Transcript Approach to Upper Gastrointestinal Tract Hemorrhage

Approach to Upper Gastrointestinal Tract
Hemorrhage
Objectives
• Outline resuscitation and treatment strategies for acute upper Gl tract
hemorrhage and hemorrhagic shock.
• Be familiar with the common causes of upper Gl tract hemorrhage and
their therapies.
• Know the adverse prognostic factors associated with continued
bleeding and increased mortality.
DEFINITION
• Upper GI bleeding is defined as bleeding from a source
proximal to th Ligament of Treitz
Causes of Upper Gl Hemorrhage
A.
B.
Nonvariceal bleeding
(80%)
Portal hypertensive bleeding (20%)
• Up to 30% multiple etiologies.
• a proportion of cases have no endoscopically discernible
cause, these cases are associated with an excellent outcome.
Nonvariceal bleeding (80%)
1.
Peptic ulcer disease 30-50%
2.
Mallory-Weiss tears 15-20%
3.
Gastritis or duodenitis 10-15%
4.
Esophagitis
5-10%
5.
A.V. malformations
5%
6.
Tumors
2%
7.
Other
5%
Portal hypertensive bleeding (20%):
1.
Gastroesophageal varices
>90%
2.
Hypertensive portal gastropathy <5%
3.
Isolated gastric varices
Rare
Peptic ulcer disease
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Ulcer of the mucosa in / adjacent to an acid bearing area.
Gastric ulcer - usually lesser curve.
Duodenal ulcer – usually first part (cap).
DU: GU = 4:1 DU, male: female = 4:1
Theories of ulcer disease pathogenesis
1.
2.
3.
4.
5.
No acid, no ulcer (mostly)
Smoking
Stress
Non-steroidal drugs (NSAID’s)
DU - Zollinger-Ellison syndrome: multiple ulceration,unusual
site, not respond to medication, hypergastinemia-gastrinoma.
6. Helicobacter pylori
Presentation of bleeding peptic ulcer
• Known case of peptic ulcer disease,-endoscopy, noncompliance
• History of dyspepsia.
• Smoking
• NSAIDS
• Cardinal features:
1. Epigastric pain-pointing
2. Night pain
3. Hunger pain
• Characterized by remission and relapse course.
Treatment of peptic ulcer disease
1. H. Pylori eradication (Triple therapy)
(PPI + clarithromycin + amoxicillin)
2. H2 blocker –cimitidine, rantidine
3. PPI-omiprazole, lansoprazole
4. Stop smoking
5. Avoid aspirin +NSAID use
6. (Surgery)
Mallory-Weiss syndrome
• refers to bleeding from tears (a Mallory-Weiss tear) in the mucosa at
the junction of the stomach and esophagus, usually caused by severe
retching, coughing, or vomiting.
Mallory-Weiss syndrome
Mechanism
 Forceful contraction of abdominal wall against an unrelaxed
cardia, resulting in mucosal laceration of proximal cardia as a
result of increase in intragastric pressure.
Causes: Alcoholism
The bleeding is self-limiting, mild, and amenable to supportive
care and endoscopic management.
Stress gastritis:
• multiple superficial erosions of entire stomach, most
commonly in the body.
decrease
splanchnic
mucosal
blood flow
altered
gastric
luminal
acidity
Stress
Gastritis
Stress gastritis Seen in…
1.
2.
3.
4.
5.
6.
7.
NSAID users
Sepsis
Respiratory failure
Hemodynamic instability
Head injuries (Cushing ulcer)
Burn injuries (Curling ulcer)
Multiple trauma
Esophagitis:
• Mucosal erosions frequently resulting from GERD ,
infections, or medications.
• most frequently present with occult bleeding,
• Treatment: correction or avoidance of underlying causes.
Esophageal variceal bleeding:
• Engorged veins of the GE region, which may ulcerate and
lead to massive hemorrhage; related to portal hypertension
and cirrhosis.
• The most common cause of upper Gl tract hemorrhage in a
patient with cirrhosis and portal hypertension which carries
a high rate of mortality and risk of rebleeding.?PUD.
• The most common cause of pediatric significant upper Gl
tract hemorrhage is variceal bleeding from extrahepatic
portal venous obstruction.
Dieulafoy's erosion:
• Infrequent, may be missed.
• aberrant submucosal artery located in the stomach.
• bleeding is frequently significant and requires prompt diagnosis
by endoscopy, followed by endoscopic or operative therapy.
