Transcript الشريحة 1 - MEDtube.net

Guidelines for the
Management of Upper
Gastrointestinal Bleeding
Nasser Ahmed A- Harhra – MD Surgery Consultant
Surgeon - Associate Professor of Surgery
Guidlines UGIT
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Background :
The management of patients with acute
upper gastrointestinal bleeding has evolved
worldwide substantially over the past 10
years amid a paucity and absence of local
consensus guidelines.
Purpose :
To provide evidence-based management
recommendations that address clinically
relevant issues for these patients in our
hospital .
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Determination of Need for Guidelines :
The need for clinical practice guidelines on
the management of patients with upper GI
bleeding was identified worldwide by
different systems , hospitals and GIT units .
Review of the existing literature and the
current local situation will guide to
recommendations to the management of UGI
bleeding in our hospital .
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What is a guideline ?
It is meant to be a guide for clinical practice ,
based on the best available evidence at the time of
development.
Adherence to these guidelines may not necessarily
ensure the best outcome in every case.
Every health care provider is responsible for the
management of his/her unique patient based on
the clinical picture presented by the patient and
the management options available locally.
Review of the Guidelines :
The guideline is issued and reviewed periodically
according to the outcome or sooner if new evidence
becomes available
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Validity and grading of recommendations
These guidelines have been produced to conform to the
system proposed by a specialized professional unit ( eg :
British Society of Gastroenterology by North of England
evidence based guidelines development project ) .
CATEGORIES OF EVIDENCE as follows:
Gra Ia: evidence obtained from meta-analysis of randomised trials.
Gra Ib: evidence obtained from at least one randomised trial.
Gra IIa: evidence obtained from at least one well designed controlled
study without randomisation.
Gra IIb: evidence obtained from at least one other type of well designed
quasi experimental study.
Gra III: evidence obtained from well designed non-experimental
descriptive studies such as comparative studies, correlation
studies, and case studies.
Gra IV: evidence obtained from expert committee reports, or opinions
or clinical experiences of respected authorities.
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The current guidelines are a consensus paper with
multisociety representation by The Canadian Registry in
Upper Gastrointestinal Bleeding and Endoscopy(RUGBE)
General Organization
A 2-day consensus conference was held in June 2002 under
the auspices of the Canadian Association of
Gastroenterology.
The conference was conducted according to generally
accepted standards for the development of clinical practice
guidelines .
At the consensus conference, data were presented and the
statements and the grades attributed to evidence were
discussed, modified if necessary, and voted on by each
participant according to the recognized criteria
Categorization of Evidence, Classification of
Recommendations, and Voting Schema
Category
and Grade Description
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Quality of evidence
I Evidence obtained from at least 1 properly randomized,
controlled trial.
II-1 Evidence obtained from well-designed controlled trials
without ndomization.
II-2 Evidence obtained from well-designed cohort or case–
control analytic studies, preferably from more than 1
center or research group.
II-3 Evidence obtained from comparisons between times or
places with or without the intervention, or dramatic
results in uncontrolled experiments.
III Opinions of respected authorities, based on clinical
experience, descriptive studies, or reports of expert
committees.
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Classification of recommendations
A There is good evidence to support the procedure or treatment.
B There is fair evidence to support the procedure or treatment.
C There is poor evidence to support the procedure or treatment,
but recommendations may be made on other grounds.
D There is fair evidence that the procedure or treatment should
not be used.
E There is good evidence that the procedure or treatment should
not be used.
Voting on the recommendations*
a Accept completely.
b Accept with some reservation.
c Accept with major reservation.
d Reject with reservation.
e Reject completely.
•Statements for which more than 50% of participants voted a,
b, or c were
accepted.
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It is reported that , mortality is found to be lower in
specialist units and this is probably not related to
technical developments but because of adherence to
protocols and guidelines .
Thus guidelines do have the potential
* To improve prognosis
* In addition may be of value in making the best use
of resources by fast tracking low risk patients ,
* thereby optimizing duration of hospital stay.
What is the problem ?
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Worldwide :
Epidemiology :
incidence ranging 50 – 100 per 100 000 / year
Etiology :
Peptic ulcer disease 35 – 50 %
liver cirrhosis and portal hypertension
( Alcohol ) 5 – 10 % ( High risk patients : old ,
coagulopathies and impaired liver Function )
Significant improvements in patient assessment and
management have reduced :
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mortality from 10-40 % to 5 % .
