GIT GIB 2012 ASGE ACG 2012 UPDATES.
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Transcript of GIT GIB 2012 ASGE ACG 2012 UPDATES.
LOGO
Gastrointestinal bleeding: GIB(UGIB,LGIB)
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UGIB: bleeding proximal to the ligament of Treitz
UGIB requiring hospitalization is *5 more common than
LGIB& has a mortality rate of up to 10%.
GIB
NVUGIBA
LGIB2
VUGIB3B
UGIB31
NVUGIB:Causes
GERD/Erosive gastritis 25%2
AVM (HHT),GAVE4
Dieulafoy lesions33
PUD 50%31
Tumors(benign/malignan)6
Bleeding tendencies8
Aortoduodenalfistula37
MW eso tears 15%35
NVUGIB:Causes
Hemosuccus pancreaticus10
hemobilia39
VUGIB:Causes
Fundal varices2
Non-PHT – related
bleeding PDU (50%)4
Portalhypertensive gastropathy33
Bleeding eso varies31
LGIB:Causes
SRUS2
Bleeding diverticuli4
IBD33
Anal pathologies.31
Radiation colitis6
Ischemic colitis8
CD colitis37
CR Adenoma polyps or CRC.35
The Overall Management of UGIB:RESUSCITATION ER:
Use of Blood Components2
NGT4
Correction of Coagulopathy33
31
PREENDOSCOPY PPI6
PREENDOSCOPY ANTIFIBRINOLTYICS8
PREENDOSCOPY Prokinetics37
Risk stratification scoring35
Initial Assessment &Fluid Resuscitation
The Overall Management of UGIB:RESUSCITATION ER:
Optimal time to endoscope10
Test & treat H Pylori12
Postendoscopy PPI311
39
14
NSAIDs issues16
On discharge315
Tailor PPI dose to underlying cause313
PREENDOSCOPY: SMST/OCTT
Postendoscopy Gen in-hosp management
Initial Assessment &Fluid Resuscitation
2 IV line
Blood group/cross
match
with pulse
oximetry,cardiac
monitoring,
automated BP
readings,close
monitoring of UO
&ideally, CVP
ERABC(shock/airway
compromise)
IVF
Crystalloids
until blood
ready
Colloids or
albumen
preferred for
cirrhotics.
Restoration of circulating volume takes
priority over endoscopy.
Use of Blood Components
regionalO2 delivery
ImproveGlobalO2 delivery
Improve hemostasis
BTSF if Hb>8*2 rebleedTSF>10
pints needs plts , FRP,Ca
Blood benefits
(43% require it
Target Hb 7-8gms
If no Continuous bleeding or
CVD).
Coagulopathy correction
Coagulation screen
Correction: FFP,PC
Should not delay urgerny OGD
Causes
•Multifactorial•Marker of disease severity
Associated with
•Increased mortalty•Rebleeding•INR <1.8 Associated with lower mortality& fewer MI
6.2 coagulopathy even without cirrhosis
Endoscopic hemostasis can be done
safely if INR up to 2.5
NGT: Routine use Pre OGD controversial
BENEFITS
(1)presence fresh red blood in the NGT aspirate found to be an independent predictor
of adverse outcome & predictor of high-risk lesions in patients who are
hemodynamically stable without evidence of hematemesis.
Ptognostic index(1)
Confirm UGI source(85%)
Remove blood & clots
To clear field for OGD
?ENSURE HEMOSTSIS
Monitor continuous loss
?collect it to use
It for lesion injection?
Risk stratification scoring:
low risk/high risk:
Early hospital dischare
Mortality
Need for endohemostasis
Rebleeding
Using:
Clinical data
Lab date
OGD findings
Risk stratification: other than
scoring systems
Age>60 Inc mortality
HD Shock >*3 mortality & more need
For endohemostasis
Hematemesis
*2 mortalty,rebleed & endohemostasis
Risky states
Risk stratification: other than
scoring systems
Inpatient at time of bleed *3 mortality
Compared to new admisions
High BU increase need for
Endohemostasis
hematochezia
*2 mortalty,rebleed & endohemostasis
Risky states
Risk stratification: other than
scoring systems
A large ulcer size (>2 cm )
Rebleed /mortality
specific locations
(lesser wall curve or on the posterior
duodenal wall),rebleed,mortality,surgery
Endo stigma Forrest Class IA, IB, IIA& IIB
are high risk, Class IIC & III are low-risk
Risky Ulcer
PREENDOSCOPY:PPI either oral or
IV (better)
reduceHigh risk lesions
at OGDENDO Interventions
PH>6
Optimal plat agg clot formation
No effect on mortality, syrgery need or rebleeding
Preendoscopy PPI: Most suitable for
Pre OGD PPI
IV
preferred
Sp if vomiting
HR lesion?:
Hematemes or
bloody NGT
NVUGIB
OGD delayed or not
available for 24 hours
PREENDOSCOPY Prokinetics:
IV erythro or metochlorpromide
PK
REDUCE repeat endoscopyErhthro is motilin agonist
No improve other clinical
endpoints
IV erythro most suitable for patients
Most likely to have blood in
stomach at initial OGD.
