ACUT GI ACUT GI
BLEEDINGBLEEDING
Dr. LDr. Láászlszlóó AndrAndráás, MD. PhDs, MD. PhD
Semmelweis University,Semmelweis University,
KKúútvtvöölgyi lgyi ClinicalClinical CenterCenter
GI BLEEDINGGI BLEEDING
�� UGIBUGIB -- melaenamelaena
�� EsophagusEsophagus
�� EsophagitisEsophagitis
�� RefluxReflux
�� SoorSoor
�� VarixVarix
�� TuTu
�� StomachStomach
�� UlcerUlcer
�� ErosionErosion
�� TuTu
�� DuodenumDuodenum
�� UlcerUlcer
�� TuTu (pancreas?)(pancreas?)
�� LGIBLGIB -- hematochesiahematochesia
�� SmallSmall bowelbowel
�� Large bowelLarge bowel
�� DiverticulumDiverticulum
�� HemorrhoidsHemorrhoids
�� TuTu
�� PolypPolyp
�� CancerCancer
�� ColitisColitis
�� UCUC
�� CDCD
�� RadiationRadiation
�� IschaemieIschaemie
�� InfectionsInfections
�� PostpolypectomyPostpolypectomy
WhyWhy dodo wewe needneed urgenturgent endoscopyendoscopy??
Because the finding of the endoscopy determines the Because the finding of the endoscopy determines the
therapy:therapy:
�� Endoscopic treatment to stop bleedingEndoscopic treatment to stop bleeding
�� SengstakenSengstaken--BlackmooreBlackmoore tubetube
�� Esophageal Esophageal varixvarix bleedingbleeding
�� Conservative therapyConservative therapy
�� Erosions, notErosions, not--bleeding ulcersbleeding ulcers
�� SurgerySurgery
�� Active bleeding, Active bleeding, rebleedingrebleeding
ContraindicationsContraindications toto
emergencyemergency endoscopyendoscopy
�� GI perforationGI perforation
�� Sever hemodynamic instabilitySever hemodynamic instability
�� Uncooperative pt.Uncooperative pt.
�� Lack of informed consentLack of informed consent
TherapyTherapy forfor oesophagealoesophageal
varixvarix bleedingbleeding
�� InjectionInjection therapytherapy withwith aethoxysclerolaethoxysclerol
�� Esophageal Esophageal varixvarix band ligationband ligation
�� SengstakenSengstaken--BlackmooreBlackmoore TubeTube
NONVARICEAL UGIBNONVARICEAL UGIB
�� > 300.000 > 300.000 hosp.admhosp.adm./year in the US./year in the US
�� Mortality 8 Mortality 8 –– 10 % (no change in the last 50 10 % (no change in the last 50
years years -- age, age, comorbidcomorbid illnesses)illnesses)
�� 8080--85% of bl. stop with supportive 85% of bl. stop with supportive thth..
�� 1515--20 % high risk group, require early 20 % high risk group, require early
identification:identification:enendoscopy,surgary,angigr.thdoscopy,surgary,angigr.th..
Rapid AssessmentRapid Assessment
Hemodynamic statusHemodynamic status
Fluid resuscitationFluid resuscitation
Gastric Gastric lavagelavage??
Empirical medical therapyEmpirical medical therapy
Self limited hemorrh.(80%) Self limited hemorrh.(80%)
Elective endoscopyElective endoscopy
(within 12(within 12--24 h)24 h)
Definitive therapyDefinitive therapy
Active or severe hemorrh.(10Active or severe hemorrh.(10--20%)20%)
Urgent endoscopy Urgent endoscopy
(within 6 h)(within 6 h)
Site not localized Site localizedSite not localized Site localized
Further assessment:Further assessment:
Bleeding scan,Bleeding scan,
EnteroscopyEnteroscopy
AngiographyAngiography
SurgerySurgery
Definitive therapyDefinitive therapy
GastroGastro--duodenal ulcerduodenal ulcer
�� Common Common
�� HelHeliicobactercobacter pylori infectionpylori infection
�� NSAID inducedNSAID induced
�� Stress ulcerStress ulcer
�� UncommonUncommon
�� ZollingerZollinger--Ellison syndrome (Ellison syndrome (gastrinomagastrinoma))
�� CrohnCrohn diseasedisease
�� InfectionsInfections
�� Chr. renal failureChr. renal failure
�� Radiation inducedRadiation induced
�� Penetrating tumorPenetrating tumor
HowHow cancan wewe assessassess thethe severityseverity of of
hemorrhagehemorrhage??
�� Orthostatic decrease of 20 mmHgOrthostatic decrease of 20 mmHg
�� Increase in pulse rate of 20 beats/minIncrease in pulse rate of 20 beats/min≥≥ 20% 20% intravascintravasc. volume depletion. volume depletion
HypovolemicHypovolemic shockshock
�� HematocritHematocrit? ? –– misleading! Equivalent loss of plasma & misleading! Equivalent loss of plasma & RBC RBC –– after 72 h is competent.after 72 h is competent.
WhatWhat toto dodo firstfirst??
�� Blood to the lab, typing, Blood to the lab, typing, crossmatchingcrossmatching
�� 2 large intravenous catheters2 large intravenous catheters
�� Fluid replacement Fluid replacement
�� RingerRinger’’s lactates lactate
�� Colloid Colloid –– only in sever only in sever hypoalbuminemiahypoalbuminemia
�� SympathomimeticSympathomimetic agents agents –– only in only in refrrefr. shock. shock
�� Transfusion Transfusion –– not whole blood (fluid overdose, immunoreactions), but PRBC not whole blood (fluid overdose, immunoreactions), but PRBC
�� Hgb:7Hgb:7--10g/l 10g/l
�� 1 U of PRBC 1 U of PRBC HgbHgb 1,0 1,0 g/lg/l in in nonbl.ptnonbl.pt..
