ugi bleeding [وضع التوافق] - kau.edu.sa bleeding.pdf · melaena: black tarry stool ......
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fDefinitions
■ Haematemesis: vomiting up of blood■ Haematemesis: vomiting up of bloodProximal to ligament of Trietz
■ Bright red: rapid and sizeable bleeding
■ Coffee-ground: smaller bleed■ Coffee ground: smaller bleed
■ Melaena: Black tarry stool ( > 60 ml )y ( )
O i ll h h i j j ■ Occasionally hemorrhage into jejunum, ileum & right colon can cause melaena if transit is low Contact time 8 h
■ Massive UGIH may cause haematochezia if transit is rapid
E id i lEpidemiologyIncidence:
USA: 100 per 100,000 / yearUK : 103 per 100,000 / yearUK : 103 per 100,000 / year
M li 10 15%Mortality: 10 - 15%Almost all deaths:
1- Elderly2- Medical problemsp
CCauses
Di ib i i■ Distribution varies■ Cause° 10 15%■ Cause : 10 - 15%■ Multiple causes: 20 - 30%■ Multiple causes: 20 - 30%
Th 3 M t C CThe 3 Most Common Causes
1 O i1- Oes varices2 Gastritis / Erosions 2- Gastritis / Erosions 3- DU3 DU
Oes:■ Varices■ Mallory - Weiss tear Duod / Juju:y■ Ca■ Reflux■ Foreign body
■ Peptic ulcer■ Erosions / duodenitis■ Vascular malformations
H bili
Stom:P i l
■ Haemobilia■ Polyps (including Peutz-Jeghers syndrome and other polyposis
d )■ Peptic ulcer■ Erosions / gastritis■ Varices
l h h
syndromes)■ Aorto - enteric fistula
Idiopathic■ Portal hypertensive gastropathy■ Ca■ Lymphoma
Idiopathic
y p■ Leiomyoma■ Angiodysplasis (including Osler’s disease)d sease)■ Dieulafoy’s
Massive UGIB
1 O / i1- Oes / gas varices2- Gas ulcer2 Gas ulcer3- DU4- Stress5- Dieulafoy’s5- Dieulafoy s 6- Aorto - enteric fistula
Bleeding with Cutaneous Stigmata
di h h i l i i (1- Hereditary haemorrhagic telangiectasia (R-O-W Syndrome)y )
2- Pseudoxanthoma elasticum3 Ehl D l S d3- Ehlers - Danlos Syndrome4- Degos’ Diseaseg5- Peutz - Jeghers Syndrome
Upper G I Toxicity of NSAIDUpper G I Toxicity of NSAID
Relative RiskRelative Risk■ Ibuprofen +■ Fenoprofen +■ Aspirin +■ Diclofenac +■ Sulindac ++■ Sulindac ++■ Diflunisal ++■ Naproxen ++
I d h i■ Indomethacin ++■ Tolmetin +++■ Piroxicam +++■ Ketoprofen +++■ Azopropazone ++++ l ++ di +++ hi h+, low; ++ medium; +++, high
B d R f A t Bl diBody Response of Acute Bleeding
1- Significant:Syncope, p hypotension, pallor, tach & JVP
2- 500 ml loss: changes° except:g pa- Elderlyb Existing anemiab- Existing anemiac- Cardiovascular disease
3- Tach & postural fall >20 mmHg The most sensitive signs of hypovolaemiag yp
Hi t 50 %History : 50 %
1- Dyspepsia2- Heart burn 7- Chronic liver disease
8 NSAID3- Dysphagia & weight loss4- Peptic ulcer5- Vomiting / retching followed
8- NSAID9- Anticoagulants10- Bruises11 A i f
g gby haematemesis
6- Recent high alcohol
11- Aortic graft
ExaminationExamination
1- Shock: Pallor, Pulse, BP, P. hypotension2- Stigmata of cirrhosis2 Stigmata of cirrhosis3- Purpura, pigmentaion, Telangiectasia4 Abdomen:4- Abdomen:
■ TendernessM■ Masses
■ Hepato, spleno, dilated veins, ascites5- Jaun + abd pain + melaena: Haemobilia6- DRE
InvestigationsInvestigations
1- CBC : “Hb poor indicator of volume loss”2- U & Es3- LFTs3 LFTs4- INR , PTT5 G i & X hi5- Grouping & X-matching6- ABG7- CXR8 ECG8- ECG
OGD I ti ti f Ch iOGD Investigation of Choice
1 Diagnostic1- Diagnostic
2- Therapeutic
3 P di f i / 3- Predictor of continuous / recurrence
E d C i i f ↑Endo Criteria of ↑Risk Bleed in Oes Varices1 Diff d1- Diffuse redness2- Haematocystic spoty p3- Large tortous varicesvarices4- Proximal extension5- Oesophagitis
Endo Criteria of d aCont/Rec DU Bleed
1- Arterial spurter1- Arterial spurter2- Vessel in base of ulcer
Adh l3- Adherent clot
Complications of OGD
1- Aspiration1 Aspiration2- Bleeding3- Perforation4 F4- Fever5- Respiratory depression5- Respiratory depression6- Reactions to sedatives
Relationship Between Clin and Endo Diag and Risk of p gRecu Bleed (MacLeod & Mills, 1982)
Clinical Rebleed Rate (%)