Plasil if IV eryhthro
No available
IV eryhthro
Need PRIOR ECG
Pre-endoscopic antifibrinolytics
1
At present there is
insufficient evidence
to recommend TXA
in the treatment of
NVUGIB
2
large-scale RCT will be
required to address this
question.
Pre-endoscopic SST,OCT
SST,OCT
not recommended in
the routine
management of
patients with acute
NVUGIB.(for VGIB)
?Blee du not
controllable while
waiting OGD or
surgery, or if surgery
is contraindicated
Optimal time to endoscope
WITHIN 25 Hoursafter initial stabilization
<24 if very HR patient with high blatchford scores after initial stabilization
1 2 3
Optimal time to endoscope:
benefits
Improvement in other
clin endponits
risk stratification :
early discharge of
those patients with
low-risk
early &targeted
endoscopic
hemostasis in higher-
risk patients who are
actively bleeding or
with high-risk
stigmata of bleeding.
Targeted endoscopic hemostasis(dual endoscopic therapy): NS/Adrenaline inj+
one of other modalities(APC,Clip,band,thermal)
Post endoscopy PPI
For high-risk stigmata
who have
received successful OGD therapy.
reduced Mortality
In active bleeders& NBVV
Reduce
rebleedNeed for
surgery
Postendoscopy Test&treat H Pylori
Eradication Reduces rebleed.
Tested to confirmeradication
Tested for HP
All bleeding PUSHOULD
IncreasedFalse –ve testing
Post endoscopy general in-hosp
management.
High risk lesions
Re-bleeding
If was on asp/NSAIDs
Low risk
Intervention radiology/SurgeyAfter 2 OGDs
Re OGD interven
Evaluate risk/benefir ratio
Reuse within 5 days.
Fed within 24 hs & discharged on
Oral PPI within1-2 days.
72 hour monitoring for rebleeding
subsequent pharma management.
After discharge:once-daily oral PPI dose (in the case of bleeding
esophagitis, twice-a-day dosing), the duration of which should be
determined by the underlying etiology of the bleeding.
ASGE Guidelines 2012
We recommend that patients with UGIB be adequately
resuscitated before endoscopy.
We recommend antisecretory therapy with PPIs for PUD
Bleeding or in those with suspected PUD bleeding awaiting
endoscopy.
We suggest prokinetic agents in patients with a high probability
of having fresh blood or a clot in the stomach when undergoing
endoscopy.
We recommend endoscopy to diagnose etiology of acute UGIB.
The timing of endoscopy should depend on clinical factors. Urgent
endoscopy (within 24 hours of presen-tion) is recommended for
patients with a history of malignancy or cirrhosis, presentation
with hematemesis&signs of hypovolemia including hypotension,
tachycardia&shock, &Hb 8 g/dL.
ASGE Guidelines 2012
We recommend endoscopic therapy for PU with high-risk
stigmata (active spurting, visible vessel).
The management of PUD with an adherent clot is controversial
&recommended endoscopic treatments include inj (sclerosants,
thrombin, fibrin, or cyanoacrylate glue), cautery, & mechanical
therapies.
We recommend against epinephrine inj alone for PU bleeding. If
epinephrine inj is performed, it should be combined with a second
endoscopic treatment modality (eg, cautery or clips).
We recommend low-risk lesions be considered for OP TRT.
We recommend against routine second-look endoscopy in patients
who have received adequate endoscopic therapy.
We recommend repeat OGD for patients with evidence of
recurrent bleeding.
Summary Adequate resuscitation.
Risk stratification .
Early endoscopy to enable further risk stratification.
Application of endotherapy to high-risk lesions to achieve
hemostasis &downgrade stigmata.
Injection of epinephrine alone is not optimal when treating all
high-risk lesions which needs in addition one of the other
endoscopic hemostatic modalities as APC or cliping.
All endoscopic hemostasis should be complemented by a 72-hour
infusion of high dose PPI.
All patients should be tested for H pylori & treated if necessary,
Secondary prophylaxis should be considered for appropriate
patients ie PPI covering asp/NSAIDs requiring patients.
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