�� Massive blood transfusion Massive blood transfusion –– hypocalcemiahypocalcemia, hypothermia, , hypothermia, thrombopeniathrombopenia, ,
coagcoag. . factor(Vfactor(V, VIII) deficiencies (stored blood), VIII) deficiencies (stored blood)
�� FFP, platelets FFP, platelets –– 80.000, but aspirin, 80.000, but aspirin, NSAIDsNSAIDs make make pltplt. dysfunctional. dysfunctional
ClinicalClinical prognosticprognostic factorsfactors
�� Severity of bleedingSeverity of bleeding
�� Hemodynamic instability on initial examinationHemodynamic instability on initial examination
�� Persistent hypotensionPersistent hypotension
�� Transfusion requirements: 4Transfusion requirements: 4--6 U/24h6 U/24h
�� HematemesisHematemesis, , hematocheziahematochezia, bloody gastric asp., bloody gastric asp.
�� Age > 60Age > 60
�� ComorbidComorbid illnessesillnesses
�� Onset of bl. while already hospitalizedOnset of bl. while already hospitalized
�� Recurrent hemorrhage (20%, mortality 30%)Recurrent hemorrhage (20%, mortality 30%)
EndoscopicEndoscopic diagnosticdiagnostic factorsfactors
�� Ulcer location Ulcer location –– close large vessels close large vessels
�� Posterior duodenal bulbPosterior duodenal bulb
�� Higher lesser gastric curvatureHigher lesser gastric curvature
�� Ulcer size Ulcer size –– 11--2 cm diameter2 cm diameter
�� Adherent clotAdherent clot
�� Visible vesselVisible vessel
�� Active bleedingActive bleeding
INCREASED LIKELIHOOD OF REBLEEDING & DEATHINCREASED LIKELIHOOD OF REBLEEDING & DEATH
MedicalMedical treatmenttreatment of UGIBof UGIB
�� Gastric Gastric lavagelavage
�� Iced salineIced saline
�� VasoconstrictingVasoconstricting agentsagents
�� AntifibrinolyticsAntifibrinolytics
�� Pharmacologic agentsPharmacologic agents
�� H2RAH2RA
�� PPIPPI
�� ProstoglandinProstoglandin analoguesanalogues
�� VasoconstrictorsVasoconstrictors
NO MEDICAL THERAPY CAN BE STRONGLY RECOMMENDEDNO MEDICAL THERAPY CAN BE STRONGLY RECOMMENDED
TherapeuticTherapeutic endoscopyendoscopy forfor
acuteacute nonvaricealnonvariceal UGIBUGIB
�� Thermally active methodsThermally active methods
�� Laser photocoagulationLaser photocoagulation
�� Topical or injection methodsTopical or injection methods
�� SclerotherapySclerotherapy
�� Tissue gluesTissue glues
�� Clotting factorsClotting factors
�� Mechanical methodsMechanical methods
�� Band ligationBand ligation
�� Endoscopic staplingEndoscopic stapling
AngiographicAngiographic interventionintervention inin UGIBUGIB
�� UncommonUncommon
�� Severe, persistent bleeding, if surgery confers a Severe, persistent bleeding, if surgery confers a
high risk, and endoscopic high risk, and endoscopic thth. is not available or . is not available or
unsuccessful.unsuccessful.
�� Art.embArt.emb. with absorbable gelatin sponge, or with . with absorbable gelatin sponge, or with
nonadsorbnonadsorb. . polyvinilpolyvinil alcohol, or alcohol, or spongspong--wire coils wire coils
–– 7575--80 % success80 % success
SurgicalSurgical treatmenttreatment of UGIBof UGIB
�� Failure to control bl. with Failure to control bl. with nonoperativenonoperative meansmeans
�� Severe Severe rebleedingrebleeding despite of 2 attempts of endoscopic despite of 2 attempts of endoscopic hemostasishemostasis
�� A lesion inaccessible to endoscopyA lesion inaccessible to endoscopy�� Prior surgeryPrior surgery
�� Anatomic anomalyAnatomic anomaly
�� Pyloric Pyloric stenosisstenosis
�� Sever shockSever shock
�� Severe complication of endoscopic therapySevere complication of endoscopic therapy�� PerforationPerforation
�� Worsening bleedingWorsening bleeding
Prevention of ulcer Prevention of ulcer rebleedingrebleeding
�� Acid suppressive medications: H2RA, PPIAcid suppressive medications: H2RA, PPI
�� Eradication of Helicobacter pyloriEradication of Helicobacter pylori
�� Cessation of NSAID useCessation of NSAID use
SpecificSpecific cousescouses of UGIBof UGIB
�� Stress related mucosal injuryStress related mucosal injury
�� Congestive Congestive gastropathygastropathy
�� MalloryMallory--Weiss Weiss sysy
�� TumorsTumors
�� Vascular Vascular malformmalform..�� AngiodysplasiaAngiodysplasia
�� OslerOsler--WeberWeber--RenduRendu diseasedisease
�� General General antralantral vascvasc. . ectasiaectasia
(watermelon stomach(watermelon stomach))
�� HemobiliaHemobilia
�� DieulafoyDieulafoy’’ss lesion (caliber lesion (caliber persist.artpersist.art.).)
�� AortoentericAortoenteric fistulafistula