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Acute UGI Bleeding

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Acute UGI Bleeding Stephen Matarazzo MD Hillmont G.I. p.c. Acute UGI Bleeding Common cause of hospitalization Appropriate resuscitation effects outcome Endoscopic ... – PowerPoint PPT presentation

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Title: Acute UGI Bleeding


1
Acute UGI Bleeding
  • Stephen Matarazzo MD
  • Hillmont G.I. p.c.

2
Acute UGI Bleeding
  • Common cause of hospitalization
  • Appropriate resuscitation effects outcome
  • Endoscopic intervention is highly successful
  • Management decisions based on Endoscopic findings

3
Acute UGI Bleeding
  • Presentation
  • Hematemesis
  • Vomiting BRB or coffee ground material
  • Melena
  • Black tarry stool
  • Hematochezia
  • Bright red or maroon rectal discharge
  • 11 are UGI Bleeding
  • NG Lavage
  • Positive result
  • Blood or coffee ground material
  • Negative Result
  • Bile with no blood
  • Bleeding stopped
  • Bleeding beyond closed pylorus

4
Acute UGI Bleeding
  • Approach to the patient
  • Assess hemodynamic stability
  • Resuscitation
  • Diagnostic studies
  • Treatment

5
Acute UGI Bleeding
  • Hemodynamic Instability
  • Shock
  • Orthostatic hypotension
  • Profuse active bleeding
  • Decrease in HCT 10
  • Anticipated transfusion gt 2 units RBCs

6
Acute UGI Bleeding
  • Resuscitation
  • Large bore I.V.
  • NSS
  • Blood Transfusions
  • Correct coagulopathy INR gt 1.5
  • FFP
  • Vitamin K
  • Correct thrombocytopenia lt 50,000
  • NG Lavage to remove blood clots
  • Protect airway if necessary with elective
    intubation
  • PPI
  • Octreotide
  • GI and Surgical Consults

7
Acute UGI Bleeding
  • Diagnostic Studies
  • Endoscopy
  • Tagged red cell bleeding scan
  • Angiography

8
Acute UGI Bleeding
  • Differential Diagnosis
  • PUD
  • H. Pylori
  • NSAIDS
  • Z.E.
  • Stress
  • Idiopathic
  • ESO / gastric varices
  • Portal gastropathy
  • Mallory Weiss tear
  • Esophagitis
  • Peptic
  • Pill
  • Infectious
  • Gastric Malignancy
  • Adeno Ca
  • Lymphoma
  • AVM
  • Dieulafoy

9
Acute UGI Bleeding
  • Endoscopy
  • Gold standard for Dx
  • Most sensitive study
  • Therapeutic potential is major asset
  • Decrease re-bleeding
  • Fewer blood transfusions
  • Decreases LOS
  • Reduces mortality
  • Reduces surgical procedure
  • Pre-Endoscopy Emycin

10
Acute UGI Bleeding
  • Risks of Endoscopy
  • Aspiration
  • Hypoventilation
  • Perforation
  • Co-Morbid Events
  • AMI
  • COPD

11
Acute UGI Bleeding
  • Risk of Stratification of PUD
  • Major Stigmata
  • Bleeding visible vessel re-bleeds 80-90
  • Non-bleeding visible vessel re-bleeds 45-50
  • Adherent clot re-bleeds 25-30
  • Minor Stigmata
  • Oozing without visible vessel re-bleeds 10-15
  • Flat spot re-bleeds 7-10
  • Clean ulcer base re-bleeds 3-5

12
Acute UGI Bleeding
  • Risk Stratification of PUD
  • Clean ulcer base
  • Ok to discharge after Endoscopy
  • Re-admission rate 1
  • Exceptions
  • Severe Anemia
  • Serious co-morbid diseases
  • Anticoagulation therapy
  • Coagulopathy
  • 46 of patients discharge in ER or 12-24hrs.

13
Acute UGI Bleeding
  • Endoscopic treatment of PUD
  • Epinephrine injection initial Rx only
  • Heater probe
  • Bipolar electro-coagulation
  • Endo clips 15-20 of ulcers cannot be clipped
  • Use double channel scope
  • Re-bleeding occurs 15-20 of non-variceal lesions
  • Re-bleeding usually occurs in 24-48 hrs.
  • Re-scope successful 50

14
Acute UGI Bleeding
  • PPI Treatment
  • Decreases re-bleeding in PUD
  • Decreases blood transfusions and LOS
  • High risk ulcers use PPI infusion
  • 80 mg IV bolus
  • 8 mg 1 hr. infusion
  • Switch to PPI BID orally in 72 hrs.
  • Positive H. pylori treat as outpatient

15
Variceal Bleeding
  • Prediction of patients at risk
  • Prophylaxis against first bleed
  • Treatment of active bleeding
  • Prevention of re-bleeding

16
Variceal Bleeding
  • 30-40 mortality
  • Directly related to portal hypertension
  • 70 risk of re-bleeding in 1 year
  • Occurs in 25-40 of patients with cirrhosis most
    common etiology
  • Portal pressure flow X resistance
  • Normal portal pressure 5mm Hg

17
Variceal Bleeding
  • Treatment of Active Bleeding
  • Current Options
  • Octreotide
  • Endoscopy
  • Surgery
  • TIPS

18
Variceal Bleeding
  • Octreotide
  • Splanchnic vasoconstriction by inhibiting
    glucagon
  • Decrease portal flow
  • Rapid onset of action
  • Magic number 12mm Hg portal pressure
  • Absent side-effects
  • Initial hemostasis gt 75
  • 50ug bolus followed by 50ug/hr x5 days
  • Endoscopy
  • Endoscopic Variceal Ligation EVL
  • Endoscopic Variceal Sclerosis EVS
  • Current Recommendations
  • Octreotide plus EVL
  • Antibiotics improve survival in cirrhotics with
    hemorrhage

19
Prevention of Variceal Re-bleeding
  • 70 re-bleeding rate after index bleed
  • Risk of re-bleeding greatest immediately after
    cessation of index bleeding
  • 70 of untreated patients die in 1 year
  • EVL treatment of choice
  • EVS less successful with higher morbidity and
    mortality
  • Requires at least 4-6 bandings
  • Medical treatment
  • Propanolol
  • Decreases portal pressure
  • Titrate dose to decrease heart rate by 25
  • Reduces risk of re-bleeding by 40
  • Reduces mortality by 20
  • Propanolol plus oral nitrates
  • Increase side effects
  • Not routinely used unless you fail beta blocker
    Rx

20
Transjugular Intrahepatic Porto Systemic Shunts
  • Functions similar to surgical shunts
  • No surgery, done transjugular
  • Re-bleed rate 20 in first year
  • Major drawback is hepatic encephrlopathy
  • Shunt stenosis common
  • Very expensive
  • Best used as salvage procedure
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