II c
Hematin covered lesion
LESIONS WITHOUT RECENT BLEEDING
Forrest III
No signs of recent hemorrhage
Forrest IIb
Forrest IIa
FORREST
CLASSIFICATION
Forrest 1a
Spurting bleeding
Forrest 2a
Non-bleeding visible vessel
Forrest 2c
Ulcer with haematin-covered base
Forrest 1b
Non-spurting active bleeding
Forrest 2b
Non-bleeding with adherent clot
Forrest 3
Ulcer with clean base
PEPTIC ULCERS:
RISK FACTORS?
•
•
•
•
•
•
Male, Advanced age
History of ulcer disease
Helicobacter Pylori
Corticosteroids
NSAIDs
Blood-thinning drugs
MANAGEMENT OF UGIB
• Resuscitation
• Endoscopy and endoscopic therapy
• Drug Therapy
MANAGEMENT OF UGIB
• Resuscitation
• Endoscopy and endoscopic therapy
• Drug Therapy
RESUSCITATION
• Airway, Breathing, Circulation
• Central Venous Pressure (elderly and cardiopathic)
• Crystalloids (carefully in liver disease!)
• Colloids in major hypotension
• Blood transfusion
Shocked
Actively
bleeding
Hb < 10 g/dL
Palmer, PMJ 2004
WHEN SHOULD WE
TRANSFUSE PATIENTS?
Age > 60 years
Hb < 8.2 g/dL
 Blood Transfusion
 Cardiologic Evaluation
 cTropI Curve
Gastro PD, BLISC
MANAGEMENT OF UGIB
• Resuscitation
• Endoscopy and endoscopic therapy
• Drug Therapy
UGIB: TO SCOPE
• Early endoscopy identifies and treats
patients with high risk of rebleed
improving patient outcomes
• PPI therapy alone is not as effective as
endoscopic therapy for high risk lesions
UGIB: NOT TO SCOPE
• No benefit from early
endoscopy if the findings do not
change patient care
DRUG THERAPY
IV PPI vs IV RANITIDINE
Time with intragastric pH>4 / 24h
100%
80%
93%
96%
67%
60%
40%
p<0,001
43%
Day 1
Day 3
20%
0%
IV PPI
IV H2RA
Merki,
Gastroenterology 1996
MANAGEMENT OF
NON VARICEAL BLEEDING
Non-variceal, upper GI bleeding
IV PPI bolus + infusion
Upper Endoscopy
High-risk stigmata
Endo therapy +
IV PPI
Low-risk stigmata
Oral PPI therapy
Triadafilopoulos,
Alim Pharm Ther 2005
OESOPHAGEAL VARICES
• 80-90% CIRRHOSIS
• BLEEDING PREVALENCE: 30-40%
• MORTALITY I BLEEDING: 20-45%
• PRIMARY PREVENTION
• SECONDARY
PREVENTION
• TREATMENT ACUTE
BLEEDING
INCIDENCE/YEAR
5-10%
INCIDENCE/YEAR
INCIDENCE/YEAR
5-30%
5-50%
MORTALITY 30-50%
CIRRHOSIS
SMALL VARICES
LARGE VARICES
PRIMARY
PREVENTION
 50% BLEEDING
25-45%
MORTALITY’
ACUTE BLEEDING
REBLEEDING
60% 1 YEAR
RISK FACTORS
• CHILD B-C
• EXTENSION (63% Ls vs 45% Li)
• DIMENSION (F1,15%;F2,32%;F3,68%)
• RED WALL MARK
(red spots e wall marking 76% vs 17% without)
• COLOR (blue 80% vs white 45%)
• PORTAL VEIN PRESSURE (> 12 mmHg)
HIGHER
BLEEDING RISK
VARICEAL
BLEEDING
De Franchis, J Hepatol 2000
MEDICAL TREATMENT
ANTIBIOTICS
INFECTIONS

35-66% BLEEDING CIRRHOTICS
• UTI 12-29% E.Coli + Klebsiella
• SBP 7-23% Gram -/+
• PULMONARY INFECTIONS 6-10%
• SEPSI 4-11%
Dell’Era, APT 2004
INFECTIONS
•  BLEEDING CONTROL FAILURE
•  MORTALITY RELATED BLEEDING
• PREDICTIVE FACTOR OF REBLEEDING
MEDICAL TERATMENT
VASOACTIVE DRUGS
TERLIPRESSIN
2 mg e.v. qd 4-6 hrs per 24 hrs
then
1 mg e.v. qd 6 hrs per 4 days
TAKE HOME MESSAGES
VASOACTIVE DRUGS, BLOOD TRASFUSION
RESUSCITATION, COLLOIDS, ANTIBIOTICS
EGDS
MEDICAL TREATMENT
Vasoactive drugs (5 days long)
VARICEAL BAND LIGATION
SCLEROTHERAPY
Failure
II EGDS
BLAKEMORE
Lata J et al Dig Dis 2003
Failure
Surgery (child A) TIPS (child B,C)