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Gastrointestinal bleeding: GIB(UGIB,LGIB)

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UGIB: bleeding proximal to the ligament of Treitz

UGIB requiring hospitalization is *5 more common than

LGIB& has a mortality rate of up to 10%.

GIB

NVUGIBA

LGIB2

VUGIB3B

UGIB31

NVUGIB:Causes

GERD/Erosive gastritis 25%2

AVM (HHT),GAVE4

Dieulafoy lesions33

PUD 50%31

Tumors(benign/malignan)6

Bleeding tendencies8

Aortoduodenalfistula37

MW eso tears 15%35

NVUGIB:Causes

Hemosuccus pancreaticus10

hemobilia39

VUGIB:Causes

Fundal varices2

Non-PHT – related

bleeding PDU (50%)4

Portalhypertensive gastropathy33

Bleeding eso varies31

LGIB:Causes

SRUS2

Bleeding diverticuli4

IBD33

Anal pathologies.31

Radiation colitis6

Ischemic colitis8

CD colitis37

CR Adenoma polyps or CRC.35

The Overall Management of UGIB:RESUSCITATION ER:

Use of Blood Components2

NGT4

Correction of Coagulopathy33

31

PREENDOSCOPY PPI6

PREENDOSCOPY ANTIFIBRINOLTYICS8

PREENDOSCOPY Prokinetics37

Risk stratification scoring35

Initial Assessment &Fluid Resuscitation

The Overall Management of UGIB:RESUSCITATION ER:

Optimal time to endoscope10

Test & treat H Pylori12

Postendoscopy PPI311

39

14

NSAIDs issues16

On discharge315

Tailor PPI dose to underlying cause313

PREENDOSCOPY: SMST/OCTT

Postendoscopy Gen in-hosp management

Initial Assessment &Fluid Resuscitation

2 IV line

Blood group/cross

match

with pulse

oximetry,cardiac

monitoring,

automated BP

readings,close

monitoring of UO

&ideally, CVP

ERABC(shock/airway

compromise)

IVF

Crystalloids

until blood

ready

Colloids or

albumen

preferred for

cirrhotics.

Restoration of circulating volume takes

priority over endoscopy.

Use of Blood Components

regionalO2 delivery

ImproveGlobalO2 delivery

Improve hemostasis

BTSF if Hb>8*2 rebleedTSF>10

pints needs plts , FRP,Ca

Blood benefits

(43% require it

Target Hb 7-8gms

If no Continuous bleeding or

CVD).

Coagulopathy correction

Coagulation screen

Correction: FFP,PC

Should not delay urgerny OGD

Causes

•Multifactorial•Marker of disease severity

Associated with

•Increased mortalty•Rebleeding•INR <1.8 Associated with lower mortality& fewer MI

6.2 coagulopathy even without cirrhosis

Endoscopic hemostasis can be done

safely if INR up to 2.5

NGT: Routine use Pre OGD controversial

BENEFITS

(1)presence fresh red blood in the NGT aspirate found to be an independent predictor

of adverse outcome & predictor of high-risk lesions in patients who are

hemodynamically stable without evidence of hematemesis.

Ptognostic index(1)

Confirm UGI source(85%)

Remove blood & clots

To clear field for OGD

?ENSURE HEMOSTSIS

Monitor continuous loss

?collect it to use

It for lesion injection?

Risk stratification scoring:

low risk/high risk:

Early hospital dischare

Mortality

Need for endohemostasis

Rebleeding

Using:

Clinical data

Lab date

OGD findings

Risk stratification: other than

scoring systems

Age>60 Inc mortality

HD Shock >*3 mortality & more need

For endohemostasis

Hematemesis

*2 mortalty,rebleed & endohemostasis

Risky states

Risk stratification: other than

scoring systems

Inpatient at time of bleed *3 mortality

Compared to new admisions

High BU increase need for

Endohemostasis

hematochezia

*2 mortalty,rebleed & endohemostasis

Risky states

Risk stratification: other than

scoring systems

A large ulcer size (>2 cm )

Rebleed /mortality

specific locations

(lesser wall curve or on the posterior

duodenal wall),rebleed,mortality,surgery

Endo stigma Forrest Class IA, IB, IIA& IIB

are high risk, Class IIC & III are low-risk

Risky Ulcer

PREENDOSCOPY:PPI either oral or

IV (better)

reduceHigh risk lesions

at OGDENDO Interventions

PH>6

Optimal plat agg clot formation

No effect on mortality, syrgery need or rebleeding

Preendoscopy PPI: Most suitable for

Pre OGD PPI

IV

preferred

Sp if vomiting

HR lesion?:

Hematemes or

bloody NGT

NVUGIB

OGD delayed or not

available for 24 hours

PREENDOSCOPY Prokinetics:

IV erythro or metochlorpromide

PK

REDUCE repeat endoscopyErhthro is motilin agonist

No improve other clinical

endpoints

IV erythro most suitable for patients

Most likely to have blood in

stomach at initial OGD.

