CIRRHOSIS ASSIT.PROF. ZAHER TARIK IBRAHIM ZAHER TARIK IBRAHIM AMANY MOHAMAD IBRAHIM.
PROF. IBRAHIM A. AL-MOFLEH Professor of Medicine, College of Medicine & University Hospitals, KSU...
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Transcript of PROF. IBRAHIM A. AL-MOFLEH Professor of Medicine, College of Medicine & University Hospitals, KSU...
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PROF. IBRAHIM A. AL-MOFLEH Professor of Medicine, College of Medicine
& University Hospitals, KSU
PROF. IBRAHIM A. AL-MOFLEH Professor of Medicine, College of Medicine
& University Hospitals, KSU
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ACUTE GI – BLEEDING
(AGIB)
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Forms
• Upper
• Lower
• Obscure
AGIB
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Epidemiology
•Common (e.g. 15000 deaths/yr in USA)
•Upper is 5 x more than lower
•More frequent in men and elderly
•Spontaneous cessation in 80%
•Mortality in general 10%
in elderly 20%
cont. bl/rebleeding >30%
AGIB
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A 60 yrs old patient was brought with the ambulance to the emergency room with acute GI-bleeding ; you are asked to care for this patient
What are your plans (objectives)? How would you approach him?
Mention the adverse prognostic factors?
AGIB
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Objectives
• Maintain the hemodynamics
• Determine the level
• Determine the cause
• Treat and prevent rebleeding
AGIB
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How to approach the patient?
1. Initial assessment
2. Resuscitation
3. History and exam
4. Lab evaluation
5. Localization
6. Treatment
AGIB
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Initial assessment – A
How urgent is the situation
stable
or in shock ?
What are the features of shock ?
What is the magnitude of blood loss ?
)1 (
AGIB
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Initial assessment – B
What are the features of shock ?
• Agitation
• Pallor
• Hypotension
• Tachycardia
) 1(
AGIB
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VS Blood loss (% of total volume)VS Blood loss (% of total volume) Severity of bleed Severity of bleed
Normal < 10% Mild
Postural drop 10 – 20% Moderate
Shock > 20% Severe
How to assess the magnitude of blood loss?
AGIB
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How to approach the patient?
1. Initial assessment
2. Resuscitation
3. History and exam
4. Lab evaluation
5. Localization
6. Treatment
AGIB
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Resuscitation Hemodynamically unstable patient
• Restore and maintain hemodynamics
• Oxygen
• Monitor VS and urinary output
• Admission to ICU
• Blood transfusion
• ? FFP
) 2(
AGIB
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AGIB
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Resuscitation Indications for blood transfusion
• Unstable VS
• Continuous bleeding
• Bright blood
• Age > 60
• Concomitant CPD
) 2(
AGIB
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How to approach a patient with AGIB?
1. Initial assessment
2. Resuscitation
3. History and exam
4. Lab evaluation
5. Localization
6. Treatment
AGIB
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History and examination
HistoryHistory Exam Exam
Age Stigmata of CLD
Dyspepsia Hereditary vascular anomalies
Previous bleeding Scars
Previous PUD Palpable organs / masses
Previous endoscopy Lymphadenopathy
Previous surgery PR
(PUD aortic graft etc..)
Drugs
CLD
Weight loss, Anorexia
Changing bowel habits
) 3( AGIB
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How to approach a patient with AGIB?
1. Initial assessment
2. Resuscitation
3. History and exam
4. Lab evaluation
5. Localization
6. Treatment
AGIB
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Laboratory parameters
• Type and crossmatchingType and crossmatching
• CBC, PT, PTT,CBC, PT, PTT,
• BUN , BUN / Creatinin ratioBUN , BUN / Creatinin ratio
• LFTLFT
• ABGABG
) 4(
AGIB
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How to approach a patient with AGIB?
1. Initial assessment
2. Resuscitation
3. History and exam
4. Lab evaluation
5. Localization
6. Treatment
AGIB
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Localization
• Clinical
• Endoscopy
• RBC scan
• Angiography
) 5 (
AGIB
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How to approach a patient with AGIB?
1. Initial assessment
2. Resuscitation
3. History and exam
4. Lab evaluation
5. Localization
6. Treatment
AGIB
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Treatment
• Medical
• Endoscopic
• Angiographic
• Surgical
) 6(
AGIB
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Adverse prognostic factors
ClinicalClinical
• Old age
• Comorbid diseases
• Bright blood (NGA, vomitus, stool)
• Onset of bleeding in the hospital
• Amount of blood lost
• Shock or hypotension on presentation
• Emergency surgery
AGIB
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Adverse prognostic factors
EndoscopicEndoscopic
• Vascular bleeding
• Active bleeding
• Visible vessel
• Clot
• Giant ulcer
AGIB
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Indications for emergency endoscopy
• Cause
• Severity
• Age
• Cirrhosis
• Persistent bleeding
• Rebleeding
AGIB
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Role of endoscopy
• Site of bleeding
• Source of bleeding
• Stigmata of bleeding PUD
−Active bleeding
−Visible vessel
−Clot
−Black spot
• Endoscopic therapy
AGIB
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Endoscopic hemostatic methods
• Variceal bleeding
Injection
Banding
• Non-variceal bleeding
Injection
Thermal
Clips
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Bleeding Esophageal Varices
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EVL
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Gastric Varices
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GU – Visible Vessel
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Sentinel Clot
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Gastric Angiodysplasia
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Bleeding Angiodysplasia
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DU – Bleeding Control
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DU – Bleeding
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GU Clips
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Bleeding GU
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Bleeding Diverticulum
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Diverticulum Visible Vessel
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Bleeding hemorrhoids
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Dieulafoy - Colon
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Thank you !Thank you !