GI Bleeding kuliah

8/18/2019 GI Bleeding kuliah

1/31

MANAGEMENT

GASTROINTESTINALBLEEDINGTHE ROLE OF NATURAL

HEMOSTATIC


2/31


3/31

DEFINITIONS

UPPER GASTROINTESTINAL

BLEEDING:

originating proximal to the

ligament of Treitz

emateme!i! " melena

LO#ER GASTROINTESTINAL

BLEEDING:

originating from the !mall

$o%el an& 'olon(

hemato!'hezia) melena


4/31


5/31

CAUSE OF SMALL BOWEL BLEEDING

(Based on 76 cases)

1. Tumor (37/76)

2. Meckel’s diverticulum (21/76)

3. Angiopat! (1"/76)#. $ctopic pancreas (3/76).

%orld & 'astroenterol 26 ecem*er 7+ 12(#"), 7371-737#


6/31


7/31

INITIAL EVALUATION

emo&*nami'!nsta*le esuscitate

Admit to 0

ta*le

Re!+!'itate2 large *ore 0’s 16 gauge or larger

Trans4use 5sig risk cardiac8 liver disease 8

elderl! * 91

:oung lo; risk * 97

0


8/31

=ull ockall score

INITIAL RO,-ALL S,ORE ./ E0ERGEN,1

ENDOS,OP1 UNDERTA-EN #ITIN 23 OURS


9/31

D%&%C&I'N S'()C% '* BL%%D


10/31


11/31

=@$T 'A0


12/31

INJECTION TO STO

BLEEDING

Te commonest inDection 4luid is 1,18

adrenaline (epineprine)

$ndoscopic inDection o4 4luid around and into te

*leeding point reduces te rate o4 re*leeding inpatients ;it non-*leeding visi*le vessels 4rom

approEimatel! "C to 1"-2C.

e*leeding 4ollo;ing inDection into ulcers ;it

aderent *lood clot is also signi4icantl! reduced 4romapproEimatel! 3" to 1C.


13/31

STO ETIC ULCER BLEEDING B!

ENDOCLI

,LIPPING $etter than ADRENALIN IN4E,TIONe4initive aemostasis, clipping (F6."C) inDection

(7".#C+ relative risk8 1.1#8 B"C 0 1. to 1.3).educed re*leeding, clipping (B."C)8 inDection (1B.6C+

.#B8 B"C 0 .3 to .7B) (igni4icant)


14/31

COMBINATION ENDOSCOIC

INTERVENTION" BETTER RESULT

One meta5anal*!i! of 67 R,T! a&&ing a !e'on& en&o!'opi'

inter8ention 9thermal me'hani'al or in;e'tion< follo%ing an

en&o!'opi' a&renaline in;e'tion re&+'e&:

f+rther $lee&ing rate from 6=(3> to 6/(7> 9OR /(?@ ?> ,I /(3/

to /(7


15/31

SECOND LOO# ENDOCSO!

Meta-anal!sis o4 1 studies8 including 1822 patients8so;ed reduction o4 re*leeding in patients undergoing

second look endoscop! (11.#C v 1".7C+ @ .6B+

B"C 0 .#B to .B6)

Re'ommen&ation:

$ndoscop! and endo-terap! sould *e repeated

;itin 2# ours ;en initial endoscopic treatment ;as

considered su*-optimal 9$e'a+!e of &iffi'+lt a''e!!poor 8i!+ali!ation te'hni'al &iffi'+ltie!< or in

patients in ;om re*leeding is likel! to *e li4e

treatening


16/31

IV $o%&s 'o%%oed $ *n'&s*on o' +*,+-dose I.ed&ces .ec&..en/ $%eed*n,0 need 'o. .e1ea/ed

endosco10 s&.,e.0 $%ood /.ans'&s*on and

2o./a%*/ (coc+.ane 2e/a-ana%s*s) and a%so

cos/ e''ec/*3e4

a/*en/s */+ %oe. .*s5 s/*,2a/a (c%ean $ase0

'%a/ 1*,2en/ed s1o/)0 s/anda.d I /+e.a1

(e4G40 O.a% I once-da*%) *s eno&,+ /o +ea% /+e

&%ce.4

EDICAL T6ERA! AFTER ENDOSCO!

lin $ndosc 212+#",22-223


17/31

EFFICAC! OF CO BINATION OF

O ERA7OLE AND !UNNAN BAI!AO IN

GASTRO INTESTINAL BLEEDING

R,T =2 ga!tro inte!tinal $lee&ing 'a!e! %ere ran&oml*

&i8i&e& into t%o gro+p!(

Inter8ention: Inf+!ion of 3/ mg omeprazole !ol8e& in ?>

!aline 2?/ mL an& oral 6 g of 1+nnan Bai*ao 9STOBLED< ti&(

,ontrol: Inf+!ion of 3/ mg omeprazole &il+te& in ?> !aline

2?/ mL (

Therape+ti' perio& i! 6/ &a*!

Effi'a'* an& a&8er!e effe't %ere 'ompare& $et%een t%o

gro+p!(

Pra'ti'al ,lini'al 0e&i'ine 2/6/ Col 66


18/31

RESULT

Si&e effe't: trial group, one pts ad eadace8 diGGiness8 and nausea+ control group, t;o patients eadace8 and diGGiness8 1 patient

a*domen distention and diarrea. all s!mptoms ;ere vanised once te terap! is stopped.

