MANAGEMENT OF UPPER GASTROINTESTINAL

BLEEDINGDR. TALHA-SAMI-UL-

HAQUEBATCH- IM 7-D

BIRDEM General Hospital

Basic principles of Management:

• Careful history and physical examinations.• Gain IV access with large bore cannula• Full blood count & cross matching• Monitoring Blood pressure, pulse, urine output• IV colloids or crystalloid • Blood transfusion• ENDOSCOPY for diagnosis & treatment• PUD- IV PPI• Bleeding recurs: surgery

When the patient is first seen, a quick examination must be made to answer the three following critical questions :

a) Is there evidence of airway obstruction ?

b) Is there evidence of active bleeding ?

c) Is there evidence of hypovolemia ?

Measure pulse and blood pressure

If hemodynamically stable• Obtain full history• Carry out full examination• Proceed with investigation

If hemodynamically unstable• Resuscitate• If rapid responsive, then proceed as

for stable patient• If transient or non-responsive

prompt investigation to locate the source of bleeding and to established ideal treatment

Management:

• Intravenous access– at least 1 large bore

cannula• Initial clinical assessment

– Circulatory status– Evidence of liver disease– Identify comorbidity

Continued…..• Basic investigations

– Full blood count– Blood Urea & electrolyte– Liver function test– Prothrombin time– Cross-matching

Resuscitation• Fluid replacement

Crystalloid fluid Colloid fluid

– Blood transfusion• Monitor CVP

Fluid Resuscitation [cont.]• Can start with 500 ml NaCl 0.9% over the first

15 min, followed by 500 ml colloid (eg. Gelatin) over the next 15 min

• If BP fails to come up or falls infusion rate must be increased accordingly

• If patient becomes stable ( BP > 100 mmHg, pulse < 100/min ) rapid infusion must be stopped, and maintenance fluids only given.

Indication for blood transfusion

Shock (Pallor, cold sweaty skin, systolic BP <100mmHg)

Hb <10 gm% in patients with recent or active bleeding.

Patient with coagulopathy, low platelet count should be transfused with fresh frozen plasma and platelets respectively.

• Oxygen therapy– Should be given to all patients in

shock.• IV PPI: Omeprazole

ENDOSCOPY• Ideally, endoscopy should be performed

within 24 hours.• Endoscopy can be used both in

diagnosis and therapy.

Indications of endoscopic therapy

• Actively bleeding lesion• Non-bleeding visible vessels• Ulcers with adherent clot

Specific treatment of upper GI bleeding

• Bleeding can be 2 type– 1. non- variceal bleeding– 2. variceal bleeding

Non-Variceal upper gastrointestinal

haemorrhage

Endoscopic therapy• Adrenaline(1:10,000) or sclerosant

injection• Heat probes• application of metallic clips• Bipolar diathermy• Laser photocoagulation using the Nd-

YAG laser

• Constant probe pressure tamponade

• Argon plasma coagulator

• Rubber band ligation

The preference is for dual therapy, e.g. injection of adrenaline with thermal coagulation.

Repeated endoscopy• endoscopy and endo-therapy should be

repeated within 24 hours when initial endoscopic treatment was considered sub-optimal (because of difficult access, poor visualisation,technical difficulties) or in patients in whom rebleeding is likely to be life threatening.

Medication

• Injectable proton pump inhibitor / Ranitidine

• oral PPI in high doses.• NSAIDs should be stooped and future

use should be restricted.