Arteriovenous (AV) malformation:
• A small mucosal lesion located along the GI tract.
• Bleeding is usually abrupt, but usually slow and self-limiting.
The treatment of patients with suspected upper Gl tract
hemorrhage begins with an initial assessment to determine if
the bleeding is acute or occult.
Acute bleeding is recognized by a history of:
1. Hematemesis ,
2. Coffee -ground emesis,
3. Melena ,
4. Bleeding per rectum(hematochezia),
occult bleeding may present with signs and symptoms associated
with anemia and no clear history of blood loss.
Hematemesis: Vomiting of blood.
1. Red – Fresh blood
2. Coffee ground –
3. altered blood (acid haematin)
 Differentiate from:
Haemoptysis
Bleeding from Pharynx , nasal passage
Haematochezia
 10 % of upper GI bleed
 Acute massive bleeding
 Decrease transit time
 Melaena: Black tarry offensive stools.
1) Gastric acid
2) Digestive enzymes
3) Luminal bacteria
 It is a Feature of UGI bleeding
 Can be seen in LGI bleeding.
 At least 14 hrs in GIT
 Non GI bleed – swallowing
 Oral Ferous mimics melaena
 Presents with features of chronic blood loss
 Suspected in pt with iron deficiency anaemia
TEST FOR OCCULT BLOOD
(+)
COLONOSCOPY
(--)
ENDOSCOPY
(--)
ENTEROSCOPY , CAPSULE ENDOSCOPY
Management of acute upper Gl tract hemorrhage
Assessment of severity of blood loss.
(1) Resuscitation, of hypovolemic shock of blood loss.
(2) Diagnosis,
(3) Treatment.
Initial assessment & resuscitation
History and physical examination
Localization of site of bleeding
Institution of specific therapy
• Assess A, B, C
• Severity of hemorrhage:
• 4 grade of hypovolaemic shock of blood loss
• According to parameter:
1.
PR,
2.
BP,
3.
RR,
4.
UOP,
5.
CONSCIOUSNESS
• Two large bore IV lines-Ringer lactate
• Initial lab assessment1. Hematocrit & Hb
2. Type & cross match
3. Coagulation profile, platelet count
4. Serum electrolytes,
5. LFT
• close monitoring of patient response: parameter:
• Urine output-foley catheter.
• Oxygen supply.
• Transfusion of packed red cells
• Coagulation defects corrected by FFP & platelets
1. Nasogastric tube insertion following resuscitation to
determine whether bleeding is active or not, upper or
lower GIT bleeding.
2. gastric irrigation with room-temperature water or saline
until gastric aspirates are clear.
History and examination
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Characteristics of bleeding
Time of onset, volume and frequency
Associated symptoms: syncope, vomiting, dyspepsia,
Medications: NSAIDS, anticoagulant:Warfarin, LMW heparin
Past medical historypeptic ulcer,
liver disease,
heart disease
Bleeding disorder
Physical examination
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Examination of nose & oropharynx
Stigmata of chronic liver disease
abdomen examination:
inspection: distention , dilated veins, swelling, visible peristalsis
palpation: tenderness, hepatosplenomegaly,secondary metastasis, mass
percussion: shifting dullness ,transmitted thrill, hepatosplenomegaly,
auscultation: absent bowel sound, venous hum
Localisation of site of bleeding by endoscopy.
1.
2.
3.
4.
5.
establishes a diagnosis in more than 90% .
assesses the current activity of bleeding.
aids in directing therapy.
predicts the risk of rebleeding.
allows for endoscopic therapy.
FI
Active bleeding
FII a
Ulcer with visible vessel or pigmented protuberance (40
– 80%)
FII b
Ulcer with an adherent clot (20%)
FII c
Ulcer with a pigmented spot (10%)
FIII
Ulcer with clean base (rarely bleeds)
Institution of specific therapy
1. Pharmacological
2. Endoscopic
3. Surgical modalities
Pharmacological
• Antisecretory agents such as:
1. Histamine-2 blockers
2. Proton pump inhibitors
• Testing for Helicobacter pylori should be performed and
if this organism is present, treatment should be initiated.
Eradication of H pylori.
• Any NSAID use should be discontinued.
• Stop smoking,alcoholism.
Therapeutic endoscopy
Endoscopic hemostasis can be achieved through:
1. injection therapy.
2. sclerotherapy.
3. thermotherapy.
4. electrocoagulation.
