Discuss the management of upper gastrointestinal haemorrhage
-
Upload
bashir-bnyunus -
Category
Health & Medicine
-
view
1.148 -
download
0
description
Transcript of Discuss the management of upper gastrointestinal haemorrhage
![Page 1: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/1.jpg)
DISCUSS THE MANAGEMENT OF UPPER GASTROINTESTINAL HAEMORRHAGE
DR BASHIR YUNUSSURGERY DEPARTMENT
AKTH14th October 2014
10/13/2014 1
![Page 2: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/2.jpg)
OUTLINE
•INTRODUCTION
•PRINCIPLE OF MANAGEMENT
•COMPLICATIONS
•PROGNOSIS
•CONCLUSION
•REFERENCES
10/13/2014 2
![Page 3: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/3.jpg)
INTRODUCTION
• The gastrointestinal tract extend from the mouth to the anus and divided into two parts;
• Upper GIT
• Lower GIT
• By the ligament of treitzat the duodenojejunaljunction.
10/13/2014 3
![Page 4: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/4.jpg)
INTRODUCTION
• The part above the ligament is the upper GI
10/13/2014 4
Definition:Any bleeding from GI tract proximal to ligament of treitz.
It is a common cause of emergency hospital admission and accounts for 5-10% mortality which increase in the elderly.
![Page 5: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/5.jpg)
INTRODUCTION
• modes of presentation
– Hematemesis- 40-50%
– Melena-70-80%
– Hematochezia- 15-20%
10/13/2014 5
![Page 6: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/6.jpg)
INTRODUCTION
• Hematemesis Vomiting of fresh or old blood
(40-50%) Proximal to Treitz ligament
Bright red blood = significant bleeding
Coffee ground emesis = no active bleeding
• Melena Passage of black & foul-smelling stools
(70-80%) Usually upper source – may be right colon
• Hematochezia Passage of bright red blood from rectum
(15-20%) If brisk & significant → UGI source
10/13/2014 6
![Page 7: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/7.jpg)
PRINCINPLES OF MANAGEMENT
• INITIAL ASSESSMENT
• RESUSCITATION
• DETERMINATION OF BLEEDING SITE
• TREATMENT/INTERVENTION
• PREVENTION OF RECURRENCE
10/13/2014 7
![Page 8: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/8.jpg)
PRINCIPLES
10/13/2014 8
Immediate Assessment
Stabilization of hemodynamic status
Identify the source of bleeding
Stopping the active bleeding
Treat the underlying
Prevent recurrent bleeding
![Page 9: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/9.jpg)
ASSESSMENT
Patient presenting with cardiovascular instability requires prompt resuscitation before detailed history and examination to find the cause of bleeding and other co-morbidity
10/13/2014 9
![Page 10: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/10.jpg)
ASSESSMENT
Severity of bleeding can be determined:
• Level of consciousness - obtundation
• Pulse rate >100bpm
• Postural hypotension.
• Severe blood loss—Vagal slowing of the heart
10/13/2014 10
![Page 11: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/11.jpg)
ASSESSING SEVERITY
10/13/2014 11
eeding
Bleeding severity Vital Signs Blood loss (%)
Minor Normal < 10 %
Moderate Postural
(Orthostatic hypotension)
10 – 20 %
Massive Shock
(Resting hypotension)
20 – 25 %
![Page 12: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/12.jpg)
RESUSCITATION
• Aggressiveness of resuscitation depends on the bleeding severity
• Resuscitation is proportional to bleeding severity
• Inadequate resuscitation leads to Multi-organ failure.
10/13/2014 12
![Page 13: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/13.jpg)
RESUSCITATION• Ensure a patent airway and breathing.
• Elevate foot of bed to about 15⁰
• Secure IV access, take samples; PCV, U/Ecr, GXM, Platelet count, LFT.