History of recent Negative 15Alcohol Positive 30Shock Present 69Shock Present 69
Absent 21Age <60 18
>60 34>60 34Endo Varies 42
DU 32GU 48Oesophagitis/gastritis/ 6-14duodenitisMallory-Weiss 13
Relationship Between Endo Stigmata of Recent Bleed and Re-Bleed Rate
Stigma Re-Bleed ( )(%)
Actively spurting vessel 75 - 85y p gVisible vessel, not actively bleeding 50Flat, red/black spot 8 - 10Flat, red/black spot 8 10
No stigmata 0 - 5
B MealB Meal
1- ↓ diag accuracy
2- Obscures endo & angio studies2 Obscures endo & angio studies
3- Chronic cases
4- Diagnostic
Predictors of Poor Prognosis
1- Age > 60 y2 Sh k ( > 6 it )2- Shock ( > 6 units )3- Endo stigmata of recent bleed4- Pathology5- Concomitant disease5 Concomitant disease
TreatmentTreatment
1- Bed rest2- I V fluids3- O2: 5-10 l/min4- Transfusion
l5- Folye’s6- Lavage7 T d7- Tamponade8- CVP9 H antagonist: no role9- H2 antagonist: no role
■ Prevent errosive gastritis■ Prevent stress ulcer ? Re-bleed■ Prevent stress ulcer, ? Re-bleed
Outcome of ResuscitationOutcome of Resuscitation
■ 80 % stopp■ 20 %:
C i bl d1 - Continue to bleed2 - Re-bleed within 48 h of adm2 Re bleed within 48 h of adm
Non operative ManagementNon- operative Management1 Endo:1- Endo:
■ Nd - YAG■ Monopolar BICAP heater probe APC■ Monopolar, BICAP, heater probe, APC■ Injection: sclerosants, alcohol, vasoconstrictors,
adrenaline, thrombin, fibrin glueg■ Banding■ Haemoclip
2- Radio:■ Emoblization (varices, gastritis, angiodysplasia)■ TIPS
3- Pharma: Vasopressin, Somatostatin , β-Blockers
Endo modalities for UGIH
Injection Thermal Mechanical
Adrenaline (1:10,000 or 1:20,000) Heater probe Haemoclips
Fibrin glue Bicap probe Banding
Human thrombin Gold probe Endoloops
Sclerosants APC Staples/sutur
Alcohol Laser
UGIB
Continuing massive h h
Recent hemorrhage, d t l it t d
Hemorrhage >3 days t blhemorrhage adequately resuscitated
bleeding stoppedstable
Emergency endoscopy E l dNon-urgent endoscopy
Emergency endoscopy
D fi it bl di l i
Early endoscopy
N t bl d l
Recent bleeding but no lesion OR recurrent
Definite bleeding lesion No recent bleed, normal endoscopy
bleeder of uncertain cause OR actively
bleeding but normal
ManageObserve endoscopy
99m Tc-labelled RBC scan
NegativePositive
Angio
Laparotomy & Perioperative endoscopy
g
Erosive Gastritis
AntacidsH2-anta / PPIH2 anta / PPIGastric lavage
Eliminae underlying cause
No hemorrhage Continued hemorrhage
Endoscopic hemostasisI t t i l iMedical management
Antacids
H2 t / PPI
Intraarterial vasopressin
H2-anta / PPI
sucralfateOperative treatment
Peptic ulcerPeptic ulcer
■ 80 %: stops sponta■ 80 %: stops sponta■ 25 %: intervention■ Rx:1- Endo: Nd - YAG, Bipolar, Heat
probes, Adrenaline, Sclerosant, Cli ( h i i )Clips (no technique superior)
2- Surgery:DU suturing vago + pyloropDU : suturing, vago + pylorop
All receive anti H PyloriGastric: resection P gastrecGastric: resection, P gastrec
Bleeding Peptic UlcerBleeding Peptic Ulcer
Low risk of rebleeding Active bleeding or high risk of Low risk of rebleeding
M it
g grebleeding (shock, visible vessel)
Monitor Endoscopic therapy
Rebleed Unable to control bleedingNo further bleeding
Repeat endoscopic therapy
SurgeryRebleed
Bleeding Oes Varices
1 90 % portal hypertension have varices1- 90 % portal hypertension have varices2- 30 % with varices will bleed3- 80 % comes from varices4- 70 % rebleed5- Mortality : 50 % 6 Survival depends on degree of hepatic impairement6- Survival depends on degree of hepatic impairement
Treatment
1- Vasopressin & Octreotidep2- Tamponade: 90 % suc. 50 % re-bleed within 24 h removal3- Endo: banding , sclerog ,4- Tipss: re-bleed but enceph
Morta 1 %Morta 1 %5- Surgery: transection , devascularization , shunting
Emergency shunting: 20 % morta & 50 %encephenceph
Bleeding Esophageal Varices
Sclerotherapy
No further bleeding Continued hemorrhageNo further bleeding
D fi iti t t t
g
Temporizing methodsDefinitive treatment
Sclerotherapy
Devascularization