GROUP NO 0AR-EDEE,TICE

EE,TICE NOT EE,TICE TOTALEE,TICIT19> ,ASE > ,ASE >

TRIAL 36 @3 =2 66 / / 6//

,ONTROL

36 6 37@ 62 2@ 6/ 233 ?7

ompared ;it control group H 5>."


19/31

REBLEEDING FOLLOWING ENDOSCOIC

TERA! ULCER BLEEDING

andomiGed into operative surger! vs repeatendoscopic. Tirt! da! mortalit! and trans4usion

reIuirements ;ere lo; and similar more complications

occurred in surgical patients

=ailure, Angiograp! and simultaneous superselectivecoil transcateter em*olisation using coils and pol!vin!l

alcool8 and gelatine sponge so;ed ig rates o4

tecnical success (BFC)

A retrospective stud!, em*olisation vs surger! so;ed

no di44erence in re*leeding or mortalit!


20/31

11C o4 patients

undergoing

endoscop! 4or upper

'0 *leeding avevariceal *leeding8

maDorit! ave

*leeding

oesopageal varices

(BC)

ESOAGUS 8 GASTRIC VARICES


21/31


22/31

ESOAGEAL VARICES BLEEDING

inDection scleroterap! 4or *leeding oesopageal varices

mortalit! ;as reported at 32C 4or ilds A8 #6C 4or ilds and 7BC 4or ilds

A meta-anal!sis, variceal *and ligation terap! ;as superior

toscleroterap! in terms o4 re*leeding (@ ."28 B"C 0 .37

to .7#)8 all-cause mortalit! (@ .67 0 .#6 to .BF)8 and

deat due to *leeding (@ .#B8 0 .2# to .BB6)

5atients ;it con4irmed oesopageal variceal aemorrage

sould undergo variceal *and ligation.

ecommendation


23/31

GASTRIC VARICES

$ndoscopic o*turation using c!anoacr!late ;as more

e44ective and sa4er tan *and ligation. 0nitial aemostaticrate (de4ined as no *leeding 4or 72 ours a4ter treatment)

;as F7C #"C (pJ.3)8 re*leeding rates ;ere 31C

vs "# C pJ.").

5atients ;it con4irmed gastric variceal aemorrage sould

ave endoscopic terap!8 pre4era*l! ;it c!anoacr!late

inDection.

ecommendation


24/31

MANAGEMENT OF BLEEDING VARICES

NOT CONTROLLED B! ENDOSCO!

A retrospective stud!, overall improvement in survival ;it T05compared ;it oesopageal transection 4or te management o4

variceal aemorrage (mortalit! #2C v 7BC).

@ne T, -gra4t porto-caval sunt more e44ective tan T05 4or

uncontrolled variceal aemorrage8 *ut te proportion o4 patients

treated *! surgical sunting on an emergenc! or urgent *asis ;asmuc lo;er tan tose treated ;it T05 (2C v 37C).

TransDugular intraepatic portos!stemic stent sunting is recommended

as te treatment o4 coice 4or uncontrolled variceal aemorrage.

$@MM$


25/31

ODIFIED SUGIURA ROCEDURE FOR T6E

ANAGE ENT OF VARICEAL BLEEDING"

Vo.os4 Wo.%d J s&.,4 9:;9 2a.


26/31


27/31


28/31

MANAGEMENT OF LOWER GASTROINTESTINAL

BLEEDING

F-F"C *leeding ;ill stop spontaneousl!

ectal eEamination (digital K proctoscop!) is

essential to detect ongoing *leeding and ena*le

diagnosis o4 local anorectal conditions ( 1#C o4

acute '0).

Anal source o4 *leeding,

alloon compression (=ole! cateter)

uturing/ tapling


29/31

LOCALISING 8 MANAGING TE LGIB

,OLONOS,OP1:rgent colonoscop! (;itin eigt ours) vs standard colonoscop!

(;itin #F ours), improved diagnosis ;it urgent colonoscop! .

ource o4 *leeding can *e stopped using adrenaline in4iltration8 termo

coagulation or clipping.

ANGIOGRAP1ail+re &ete'tion of !o+r'e of $lee&ing +!ing 'olono!'op* or

fail+re in 'olono!'op* hemo!ta!i! angiograph* " em$olization

9!+''e! rate =56//><

SURGER1If no angiograph* fa'ilit* or fail+re: !+rger*( If preoperati8e

lo'alization %a! not po!!i$le a !+$total 'ole'tom* %a! a !afe

pro'e&+re %ith a''epta$le f+n'tional re!+lt!


30/31

MEDICAL TREATMENT

OF GI BLEED

0il& tr* me&i'al treatment onl*

0o&erate F Se8ere :

En&o!'opi' inter8ention em$olization or

!+rger*

0e&i'al treatment:

5 PPI

5 Antifri$rinol*ti'

5 1+nnan Bai*ao 9a'ti8ate& throm$o'*te<


31/31

TERIMA#ASI

T$0MALA0

GI Bleeding kuliah

Documents

Transcript of GI Bleeding kuliah