• IV crystalloid, N/S R/L 1L over 30-45min
• Pass urethral catheter, empty the bladder then monitor urine output. (0.5-1ml/kg/min)
• Reassess PR,BP,CVP, urine output, to determine the rate of infusion
• Supplemental Oxygen---enhances oxygen carrying capacity of blood
10/13/2014 13
![Page 14: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/14.jpg)
RESUSCITATION
• Pass N-G tube-– Decompression, prevent aspiration– Cold saline lavage
• Transfuse;– significant blood loss or pcv <30– on going bleeding,– inadequate response to fluid resuscitation,– elderly and – presence of cardiopulmonary disease
• Sedation– Phenobarb to quieten patient.
10/13/2014 14
![Page 15: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/15.jpg)
HISTORY
• History to find the cause, co-morbidity and character(onset, volume and frequency) of bleeding. Careful history and physical examination may yield no definitive cause in 50%.– HX of PUD
– Alcohol ingestion
– NSAID
– Dysphagia
10/13/2014 15
![Page 16: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/16.jpg)
HISTORY
• COMMON CAUSES
• Duodenal ulcer
• Gastric ulcer
• Stress ulcer
• Oesophageal varices
10/13/2014 16
![Page 17: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/17.jpg)
HISTORY
• LESS COMMON CAUSES
• Oesophagitis
• Mallory- Weiss syndrome
• Malignant gastric tumours
• Benign gastric tumours
• Oesophageal ulcers or tumour
• Para-oesophageal hiatal hernia
10/13/2014 17
![Page 18: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/18.jpg)
HISTORY
• RARE CAUSES
– Duodenal tumours
– Aorto-enteric fistula
– Blood dyscrasia
– Hereditary talengiectasia
– Angiodysplasia
– Dieulafoy’s lesion
10/13/2014 18
![Page 19: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/19.jpg)
EXAMINATION
– Pallor
– Sweating
– Cold extremities
– Nostrils/ pharynx
– Epigastric tenderness
10/13/2014 19
![Page 20: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/20.jpg)
EXAMINATION
• Collapse subcutaneous veins
• Tachycardia
• Hypotension
• Restlessness
• Features of CLD, gastric ca, abdominal masses,
10/13/2014 20
![Page 21: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/21.jpg)
RISK SCORING
• ROCKALL’S RISK SCORE
• Score that predicts poor prognosis, i.e. rebleeding and mortality from upper GI haemorrhage
• It uses clinical criteria (increasing age, co-morbidity, shock) as well as endoscopic finding (diagnosis, stigmata of spontaneous haemorrhage -SSH)
10/13/2014 21
![Page 22: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/22.jpg)
ROCKALL’S SCORE
10/13/2014 22
![Page 23: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/23.jpg)
10/13/2014 23
Risk category: High (> 5)Intermediate (3–5)Low (0–2)
![Page 24: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/24.jpg)
MANAGEMENT AS PER RISK
• Low risk (0-2);usually 80% of patients recovers spontaneously with medical treatment(PPI) + hospitalization for 24hrs and may be discharge if uneventful.
• Intermediate risks(3-5); same treatment + hospitalization for at least 72 hrs.
• High risk(>5); same treatment + hospitalization in ICU
10/13/2014 24
![Page 25: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/25.jpg)
DETERMINATION OF BLEEDING SITE
• NG-tube aspiration
• Endoscopy
• Barium studies
• Angiography
• Tagged rbc scan
10/13/2014 25
![Page 26: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/26.jpg)
LOCALIZATION
10/13/2014 26
![Page 27: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/27.jpg)
N-G TUBE ASPIRATION
Nasogastric aspiration with saline lavage is beneficial
• to detect the presence of intragastric blood,
• to determine the type of gross bleeding,
• to clear the gastric field for endoscopic visualization
• to prevent aspiration of gastric contents.
10/13/2014 27
![Page 28: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/28.jpg)
ENDOSCOPY
• Diagnostic; direct visualization of source of bleeding
• Therapeutic; control of active bleeding
• To assess the prognostic indicator using the Forrest classification
10/13/2014 28
![Page 29: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/29.jpg)
Modified Forrest Classification for Upper GI bleeding
10/13/2014 29
![Page 30: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/30.jpg)
10/13/2014 30
![Page 31: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/31.jpg)
BARIUM MEAL
• In the absence of endoscopy, barium is attempted. It may show ulcer craters, varices, filling defect or tumors in the stomach.