Endoscopic hemostasis vs medical therapy

SIGNSRISK OF RECURRENT

BLEEDING WITH MEDICAL THERAPY

ALONE

RISK OF RECURRENT BLEEDING WITH

ENDOSCOPIC HEMOSTASIS

Active arterial bleeding (spurting) 85%–95% 10%–20%

Nonbleeding visible vessel 50% 5%–−10%

Nonbleeding adherent clot 35% < 5%

Ulcer oozing 10%–25% < 5%Flat spots 7% Not indicated

Clean-based ulcer 3% Not indicated

Surgical Treatment of Acute Peptic Ulcer Disease ( PUD )

Indications for Surgery• Perforation• Pyloric obstruction• Continued bleeding that fails to

respond to endoscopic measures• Recurrent bleeding• Patients > 60 years• Cardiovascular disease with

predictive poor response to hypotension

• Aim of surgery :

- Stops bleeding- Prevent recurrent bleeding

Surgical Treatment of Acute Peptic Ulcer Disease

Choice of operation for duodenal ulcer

– Billroth II gastrectomy– Truncal vagotomy and

pyloroplasty with suture ligation of the bleeding ulcer• Selective vagotomy• Highly selective vagotomy

– Truncal vagotomy and antrectomy with resection or suture ligation of the bleeding ulcer

Choice of operation for gastric ulcer– Billroth I gastrectomy– Billroth II gastrectomy– Truncal vagotomy and pyloroplasty

with a wedge resection of the ulcer,

Surgical Treatment of Acute Peptic Ulcer Disease

All patients should be given H. pylori eradication therapy post operatively

Complications

• The complications of UGIB are self-evident. Other complications can arise from treatments administered. For example:

• Endoscopy:– Aspiration pneumonia– Perforation– ventricular arrhythmias during endoscopy – Complications from coagulation, laser

treatments• Surgery:

– Ileus– Sepsis– Wound problems

Prognosis

• A score of less than 3 using the Rockall system above is associated with an excellent prognosis

• whereas a score of 8 or above is associated with high mortality

• Mortality is about 7%.

Rockall risk scoring system

Prognosis is worse with the following:

• Increasing age• Co-morbidity• Liver disease• Shock at presentation• Continued bleeding after presentation• Haematemesis• Haematochezia• Elevated blood urea

Prevention

• The most important factor to consider is treatment for H. pylori infection. This should be completed as an outpatient.

Variceal upper gastrointestinal

haemorrhage

• The mortality of a variceal bleed is approximately 50%

• 70% patients will have a rebleed• Survival is dependent on the

degree of hepatic impairment

Variceal bleeding• Treatment options are:

– Endoscopic ligation– Sclerotherapy– Transjugular intrahepatic porto-

systemic shunting (TIPSS)– Surgical shunting

BALOON TAMPONADE• Temporary tamponade can be achieved

with Sengstaken-Blackmore tube– Should be considered as a salvage

procedure– Unfortunately 50% patients rebleed

within 24 hours of removal of tamponade

BAND LIGATION & SCLEROTHERAPY• Emergency endoscopic therapy

includes:– Endoscopic banding of varices– Intravariceal or paravariceal

sclerotherapy– Sclerosants include ethanolamine and

sodium tetradecyl sulphate

Transjugular intrahepatic porto-systemic shunting (TIPSS)• If endoscopic methods fail.• Recommended as the treatment of choice

for uncontrolled variceal haemorrhage.• Reduces risk of rebleeding but increases risk of

encephalopathy• Mortality of the procedure ~1%

Porto-systemic shunt operation• Only done if

– Unsuccessful endoscopic treatment– Good liver function

• Can lead to:– Post operative liver failure– Hepatic encephalopathy

• Emergency shunting associated with 20% operative mortality.

PROGNOSIS• Recurrence within 2 year

– 7% for small varies– 30% for large varies

• Poor liver function – 45%• Mortality – 15%

PREVENTIONPrimary preventionBleeding from varices more likely if poor

hepatic function or large varices• Primary prevention of bleeding is

possible with β blockers– Reduces risk of haemorrhage by 40-

50%• Band ligation may also be consideredSclerotherapy or shunting is ineffective

Secondary prevention• 70% of patients with an variceal

haemorrhage will rebleed• The following have been shown to be

effective in the prevention of rebleeding– Beta-blockers possibly combined with

isosorbide mononitrate– Endoscopic ligation– Sclerotherapy– TIPSS– Surgical shunting

THANK YOU