5. cliping.
Absolute Indications of surgery
1. Hemodynamic instability despite vigorous resuscitation (>6
units transfusion)
2. Failure of endoscopic techniques to arrest hemorrhage
3. Recurrent hemorrhage after initial stabilization (with up to two
attempts at obtaining endoscopic hemostasis)
4. Shock associated with recurrent hemorrhage
5. Continued slow bleeding with a transfusion requirement
exceeding 3 units/day
Relative Indications of surgery
1.
2.
3.
4.
5.
6.
Rare blood type or difficult cross match
Refusal to transfusion
Shock at presentation
Advanced age
Severe comorbid diseases
Bleeding chronic gastric ulcer where malignancy is a
possibility
• For a bleeding gastric ulcer where there is a concern for
possible malignancy, either gastrectomy or excision of the
ulcer is indicated.
• For other types of ulcers, the vessel may require ligation
followed by a vagotomy procedure and pyloroplasty.
• If the bleeding source cannot be identified but active
bleeding is clearly occurring, patients may undergo
selective angiography.
• This treatment strategy can diagnose and treat bleeding in
roughly 70% of patients;
• arterial embolization with gel foam, metal coil springs, or a
clot can be used to control bleeding.
• arterial vasopressin can stop in some patients with peptic
ulcer disease.
prognosis of Acute upper Gl tract Bleeding
• Acute upper Gl tract Bleeding tends to be:
• -self-limited in 80% .
• -Continuing or recurrent in 20% and is the major contributor
to mortality.
• Overall mortality is 10% .
mortality with acute upper Gl tract bleeding
Patient mortality increases with:
1. Rebleeding ,
2. Increased age,
3. Patients who develop bleeding in the hospital.
• A number of clinical predictors and endoscopic stigmata are
associated with the increased risk of recurrent bleeding.
factors associated with increased rebleeding and
mortality
CLINICAL:
1. Shock on admission
2. Prior history of bleeding requiring transfusion ,
3. Admission hemoglobin <8 g/dL
4. Transfusion requirement >5 U of packed red blood cells
5. Continued bleeding noted in nasogastric aspirate
6. Age >60 y (increased mortality but no increase in rebleeding)
factors associated with increased rebleeding and
mortality
ENDOSCOPIC:
1. Visible vessel in ulcer base (50% rebleeding risk).
2. Oozing of bright blood from ulcer base.
3. Adherent clot at ulcer base.
4. Location of ulcer (worse prognosis when located near large
arteries, eg,posterior duodenal bulb or lesser curve of
stomach)
Management of bleeding oesophageal varices
1.
2.
3.
4.
5.
6.
7.
8.
A.
B.
C.
Blood transfusion
Correct coagulopathy
Oesophageal balloon tamponade (Sengstaken–Blakemoretube)
Drug therapy (vasopressin/octreotide)
Endoscopic sclerotherapy or banding
Assess portal vein patency (Doppler ultrasound or CT)
Transjugular intrahepatic portosystemic stent shunts (TIPSS)
Surgery:
Portosystemic shunts
Oesophageal transection
Splenectomy and gastric devascularisation
case
• A 38-year-old man presents at the emergency
department with tarry stools and a feeling of lightheadedness. The patient indicates that over the past
24 hours he has had several bowel movements
containing tarry-colored stools and for the past 12
hours has felt light-headed.
• His past medical and surgical history are
unremarkable. The patient complains of
frequent headaches caused by work-related
stress, for which he has been self-medicating
with 6-8 tablets of ibuprofen a day for the past
2 weeks. He consumes two to three martinis
per day and denies tobacco or illicit drug use.
• On examination, his temperature is 37.0°C (98.6°F),
pulse rate 105/min (supine), blood pressure 104/80,
and respiratory rate 22/min. His vital signs upright
are pulse 120/min and blood pressure 90/76. He is
awake, cooperative, and pale. The cardiopulmonary
examinations are unremarkable. His abdomen is
mildly distended and mildly tender in the
epigastrium. The rectal examination reveals
melanotic stools but no masses in the vault.
• ^ What is your next step?
• ♦ What is the best initial treatment?
Summary:
• A 38-year-old man presents with signs and
symptoms of acute upper gastrointestinal (Gl)
tract hemorrhage.
• The patient's presentation suggests that he may
have had significant blood loss leading to class
III hemorrhagic shock.