• Double contrast is preferred; it shows small ulcers
• Disadvantages;
– Source remains undetected in ≥ 50% of patients
– Blood clot obscures gross lesion
10/13/2014 31
![Page 32: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/32.jpg)
ANGIOGRAPHY
• It identifies the bleeding vessel
• Targeted therapy for ongoing hemorrhage; may prevent need for surgery (with embolization).
• Angio ≥ 1 ml/min
• Disadvantages; Invasive,expensive,requiresspecial expertise, exposure to radiation, risk of contrast media–induced nephropathy, bleeding from arterial puncture site
10/13/2014 32
![Page 33: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/33.jpg)
TAGGED RBC SCAN
• Utilizes technetium labelled rbc extravasation into bowel is detected by scintillation camera.
• RBC scan may not accurately locate bleed.
• 0.5 – 1 ml/min bleeding requirement,set up req. 1-2 hours, test time 1-2 hours
• Contraindicated in;– initial Hct < 24,
– hemodyn unstable patient,
– ongoing > 100-200 cc/h bleed
10/13/2014 33
![Page 34: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/34.jpg)
TREATMENT
• Non-operative
• Operative
10/13/2014 34
![Page 35: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/35.jpg)
NON OPERATIVE
Peptic ulcer disease• Endoscopic• PPI• Elimination of H. pylori
• Endoscopic therapy: – Injection of adrenaline at the base of the vessel/
Sclerotherapy– Bipolar electro- / thermal probe coagulation– Argon plasma / laser photocoagulation– Hemostatic materials, including biologic glue
10/13/2014 35
![Page 36: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/36.jpg)
ENDOSCOPIC MODALITIES AVAILABLE FOR THE MANAGEMENT OF U.G.I. BLEED
INJECTION
Adrenalin
Fibrin glue
Human Thrombin
Sclerosants
Alcohol
THERMAL Heater Probe
Bicap Probe
Gold Probe
Argon plasma coagulation
Laser therapy
MECHANICAL
Haemoclips
Banding
Endoloops
Staples
Sutures
10/13/2014 36
![Page 37: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/37.jpg)
NON-OPERATIVE
• If bleeding controlled:• PPI- proton pump inhibitor
– omeprazole/pantoprazole, 80 mg bolus then 8 mg/hr infusion x 24 hrs. then 40 mg IV OD/BDthen transition to oral PPIs for 6-8 wks.
• Helicobacter pylori treatment, if presenttriple drug regimen x 2-3 wks.recurrent colonization 70-90% within few month to years.
• Repeat endoscopy < 6-8 wks.
10/13/2014 37
![Page 38: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/38.jpg)
NON-OPERATIVE
• VARICES• Balloon tamponade• Pharmacological • Endoscopic• Transjugular intrahepatic portosystemic stent-shunt (TIPSS)
– Balloon tamponade:– Initially temporizing measure in all pts, now < 10%
temporary hemostasis in 85%, near 100% re-bleed on removal– 20% complication rate
Esophageal rupture, Tracheal rupture, Duodenal rupture, Respiratory tract obstruction, Aspiration, Tracheoesophagealfistula, Esophageal necrosis / ulcer
10/13/2014 38
![Page 39: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/39.jpg)
Sengstaken blakemore tube
10/13/2014 39
![Page 40: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/40.jpg)
Sengstaken blakemore tube
10/13/2014 40
![Page 41: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/41.jpg)
• Pharmacologic treatment :• Vasopressin splanchnic vasoconstriction; 20IU in 250ml
of 5% DW over 30min, 4hrly. It improves hemostasis. Telipressin (pro-drug) better hemostasis and survival benefits. And longer duration of action.– Side effects
• Pallor• Hypertension• Abdominal colic• Cerebral and coronary ischemia• purgation
– Nitroglycerine 40 mcg/min may be given simultaneously to prevent coronary ischemia.