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In yemeni Local Studies ¡ ¡ :
( Hati , Al-Nawi ,and Karama ( J of Nat and App Science - University of
Aden ; 2001 ) -- Ben Silm (Yemeni J of Med & Health Res 2003 )
&Amin Abdu-Elrub et al ,Sana` ( Yemen Medical J ; 2002 ) .
Incidence : ? ?
Mortality : ?
One study : The overall mortality was 24% and
bleeding esophageal varices were the major causes of
death , in 230 patients . (Amin ; 2002 ) .
In all : Port. hypertension is the commonest cause
60 – 70 % - ( Mostly due to periportal fibrosis of
Schistosomiasis and cirrhosis due to viral hepatitis B
& C ) . Patients are mostly young and have good ,
reserved hepatic function .
Peptic
ulcer disease : 25 – 40 %
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Critical care Units ( ICU , HDU , CCU ect ..)
Endoscopy Unit Gastroenterology Unit
Specialized centers , hospitals , ……ect
An agreed protocol for the management of UGIT bleeding
should be distributed to all medical and nursing staff who
care for such patients. This includes medical, geriatric, and
surgical wards, the admission unit, laboratories, and
pharmacy.
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Bleeding - Dr.
+ UK guidelines on the management of variceal haemorrhage
in cirrhotic patients - R Jalan , P C Hayes :
Gut 2000 ;46(Suppl 3):iii1-iii15 ( June )
+ Consensus Recommendations for Managing Patients with
Nonvariceal Upper Gastrointestinal Bleeding –
Alan Barkun et al ; Ann Intern Med. 2003;139:843-857.
www.annals.org
+ Review : Non-variceal upper gastrointestinal bleeding – CB
Ferguson, RM Mitchell - www.ums.ac.uk Ulster Med J
2006; 75 (1) 32-39
+ Leeds General Infirmary Guidelines – February 2002
+ Rockall TA et al Gut 1996;38:316-21
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+ Vreeburg
EM
et al Gut 1999;44:331-5
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+ The Victorian Surgical Consultative Council
Guidelines for the Management of Upper
Gastrointestinal Bleeding
Dr Simon Travis DPhil and Dr Dermot
McGovern John Radcliffe Hospital, Oxford – 2006
+ British Society of Gastroenterology Endoscopy
Committee. Nonvariceal upper gastrointestinal
hemorrhage: guidelines ,
Gut. 2002; 51 (Suppl 4): iv1-6. www.gutjnl.com
+ CLINICAL PRACTICE GUIDELINES , April 2003 –
MANAGEMENT OF NON-VARICEAL
UPPERGASTROINTESTINAL BLEEDING
MALAYSIAN SOCIETY of GASTROENTEROLOGY AND
HEPATOLOGY ACADEMY OF MEDICINE MALAYSIA
http:// www.moh.gov.my/medical/htm or : http://
www.acadmed.org.my
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®UGIB remains a common and challenging
emergency for gastroenterologists and general
physicians.
® The annual incidence is 50 to 150 per 100,000
of the population, and , even though there have
been significant improvements in endoscopic and
supportive therapies
® Overall mortality around 10% , and even reach
35% in hospitalised patients with serious comorbidity. Patients aged over 80 years of age now
account for around 25% of all UGIB and 33% of
UGIB occurring in hospitalized patients with the
poor outcome of this condition
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®The commonest cause of UGIB is peptic ulcer disease
( 50-60 %) and then mucosal erosive diseases at 12-20%.
In a recent large (CORI )study of UGIB, peptic ulcer was the probable
cause of UGIB in only 20% of cases. The incidence is expected to continue
to decline with more widespread helicobacter pylori eradication and PPI
usage. Gastrointest Endosc 2004; 9(7): 788-94.
® Factors commonly associated with poor outcome from
UGIB may be related to the patient’s presentation and comorbidities, or to the behaviour of the pathologic cause
® RISK ASSESSMENT AND INITIAL MANAGEMENT :
Several clinical scoring systems e.g. Rockall score, the Baylor
bleeding score, the Cedars Sinai M C Pre. Index and the
Blatchford score,developed to direct appropriate patient
management and enable cost effective use of resources.
These weigh a combination of clinical, laboratory and
endoscopic variables to produce a score that predicts the risk
of mortality, recurrent haemorrhage, need for intervention or
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suitability
for
early
discharge.