Vasopressin
Balloon tamponadeDevascularization
Shunt
Liver transplantationSclerotherapy
Liver transplantation
No further bleeding Continued hemorrhage
TIPSOperative
Bleeding Gas VaricesBleeding Gas Varices
1- Endo:Sclero:
■ Ethonalamine oleate & Polidocanal: poor results
■ Ethonalamine oleate & N-butyl-2-cyanoacrylate (NC): successful ? E b liEmbolism
ligation (EVL)2- Radio:
ll l d d d■ Balloon-occluded retrograde transvenous obliteration
■ Transjugular retrograde obliteration■ TIPS
3- Surgical:DevascularizationResection of upper stomach
Prevention bleed varices
A- Primary :y
1 β blockers: bleed by 40 50 %1- β- blockers: bleed by 40 – 50 %
2- Banding: may be considered
3- Sclero / shunting: Ineffective
B S dB – Secondary:1- 70 % variceal bleed re-bleed2- β – Blockers
Li i3- Ligation4- Sclero4 Sclero5- TIPS6- Surgery
Dieulafoy’s lesion
■ Rare■ Large s/m artery protruding through ■ Large s/m artery protruding through
m■ Within 6 cm of G - O junction on
l lesser ■ Rx: injection, thermal, clipping,
bandinggSingle: 50 % rebleedingCombined: 20 % rebleed. 90 % sucsses
I di ti f SIndications for Surgery
1- Continuing bleed2- Re-bleed3- Failure of endo 4- Pathology:
■ Chronic posterior DU with clot adherent to a large artery
■ Gastric ulcer: Re-bleed is common5- Fitness: elderly or ill6- Loss > 30% blood volume
Unknown Source of BleedUnknown Source of Bleed
l f il d bl di OGD & Colonoscopy fail to detect bleeding :S. bowel lesions are often responsible
1- Haemobilia2- Ulcerating panc / duod tumours2 Ulcerating panc / duod tumours3- Aorto / cavo duod fistula4- Meckel’s5- Polyps6- Smooth muscle tumours6 Smooth muscle tumours7- Angiodysplasia8- Lymphoma9- TB10- Crohn’s 0 C o s 11- Cavernous haemangioma12- Hamartoma13- Duplication cyst14- Chronic pancreatitisp
I ti tiInvestigations
1- Small bowel enema: most useful2 R di lid2- Radionuclide3- Sel S M angio
T4- CT, MRI, MRA, MRCP5- Capsule endoscopy6- Lapa + Intraop enteroscopy
(IOE)
Radionuclide Studies
1 M i L G I bl d1- More in L G I bleed
2- Bleed rate: 0.1 ml/min
3- Of value in intermittent bleed
Radionuclide Scanning
■ Technetium Pertechnetate (99Tcm)
■ Sulphur-colloid (TcSc): emergency
■ Technetium labeled autologous red cells ■ Technetium-labeled autologous red cells (intermitent bleeding) long time
Angiography
1- Bleed rate > 0.5 - 1.0 ml/m2- Diagno & Therap3 A 90 %3- Accuracy: 90 %4- Complication: 2%
■ Catheter■ Catheter■ Contrast■ With embolization → perforation
Conclusion
1- Collaboration of Gastroentero, Radio & surgeon2 NSAID i 2- NSAID important cause3- Only 10 - 20% require intervention
E l d4- Early endoscopy5- Variceal bleed has a significantly higher mortality than
thothers
Angiographic Therapy of UGIHg g p pyProcedure Success Rate in
Arresting Hemorrhage (%)
1. Mallory-Weiss tear
Vasopressin infusion into left gastric artery
77
Gelfoam embolization 88Gelfoam embolization of left gastric artery
88
2. Stress ulceration Vasopressin infusion 75-84into left gastric arteryGelfoam embolization of left gastric artery
80of left gastric artery
3. Gastric ulcer Vasopression infusion 65-70Embolization 79
4. Duodenal ulcer Vasopressin infusion 33-62Embolization 79
d f l bl d l k fEndoscopic stigmata of ulcer bleeding : prevalence, risks of rebleeding and reduced risk of rebleeding following endoscopic
Endoscopic l (%)
Rebleed Rate with success
Rebleed Rate with Endoscopic
Appearance Prevalence (%) with success Endoscopic
Stigmata
with Endoscopic
treatment (%)Active arterial Active arterial
bleeding 12 90 15-30
Visible Vessel 22 50 15-30Adherent clot 10 33 5Oozong without
stigmata 14 10 Not availablestigmataFlat spot 10 7 Not available
Clean base ulcer 32 3 Not available
Endoscopic Management of Continuous or Recurrent DU BleedingContinuous or Recurrent DU Bleeding
1- Diluted adrenaline 1 : 10,000
2- 3 - 4 injections of 0.5-2 ml of edgesj g
3 1 i j ti f 0 5 2 l i t b3- 1 injection of 0.5 - 2 ml into base