Transcript Endoscopy in acute upper GI haemorrhage

Management of acute upper GI
haemorrhage
Causes
Peptic ulcer
Gastroduodenal erosions
Oesophagitis
Varices
Mallory Weiss tear
Upper GI malignancies
Vascular malformations
Rare
35-50%
8-15%
5-15%
5-10%
15%
1%
5%
5%
Initial resuscitation
Two large bore cannulae and take sample
Normal saline 1-2 lt
fall of pulse/improved BP/adq urine
Plasma expander if still shocked
Blood transfusion
- haematemesis/shock
- Hb <10
Severity of bleed
Current clinical scoring system( Rockall)
for risk of re-bleed or death involves OGD
So definition of mild/mod/severe remains a
matter of clinical judgement
Mild to moderate bleed
 Pulse/BP normal
 General ward
 Hb >10
 Allowed fluid if stable
 Insignificant
comorbidity
 BP/pulse hourly
 Mostly <60 yrs
 Endoscopy next
available list
 Monitor urine volm
 Early discharge
Continued
Excellent prognosis if no
SRH/varices/malignancy
Subsequent management
– May include H.Pylori eradication
– Use of acid suppressing treatment
– Advice concerning NSAIDs
Severe bleed
 Pulse>100
 Preferably HDU
 SBP < 100
 Hrly BP/pulse/ urine
volm
 Hb < 10
 Significant
comorbidity
 Mostly >60 yrs
 Fasted
 Urgent endoscopy
after resuscitation
Endoscopy in acute upper GI
haemorrhage
 Semi-elective in minor and urgent in major bleed
 Only after initial resuscitation
 Best done in endoscopy unit
 But out of hours ,operating theatre with full
resus. Equipment and anaesthetist may be better
option
 Only expert endoscopists
 Consider ET tube to prevent aspiration
Endoscopic finding & subsequent
management
No SRH :
general ward
Varices :
VBL/VScl
Ulcer with SRH : endoscopic haemostasis
1.adrenaline inj
2.heat application
3.mechanical clips
Drug therpy for non-variceal
principally ulcer bleed
Evidence suggests following successful
endoscopic treatment in patient presenting
with major ulcer bleed high dose
omeprazole stabilizes clot and prevents
rebleed
omeprazole 80mg iv stat followed by 8mg
per hour infusion for upto 72 hrs
After endoscopy
Close monitor to identify rebleed
If stable after 6hrs allow light diet ( no data
suggesting prolong fasting necessary)
Repeat endoscopy
– If active rebleed
– If concern re optimal initial therapy (after 1224 hrs)
Surgical intervention
 If endoscopic therapy unsuccessful
 In rebleed it is advisable to repeat endoscopy to
confirm bleed and also try offer one more time of
endoscopic therapy before considering surgery if
it was initially successful
 In massive rebleed sometimes surgical
intervention is needed straightway if initial OGD
was unfavourable
Surgical options
 Duodenal ulcers
– Under running ±ligation of gastroduodenal/rt
gastroepiploic arteries
– Gastrectomy to include the ulcer with Billroth I or II
reconstruction
 Gastric ulcers
– Excised
– Parial gastrectomy
– Under running if elderly with poor condition
Follow up
For ulcer bleeds standard ulcer healing
treatment
In most cases this also involves H.Pylori
eradication
Ulcer associated with NSAID -stop drug or
choose the least damaging one
Re-endoscope GU in 6wks to ensure
healing. Not necessary for DU.
Additional points for variceal
haemorrhage
For no varix on initial endoscopy repeat
3yrly
For grade 1 varix yearly F/U
Primary prophylaxis with propranolol (80160mg) for all grade 2/3 oesophageal
varices
If unsuitable for ppnl, VBL is next option
 ISMN
Acute management of variceal
haemorrhage
Antiobiotic prophylaxis for all patients
ciprofloxacin 500mg BD for a week
VBL is method of choice for OV
VScl if above difficult or unavailable
If endoscopy unavailable vasoconstrictor
therapy or balloon tamponade with
Sengstaken tube while more definitive
therapy is arranged
continued
Pharmacological therapy is with two major
classes of drugs –vasopressin or its
analogue terlipressin (glypressin) and
somatostatin or its analogue octreotide
Terlipressin is given as 2mg iv bolus
followed by 1-2mg every 4-6 hrs for up to
72hrs
OV BLEED
 Controlled – banding eradication programme.
One band /wk. F/U at 3& 6 month and then
yearly
 Uncontrolled –balloon tamponade until further
endoscopic treatment/ TIPSS/surgical
intervention
 Choice of TIPSS or surgical intervention such as
oesophageal transection depends on centre’s
preference
GV bleed
If IGV initial sclerotherapy with butyl-
cyanoacrylate
If unsuccessful balloon tamponade prior to
more definitive treatment
Secondary prophylaxis of variceal
haemorrhage
banding eradication programme
TIPSS
Portocaval shunt surgery
Thank you