Bleeding - Dr.
Risk Factors For Death After Hospital Admission
For Acute Upper Gastrointestinal Bleeding
1. Advanced age
2. Shock on admission (pulse rate >100 beats/min; systolic
blood pressure < 100mmHg)
3. Comorbidity (particularly hepatic or renal failure and
disseminated malignancy)
4. Diagnosis (worst prognosis for advanced upper
gastrointestinal malignancy)
5. Endoscopic findings (active, spurting haemorrhage from
peptic ulcer; non-bleeding visible vessel)
6. Rebleeding (increases mortality 10 fold)
Rockall TA, Logan RFA, Devlin HB, et al. Risk assessment after acute
upper gastrointestinal haemorrhage. Gut 1996; 38:316-321
Mortality is low in patients below 40 years of age but increases steeply
thereafter. Patients with severe comorbidity, particularly renal failure,
liver failure and disseminated malignancy have a poor prognosis
(Grade A).
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Rockall Score
• Initial Rockall Score
• Age <60 years
0
• 60-79 yrs
1
• >80 yrs
2
• Shock
• None
0
• Pulse>100 &
• Syst BP>100
1
• Syst BP<100
2
• Co-morbidity
• None
0
• Cardiac failure, IHD or any
• major co-morbidity 2
• Renal/liver failure, or
• dissem. malignancy 3
Initial R-sc (Max score 7)
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•
•
•
•
•
•
•
•
•
•
Full score after OGD
Endoscopic diagnosis
M-W tear*, no lesion seen
and no SRH*
0
All other diagnoses
1
Malignancy of upper GI
tract
2
Major SRH*
None or dark spot only 0
Blood in upper GI tract,
adherent clot, visible or
Spurting vessel
2
Final R- score(Max score 11)
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In the Rockall risk assessment score, a series of independent
risk factors were scored .
Patients who score 2 or less have a mortality of 0.1% and a
rebleeding rate of 4.3%
score in excess of 8 is associated with a 41% mortality and
rebleeding rate of 42.1%.
The score was more reliable in predicting mortality than it
was in predicting rebleeding (Grade A) .
Such risk assessment scores may be useful in triaging patients
for either outpatient care or admission to an high dependency
unit
® Inclusion of endoscopic stigmata of recent haemorrhage
(SRH) that relate to increased risk of re-bleeding and death
into scoring systems increases the sensitivity for predicting
patients at high or low risk compared to non-endoscopic
assessments.
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® Endoscopic intervention reduces the rate of re-bleeding,
need for surgical intervention and mortality in high risk
patients .
The optimum timing of endoscopy remains a balance between
clinical need and resources, but endoscopy performed within
24 hours of admission has been shown to reduce the length of
hospital stay and may reduce likelihood of rebleeding or
surgical intervention in the highest risk pats.
Rebleeding occurs in 55% of patients who have active bleeding
(pulsatile, oozing), in 43% who have a nonbleeding visible vessel,
in 22% who have an ulcer with an adherent clot, and in 0 – 5%
who have an ulcer with a clean base.
At endoscopy, the prevalence rate for a clean base is 42%,
for a flat spot is 20%, for an adherent clot is 17%, for a
visible vessel is 17%, and for active bleeding is 18%.
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Forrest classification of peptic ulcers in UGIB
Forrest class
Type of lesion
Risk of rebleed if
untreated [%]
Ia
Arterial spurting
100
Ib
Arterial oozing
17-100
IIa
Visible vessel
8-81
IIb
Sentinel clot
14-36
IIc
Haematin covered flat spot
0-13
III
No stigmata
0-10
SRH=Stigmata of recent haemorrhage.
Major SRH=Forrest 1a, 1b, 2a and 2b. Minor SRH=Forrest 2c and 3.
Risk Assessment :
Endoscopic findings of active, spurting haemorrhage and a
non-bleeding visible vessel within an ulcer are associated with
a definite risk of rebleeding .
The absence of these stigmata, varices or upper GIT cancer
indicates
a low risk of rebleeding (Grade A) .