10/13/2014 41
![Page 42: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/42.jpg)
• Nitroglycerine systemic hypotension and venous pooling, counteract cardiac effects of vasopressin; titrate to SBP 90-100.
• Glypressin; contains both nitroglycerin and vasopressin
• Beta-Blockers: Propranolol 40 mg bd; lowers portal pressure. Daily oral dose after bleeding has stopped is found to stop re-bleeding in about 80%.
• Octreotide: 250 mcg bolus, 250 mcg/hr infusion; Decreases gastric acid, pepsin, gastric blood flow
10/13/2014 42
![Page 43: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/43.jpg)
Endoscopy
• Sclerotherapy;– Ethanolamine oleate (3-5ml) or sodium morrhuate
is injected into each varies.
– If the bleeding is controlled, injection is repeated weekly, then at 3weeks and at 3monthly until varies obliterate.
– Use of cyanoacrylate tissue adhesive.
• Initial success rate -> 90%, re-bleed 30-50%
10/13/2014 43
![Page 44: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/44.jpg)
• Band Ligation; is efficacious and is now preferred to Sclerotherapy
• Endoscopic surveillance;
– 3 monthly for 1year then
– 6monthly for 1year then
– Annually
10/13/2014 44
![Page 45: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/45.jpg)
• TIPSS;
– In refractory bleeding after sclerotherapy or band ligation.
– A shunt is established between the portal vein and the right or middle hepatic vein
10/13/2014 45
![Page 46: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/46.jpg)
OPERATIVE
• Indications;– Massive bleeding
– Severe haemorrhage continues or recurs/not responsive to resuscitative efforts
– Associated perforation
– Blood not readily available
– Failure of medical therapy and endoscopic hemostasis with persistent / recurrent bleeding
– A second hospitalization for peptic ulcer hemorrhage
10/13/2014 46
![Page 47: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/47.jpg)
OPERATIVE
• Factors predicting further bleeding from a peptic ulcer and possible need for surgery– Age > 60years
– Hb <8g/dl
– Shock on admission
– Visible spurting vessel on endoscopy
– Giant ulcer >2cm
– Ulcer on the posterior lesser curvature or posterior inferior wall of the duodenal bulb
10/13/2014 47
![Page 48: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/48.jpg)
OPERATIVES
• AIMS;
– To stop the bleeding
– To prevent a recurrence
– To cure underlying cause
10/13/2014 48
![Page 49: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/49.jpg)
DEFINITIVE PROCEDURES
• Peptic ulcer disease
– Laparotomy
– Upper mid-line incision
– Duodenal ulcer: most common, posterior bleed;
• longitudinal anterior duodenotomy
• Under-run the vessel (i.e. gastroduodenal artery) using non-absorbable suture preferable prolene 4-O.
• Quickest and safest operation
10/13/2014 49
![Page 50: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/50.jpg)
Anterior longitudinal duodenotomy
10/13/2014 50
![Page 51: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/51.jpg)
• Common complications
– Re-bleeding
– Injury to the common bile duct.
10/13/2014 51
![Page 52: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/52.jpg)
Gastric ulcer: 1• wedge excision gastric ulcer – (always send for frozen to r/o
cancer)• Under-running the vessel• Followed by post-OP PPI, H.P. therapy, follow-up endoscopy• Effective and quicker
2Billroth 1 partial gastrectomy
3truncal vagotomy and pyloroplasty with excision of the ulcer
10/13/2014 52
![Page 53: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/53.jpg)
vagotomy
10/13/2014 53
![Page 54: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/54.jpg)
vagotomy
10/13/2014 54
![Page 55: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/55.jpg)
• Complications
– gastric atony,
– alkaline reflux gastritis,
– Dumping
– diarrhea.
