PDF Management of Upper GIT Bleeding Presentation

Management of upper GIT Bleeding Presentation by: Mustafa safaa Supervised by: Dr. Ihsan sukar GASTROINTESTINAL HAEMORRHAGE Introduction Gastrointestinal bleeding (GI bleed) or gastrointestinal...

Management of upper GIT Bleeding Presentation by: Mustafa safaa Supervised by: Dr. Ihsan sukar GASTROINTESTINAL HAEMORRHAGE Introduction Gastrointestinal bleeding (GI bleed) or gastrointestinal hemorrhage (GIB): is all forms of bleeding in the gastrointestinal tract, from the mouth to the rectum. When there is signi cant blood loss over a short time, symptoms may include vomiting red blood, vomiting black blood, bloody stool, or black stool. Small amounts of bleeding over a long time may cause iron-de ciency anemia resulting in feeling tired or heart related chest pain. Other symptoms may include abdominal pain, shortness of breath, pale skin, or passing out. Sometimes in those with small amounts of bleeding no symptoms may be present. fi fi Classi cation GI bleed is classified as upper GI and lower GI bleeding: 1. Upper GI bleed is bleeding above the level of ligament of Treitz. 2. Lower GI bleed is bleeding below the level of ligament of Treitz. fi Ligament of Treitz is a fibromuscular band, which extends from right crus of diaphragm to duodenojejunal flexure with upper part made up of striped muscle fibres, lower part smooth muscle fibres and middle part with elastic fibres. UPPER GI BLEED It is considered as: 1. Variceal. 2. Nonvariceal.  Causes Peptic ulcer 60%. Ulcer bleeding is precipitated by NSAIDs, steroids, alcohol. Ulcer bleeding is overall common in men. But NSAID induced ulcer bleeding is common in females. Duodenal ulcer (35%) more commonly bleeds than gastric ulcer (25%) Gastroduodenal erosions. Oesophageal varices. Oesophagitis and erosions. Carcinoma stomach—5% Mallory-Weiss syndrome—5-15%. Vascular anomalies—Dieulafoy’s syndrome (A-V malformation in the fundus of the stomach), Osler-Weber-Rendau syndrome, Ehlers-Danlos syndrome. Aortoduodenal fistula. Bleeding disorders. H/O drug intake—anticoagulants, clopidogrel, ecospirin.  Clinical Features Acute Bleed 1. Features of shock. 2. Haematemesis. 3. Melaena. Chronic Bleed 1. Signs of chronicity: Hypochromic microcytic anaemia, glossitis, koilonychia, congestive cardiac failure. 2. Mortality in upper GI bleed is 10%.  The initial evaluation The initial evaluation of a patient with a suspected clinically signi cant acute upper GI bleed includes: 1. History 2. Physical examination 3. Laboratory tests. The goal of the evaluation is to: 1. Assess the severity of the bleed, 2. Identify potential sources of the bleed 3. Determine if there are conditions present that may a ect subsequent management. The information gathered as part of the initial evaluation is used to guide decisions regarding triage, resuscitation, empiric medical therapy, and diagnostic testing. ff fi Past medical history 1. History of liver disease or excess alcohol use 2. History of an abdominal aortic aneurysm or an aortic graft 3. Patient with renal disease, aortic stenosis, or hereditary hemorrhagic telangiectasia 4. Peptic ulcer disease in a patient with a history of Helicobacter pylori (H. pylori) infection, nonsteroidal anti-in ammatory drug (NSAIDs) use, antithrombotic use, or smoking 5. Malignancy in a patient with a history of smoking, excess alcohol use, or H. pylori infection 6. Predispose patients to volume overload in the setting of vigorous uid resuscitation or blood transfusions (eg, renal disease, heart failure). Such patients may need more invasive monitoring during resuscitation. 7. Evidence of di cult controlling bleeding (eg, coagulopathies, thrombocytopenia, signi cant hepatic dysfunction). Such patients may need additional hemostatic therapies fl ffi fi fl Medication history 1. Predispose to peptic ulcer formation, such as aspirin and other NSAIDs. 2. Are associated with pill esophagitis (see "Pill esophagitis"). 3. Increase risk of bleeding, such as anticoagulants (including warfarin and the direct oral anticoagulants) and antiplatelet agents (eg, P2Y12 inhibitors and aspirin). 4. Have been associated with GI bleeding, including selective serotonin reuptake inhibitors (SSRI), calcium channel blockers, and aldosterone antagonists. Physical examination 1. Signs of hypovolemia include: Mild to moderate hypovolemia (less than 15 percent of blood volume lost) - Resting tachycardia. 2. Nasogastric lavage may be carried out if there is doubt 3. The signs of acute abdomin raises concern for perforation. 4. Physical examination to search for evidence of signi cant comorbid illnesses. fi Score: < 3 low-risk.. 3-8 moderate.. > 8 high.  Investigations 1. Gastroscopy: Endoscopy has a high sensitivity and speci city for locating and identifying bleeding lesions in the upper Gl tract. In addition, once a bleeding lesion has been identi ed, therapeutic endoscopy can achieve acute hemostasis and prevent recurrent bleeding in most patients. We can see: The spurting vessel Oozing Clot in the ulcer Collected blood in the lumen of the stomach. Early endoscopy - The approach is to perform upper endoscopy within 24 hours for most patients with upper GI bleeding, but only after adequate resuscitation has been provided. For patients with suspected variceal bleeding, we perform endoscopy within 12 hours of presentation. Patients need to be hemodynamically stable fi fi  Contraindications Risks of endoscopy 1. Dysphagia or any swallowing disorder Risks of upper endoscopy include 2. Non compliance pulmonary aspiration, adverse reactions 3. Cardiac devices-pacemaker/ to medications used to achieve conscious de brillator (relative) sedation, GI perforation, and increasing 4. Major abdominal surgery 6 months bleeding while attempting therapeutic (relative) intervention. 5. Pregnancy The risks versus bene ts of upper endoscopy should be considered in high- risk patients, such as those who have had a recent myocardial infarction. fi fi 2. CT angiography of coeliac trunk and SMA: On CT angiography (CTA), the critical imaging nding of GI bleeding is active extravasation of IV contrast into the bowel lumen. This can be diagnosed with CTA when an intraluminal focus of high attenuation (>90 HU) is seen on arterial phase images (“contrast blush”) 3. Hb%, packed cell volume, CVP measurement, blood grouping and crossmatching. U/S abdomen. 4. LFT; prothrombin time; platelet count; blood urea and serum creatinine; serum electrolytes. fi General measures A. Intravenous access: Two 18 gauge or larger intravenous catheters and/ or a large-bore, single-lumen central cordis. B. Fluid resuscitation: The approach to fluid resuscitation in patients who are hemodynamically unstable should begin immediately and should not be delayed pending transfer of the patient to an intensive care unit. C. Catheterisation D. Ryle’s tube aspiration E. Blood transfusion: If the initial hemoglobin level is low (