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Endoscopic Treatment For Non-variceal UGI Bleeding
Thermal
· Heater probe
· Multipolar electrocoagulation (BICAP,Gold Probe)
· Argon plasma coagulation
· Laser
Injection
· Adrenaline (1:10000)
· Procoagulants(fibrin glue,human thrombin)
· Sclerosants (ethanolamine, 1% polidoconal)
· Alcohol (98%)
Mechanical
· Clips
· Band Ligation
· Endoloops
· Staples
Guidlines UGIT
· Sutures Bleeding - Dr.
Combination therapy
. Injection plus thermal therapy
· Injection plus mechanical therapy
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A combination of therapies has become more common.
Injection therapy is applied first to better clarify the
bleeding site, especially in the actively bleeding patient;
then, heater probe or bipolar (gold) probe coagulation is
applied. Injection therapy can also be performed prior to
endoscopic placement of hemoclips. Injection therapy is
useful prior to laser therapy to reduce the heat sink effect
of rapidly flowing blood prior to laser coagulation
BALLOON TAMPONADE :
This form of treatment is highly effective and controls acute
bleeding in up to 90% of patients although about 50% rebleed
when the balloon is deflated .
It is , however, associated with serious complications such as
oesophageal ulceration and aspiration pneumonia in up to 1520% of patients. Despite this, it may be a life saving treatment in
cases of massive uncontrolled variceal haemorrhage pending
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other forms
of
treatment.
Bleeding - Dr.
PHARMACOLOGICAL THERAPY :
The use of H2 antagonists in upper gastrointestinal
bleeding is not recommended (Grade A).
A meta-analysis of randomised trials
It is recommended that following endoscopic therapy in
major peptic ulcer bleeding, high dose intravenous PPI
(eg IV Omeprazole 80mg stat followed by an infusion of
8mg hourly for 72 hours) be commenced (Grade B)
Somatostatin : High dose IV somatostatin suppresses acid
secretion and reduces sphanchnic blood flow . A metaanalysis showed benefit for treated patients (grade A) but the
quality of most of the individual trials is poor and currently
there are insufficient data to advocate routine use of this
drug in patients with nonvariceal UGIB bleeding.
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• Vasopressin (either alone or in combination with
nitroglycerine) and Octretide ( somatostatin analogue ) are
valuable vasoactive drugs that are used in the treatment of
bleeders with portal hypertension .
Glypressin is a synthetic analogue of vasopressin and is
found to be equally effective
Antifibrinolytic drugs. A meta-analysis has shown that
tranexamic acid therapy, while not reducing ulcer
rebleeding , does appear to reduce the need for surgical
intervention and tends to reduce mortality in ulcer bleeding
patients .
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• It is found in control of bleeding in esophageal
vaices that :
Variceal band ligation is the method of first choice .
(Recommendation grade AI.)
If banding is difficult because of continued bleeding or this
technique is not available, endoscopic variceal sclerotherapy
should be performed. (Recommendation grade AI.)
If endoscopy is unavailable, vasoconstrictors such as
octreotide or glypressin, or a Sengstaken tube inserted (with
adequate provision for airways protection) may be used while
more definitive therapy is arranged. (Recommendation grade AI
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Philosophy of Surgical Management
©The general philosophy is that saving lives, i.e. stopping
the bleeding, comes first. This is the main consideration in
the severely ill patients.
© The role of surgery has changed with wider use of
endoscopic hemostasis in bleeding ulcers, no longer aiming
to cure the disease but primarily to stop the hemorrhage.
© In the less compromised subjects, the secondary issue of
long-term cure of disease may be considered. But now, when
such a goal can be achieved by medical means, the role of
definitive anti-ulcer procedures is limited and should be
considered only in well-selected patients: those expected to
be not compliant with medications and in situations where
such medications are not readily available.
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Indications for Surgery as the Primary Mode of Treatment :
The rate of primary-emergency surgery varies depending on the
case mix and the expertise of endoscopic management.
Thus the surgeon should be involved from the outset in the team
caring for the patient early and close cooperation between
endoscopists/gastroenterologists and surgeons is vital.
1. Massive bleeding
Uncontrolled massive bleeding by endoscopic procedures. This may be due to
bleeding that is unresponsive to endoscopic hemostasis or failure of
endoscopic visualization of the bleeder due to profuse hemorrhage. A
continued attempt with endoscopic treatment is futile and dangerous.
2. Ulcer inaccessible to endoscopic control
This can occur in duodenums that are often deformed and narrowed.
Primary surgery is indicated in such circumstances.