Answer
^ Next step:
• The first step in the treatment of patients with
upper Gl hemorrhage is intravenous fluid
resuscitation.
• The etiology and severity of the bleeding
dictate the intensity of therapy and predict the
risk of further bleeding and/or death.
^ Best initial treatment:
Prompt attention to the patient's
airway, breathing, and circulation (ABCs) is
mandatory for patients with acute upper Gl
hemorrhage.
After attention to the ABCs, the patient is prepared
for endoscopy to identify the etiology or source
of the bleeding and possible endoscopic therapy
to control hemorrhage.
• In this patient's case, his symptoms and physiologic
parameters suggest severe, acute blood loss (class III
hemorrhagic shock with up to 35% total blood volume
loss) and should prompt:
• immediate resuscitation
• with close monitoring of patient response :
1. urine output,
2. clinical appearance,
3. blood pressure,
4. heart rate,
5. serial hemoglobin and hematocrit values,
6. central venous pressure monitoring.
• A nasogastric tube should be inserted
following resuscitation to determine
whether bleeding is active.
• The stomach should be irrigated with
room-temperature water or saline until
gastric aspirates are clear.
• For patients with massive upper GI tract bleeding,
agitation, or impaired respiratory status,
endotracheal intubation is recommended prior to
endoscopy.
• Laboratory studies to be obtained include:
1. a complete blood count,
2. liver function studies,
3. prothrombin time, and partial thromboplastin
time.
4. A type and cross-match should be ordered.
• Platelets or fresh-frozen plasma should be
administered when thrombocytopenia or
coagulopathy is identified, respectively.
• Early endoscopy identifies the bleeding source in
patients with active ongoing bleeding and may
achieve early control of bleeding.
• Given the history of nonsteroidal anti-inflammatory
drug (NSAID) use, it would be appropriate to begin
empirical therapy for a presumed gastric ulcer and
gastric erosions with a proton pump inhibitor prior
to endoscopic confirmation.
• A 55-year-old man has undergone upper
endoscopy. He is told by his gastroenterologist
that although this disorder may cause anemia, it is
unlikely to cause acute GI hemorrhage. Which of
the following is the most likely diagnosis?
A. Gastric ulcer
B. Duodenal ulcer
C. Gastric erosions
D. Esophageal varices
E. Gastric cancer
• E. Gastric cancer is relatively asymptomatic
until late in its course. Weight loss and
anorexia are the most common symptoms with
this condition. Hematemesis is unusual, but
anemia from chronic occult blood loss is
common.
• A 32-year-old man comes to the emergency
department with a history of vomiting "large amounts
of bright red blood." Which of the following is the
most appropriate first step in the treatment of this
patient?
A. Obtaining a history and performing a physical
examination
B. Determining hemoglobin and hematocrit levels
C. Fluid resuscitation
D. Inserting a nasogastric tube
E. Performing urgent endoscopy
• C. Fluid resuscitation is the first priority
to maintain sufficient intravascular
volume to perfuse vital organs.
• A 65-year-old man is brought into the emergency
department with acute upper GI hemorrhage. A
nasogastric tube is placed with bright red fluid
aspirated. After 30 minutes of saline flushes, the
aspirate is clear. Which of the following is the most
accurate statement regarding this patient's condition?
A. He has approximately a 20% chance of rebleed.
B. The mortality for his condition is much lower today
than 20 years ago.
C. His age is a poor prognostic factor for rebleeding.
D. Mesenteric ischemia is a likely cause of his condition.
• A. Approximately 20% of patients with
acute upper Gl hemorrhage have
continued or rebleeding episodes. The
mortality has remained the same
(approximately 8-10%) over the past 20
years.
• A 52-year-old man with alcoholism and known
cirrhosis comes into the emergency department
with acute hematemesis. Bleeding esophageal
varices are found during upper GI endoscopy.
Which of the following is most likely to be
effective treatment for this patient?
A.
B.
C.
D.
E.
Balloon tamponade of the esophagus
Proton pump inhibitor
Triple antibiotic therapy
Misoprostol oral therapy
Endoscopic sclerotherapy
• E. Endoscopic injection of sclerosing agents
directly into the varix is effective in controlling
acute hemorrhage caused by variceal bleeding in
approximately 90% of cases. Balloon tamponade
is a therapy used infrequently for acute
esophageal variceal bleeding because of its
limited effectiveness in achieving sustained
control of bleeding. Other therapies include
vasopressin or octreotide to decrease portal
pressure.