I/V access with large bore cannula Basic investigations-blood count,routine

biochemistry,cross match blood Hourly measurements of Bp,pulse and urine

output.. i/v colloids or crystalloids –pt with hypotension

and tachycarda Transfuse with blood Endoscopy for diagnosis & Rx Iv PPI therapy for bleeding peptic ulcer

0.9 % saline Vasopressor(terlipressin) Prophylactic antibiotics Emegency endoscope Variceal band ligation Proton pump inhibitor Phosp[hate enema/lactulose enema

ENDOSCOPIC THERAPY with * Bipolar electro coagulation * Heater probe

* Injection therapy - Absolute alcohol - 1:10000 epinephrine - Clips

High dose constant infusion of iv PPI E.g. Omeprazole – 80 mg bolus & 8 mg/hr infusion

Eradication of H.Pylori infection

Discontinue NSAIDS & acids

If NSAIDS have to be used, use along with PPI

Use selective COX-2 inhibitors like Coxib or traditional NSAIDS + Coxib

Coxib + PPI : further significant decrease in ulcers and recurrent bleeding.

Mostly bleeding stops spontaneously ( Recurrence is only 0-7 % )

Endoscopic therapy is only for actively bleeding Mallory weiss tear.

Angiographic therapy with embolization & operative therapy with over sewing of tear can be done ( but only required rarely )

I. Vasoconstrictors (somatostatin, octreotide, terlipressin) iv terlipressin infusion at 2 mg 6th hourly, generalized vasoconstriction leading to decreased blood flow to venous system.

II. Baloon tamponade – Triple lumen or Four lumen tube with esophageal and gastric balloons. (Always intubate the patient prior to this procedure to prevent aspiration)

III. Endoscopic variceal liagation[Band ligation]

IV. SclerotherapyV. Antibiotic therapy

Quinolones – for patients with cirrhosis decreases the bacterial infection & mortality.

Non selective Beta blockers – Propranalol, Nadolol

For recurrent esophageal bleeding – c/c therapy with beta blocker + endoscopic ligation

If not subsided with medical therapy, Go for:

INVASIVE THERAPY:

TIPss (Transjugular intrahepatic portosystemic shunt)

A/E : Hep encephalopathy, shunt stenosis in 1 yr

Vascular ectasias are treated by endoscopic therapy

Estrogen / progesterone components are used in vascular ectasias

avoiding the long-term use of alcohol, NSAIDs, coffee, high-fat foods and drugs

Reducing stress through relaxation techniques

Antacids, H2 blockers, PPIs

Triple therapy: 2 antibiotics + a PPI is commonly used to treat H. Pylori related gastritis

Thank you….