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Type of Surgery for Bleeding Peptic Ulcer
There appears to be no difference between local (underrunning/ over-sewing or excision of ulcer) and radical
surgery (gastric resection or vagotomy) with respect to
mortality although rebleeding rate may be higher in the
local group
Currently it is not possible to make definite
recommendations in the absence of any good prospective
randomized trials. The magnitude of surgery should be
tailored to the type of ulcer, severity of illness in the patient
and experience of the surgeon.
© The source of bleeding is always at the base of a posterior
ulcer. Hemostasis is accomplished through an anterior
duodenotomy, underrunning the base (and bleeding vessel)
with two or three (2-0 monofilament) deeply placed sutures each placed on a different axis.
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If the patient is in good shape and requires a definitive
procedure , other options are :
© Truncal vagotomy (TV), extending the duodenotomy across the pylorus,
and closing it to form a Heinke-Mikulicz pyloroplasty.
© In a fit and stable patient, close the duodenotomy and perform a highly
selective vagotomy (HSV), adding an hour or so to the procedure.
© The proponents of antrectomy plus vagotomy for bleeding DUs claim an
increased incidence of re-hemorrhage when gastric resection is avoided
Traditionally, a bleeding Gastric Ulcer mandated a partial gastrectomy.
Gastric resection is indeed effective in controlling the hemorrhage, but in
most instances represents a superfluous ritual.
For acute-superficial ulcers all that is required is simple underrunning of
the lesion through a small gastrotomy.
In fact, in most patients who bleed from a chronic GU, simple
underrunning of the ulcer from within, through a gastrotomy,
suffices
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Type I is the classical lesser curvature GU. Billroth I partial
gastrectomy . An HSV (from the ulcer proximally) plus
the excision of the ulcer (from inside the stomach) is
the alternative .
Type II is a pre-pyloric ulcer- between DU and GU –
antrectomy plus vagotomy are popular, excellent
results are achieved with HSV plus pyloroplasty.
Type III is a combination of a GU and a DU: it should be
treated as type11 .
Type IV implies a high, juxta-cardial lesser curvature GU.
Prior to the days of effective anti-ulcer medication, partial
gastrectomy – distal to the ulcer - was the procedure of choice.
Since the entire lesser curvature may be obliterated, HSV is
usually impossible - making TV plus a drainage procedure a
reasonable alternative.
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AFTER CARE
After the initial endoscopy and the institution of
endoscopic therapeutic measures where necessary, the key
point in the aftercare is the recognition of patients at high
risk of rebleeding and death who would require careful
monitoring in an intensive care or high dependency
setting .
Predictors of an increased risk of rebleeding and death (as
well as failure of endoscopic therapy) include
(i) clinical factors such as shock at the time of
presentation, advanced age, co-existing illnesses,
(ii) endoscopic features such as ulcer location (posterior
duodenal ulcer) , size of the ulcer (>2cm) , stigmata of
recent haemorrhage and the presence of blood at the time
of endoscopy as well as
(iii) laboratory features such as haemoglobin (<10g/dl) and
elevated blood urea levels
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Rebleeding After Initial Endosc. Control of Bleed Ulcers :
The major challenge in applying endoscopic therapy for
bleeding peptic ulcers is that haemostasis is not
permanent and re-bleeding occurs in about 15-20% of the
cases.
Endoscopic treatment would avoid the surgical risk .
However, delay in establishing haemostasis may result in
hypotension and adversely affect the survival.
In patients with peptic ulcers and recurrent bleeding
after initial endoscopic control of bleeding , endoscopic
retreatment reduces the need for surgery without
increasing the risk of death and is associated with fewer
complications than is surgery (Grade A) .
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1. To establish local guidelines for management of these high
risky patients according to the available resources in the
hospital .
2. Establish a system :
Team approach of these risky patients within the same
unit and between medico-surgical units
Clinical assessment of severity and risk
Medical treatment especially in patients with esophageal
varices
Discuss and enhance the role of surgery in these patients
especially in stable emergency patients ( child`s A +/_ B ) ,
young and fit patients , and patients with schistosomiasis .
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3. The hospital :
To Support the role of emergency and ICU units
Discuss the possibility of foundation of Gastroenterology
Unit in the hospital
To Support the role of endoscopy department in the
hospital
The proper registration of cases in the health center and
hospitals
4. To stimulate the research and documentation of the
experience of post graduates and senior surgeons about
this disease
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