Plasil if IV eryhthro

No available

IV eryhthro

Need PRIOR ECG

Pre-endoscopic antifibrinolytics

1

At present there is

insufficient evidence

to recommend TXA

in the treatment of

NVUGIB

2

large-scale RCT will be

required to address this

question.

Pre-endoscopic SST,OCT

SST,OCT

not recommended in

the routine

management of

patients with acute

NVUGIB.(for VGIB)

?Blee du not

controllable while

waiting OGD or

surgery, or if surgery

is contraindicated

Optimal time to endoscope

WITHIN 25 Hoursafter initial stabilization

<24 if very HR patient with high blatchford scores after initial stabilization

1 2 3

Optimal time to endoscope:

benefits

Improvement in other

clin endponits

risk stratification :

early discharge of

those patients with

low-risk

early &targeted

endoscopic

hemostasis in higher-

risk patients who are

actively bleeding or

with high-risk

stigmata of bleeding.

Targeted endoscopic hemostasis(dual endoscopic therapy): NS/Adrenaline inj+

one of other modalities(APC,Clip,band,thermal)

Post endoscopy PPI

For high-risk stigmata

who have

received successful OGD therapy.

reduced Mortality

In active bleeders& NBVV

Reduce

rebleedNeed for

surgery

Postendoscopy Test&treat H Pylori

Eradication Reduces rebleed.

Tested to confirmeradication

Tested for HP

All bleeding PUSHOULD

IncreasedFalse –ve testing

Post endoscopy general in-hosp

management.

High risk lesions

Re-bleeding

If was on asp/NSAIDs

Low risk

Intervention radiology/SurgeyAfter 2 OGDs

Re OGD interven

Evaluate risk/benefir ratio

Reuse within 5 days.

Fed within 24 hs & discharged on

Oral PPI within1-2 days.

72 hour monitoring for rebleeding

subsequent pharma management.

After discharge:once-daily oral PPI dose (in the case of bleeding

esophagitis, twice-a-day dosing), the duration of which should be

determined by the underlying etiology of the bleeding.

ASGE Guidelines 2012

We recommend that patients with UGIB be adequately

resuscitated before endoscopy.

We recommend antisecretory therapy with PPIs for PUD

Bleeding or in those with suspected PUD bleeding awaiting

endoscopy.

We suggest prokinetic agents in patients with a high probability

of having fresh blood or a clot in the stomach when undergoing

endoscopy.

We recommend endoscopy to diagnose etiology of acute UGIB.

The timing of endoscopy should depend on clinical factors. Urgent

endoscopy (within 24 hours of presen-tion) is recommended for

patients with a history of malignancy or cirrhosis, presentation

with hematemesis&signs of hypovolemia including hypotension,

tachycardia&shock, &Hb 8 g/dL.

ASGE Guidelines 2012

We recommend endoscopic therapy for PU with high-risk

stigmata (active spurting, visible vessel).

The management of PUD with an adherent clot is controversial

&recommended endoscopic treatments include inj (sclerosants,

thrombin, fibrin, or cyanoacrylate glue), cautery, & mechanical

therapies.

We recommend against epinephrine inj alone for PU bleeding. If

epinephrine inj is performed, it should be combined with a second

endoscopic treatment modality (eg, cautery or clips).

We recommend low-risk lesions be considered for OP TRT.

We recommend against routine second-look endoscopy in patients

who have received adequate endoscopic therapy.

We recommend repeat OGD for patients with evidence of

recurrent bleeding.

Summary Adequate resuscitation.

Risk stratification .

Early endoscopy to enable further risk stratification.

Application of endotherapy to high-risk lesions to achieve

hemostasis &downgrade stigmata.

Injection of epinephrine alone is not optimal when treating all

high-risk lesions which needs in addition one of the other

endoscopic hemostatic modalities as APC or cliping.

All endoscopic hemostasis should be complemented by a 72-hour

infusion of high dose PPI.

All patients should be tested for H pylori & treated if necessary,

Secondary prophylaxis should be considered for appropriate

patients ie PPI covering asp/NSAIDs requiring patients.

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