10/13/2014 55
![Page 56: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/56.jpg)
VARICES
• Surgical Shunts:• Goal: decompression of the high-
pressure portal venous system into a low-pressure systemic venous system and devascularization of the distal esophagus and proximal stomach
• Portacaval shunt (end-to-side, side to side, interposition graft)
• Mesocaval shunt (Large- or small diameter interposition graft)
• Distal splenorenal (Warren) shunt
• Esophagogastricdevascularization,
• Esophageal transsection, & reanastomosis
• Orthotopic liver transplantation• Splenectomy (for splenic vein
thrombosis)
10/13/2014 56
![Page 57: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/57.jpg)
VARICES
• Surgical Shunts:
• bleeding control rate >90%
• No differences in survival rates: ~5%.
• Complications;
– Re-bleeding
– Encephalopathy
– Ascites
10/13/2014 57
![Page 58: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/58.jpg)
• Stress ulcers– Numerous ulcers- vagotomy + hemi-gastrectomy
– Few - oversewn
• Mallory-Weiss syndrome– Mucosal laceration is sutured
• Aorto-enteric fistula– Fistula disconnected and closed
– Aorta grafted with antibiotic primed graft and covered with omentum
– Antibiotic cover
10/13/2014 58
![Page 59: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/59.jpg)
NEGATIVE LAPAROTOMY
• No lesion may be found in the eosophagus, stomach or duodenum
• The small and larged intestined are carefully examined for possible source of bleeding
• If negative, the abdomen is closed
10/13/2014 59
![Page 60: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/60.jpg)
COMPLICATION OF UPPER GI BLEEDING
• Anaemia
• Sepsis
• DIC
• MODS
10/13/2014 60
![Page 61: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/61.jpg)
PROGNOSIS
• Overall mortality is 10-15%• 33% in patient over 70years• 70-80% of bleeding peptic ulcer stop bleeding
sponteneously• Predictors of mortality:
– Age– Shock– Co-morbidities– Delay in diagnosis – Re-bleeding
10/13/2014 61
![Page 62: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/62.jpg)
PROGNOSIS
• 20% re-bleed in 5-10years when treated conservatively
• When treated surgically, 4.5% re-bleed in 5-10years
• With H.pylori eradication, the re-bleeding rate is likely to go down.
10/13/2014 62
![Page 63: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/63.jpg)
CHALLANGES
• ICU space limited
– Hemodynamic instability
– Massive
• Delayed definitive diagnosis
10/13/2014 63
![Page 64: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/64.jpg)
CONCLUSION
• Even though 70-80% stops spontaneously,
• Bleeding frighten the patient it requires expeditious work-up ,prompt diagnosis and treatment.
• Accurate patient evaluation and early resuscitation before esophagogastroduodenoscopy (EGD) is critical to decrease the morbidity and mortality.
10/13/2014 64
![Page 65: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/65.jpg)
REFERENCES
• E.A. Badoe, E.Q. Arcampompong, J.T Rocha; “Principles and Practice of surgery including pathology in the tropics”. 4th edition, Assembly of God Literature Center ltd, 2009. P 637-641
• Souba, Wiley et al; “ACS Surgery principles and practice” 6th edition, WebMD Inc. (Professional Publishing), 2007.
• Sriram Bhat M; “SRB’s Manual of surgery” . 4th edition, Jaypee brothers medical publishers ltd, 2013.
• Mitchell S. Cappell, David Friedel,; Initial Management of Acute Upper Gastrointestinal Bleeding: From Initial Evaluation up to Gastrointestinal Endoscopy.Med Clin N Am 92 (2008) 491–509
• Ingrid Lisanne Holster, Ernst Johan Kuipers; Management of acute nonvaricealupper gastrointestinal bleeding: Current policies and future perspectives. World J Gastroenterol 2012 March 21; 18(11): 1202-1207
• Jiwon Kim; management and prevention of upper GI bleeding: Gastroenterology and Nutrition. PSAP -VII
10/13/2014 65
![Page 66: Discuss the management of upper gastrointestinal haemorrhage](https://reader036.fdocuments.us/reader036/viewer/2022081401/559dbabd1a28ab233b8b4847/html5/thumbnails/66.jpg)
»THANK YOU
10/13/2014 66