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Gastrointestinal bleeding: GIB(UGIB,LGIB)

Gastrointestinal bleeding: GIB(UGIB,LGIB)

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GIB

NVUGIBA

LGIB2

VUGIB3B

UGIB31

NVUGIB:Causes

Erosive gastropathy2

AVM (HHT)4

Dialafoey lesions33

PUD31

Tumors(benign/malignan)6

Bleeding tendencies8

Aortoduodenalfistula37

MW eso tears35

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 lineBlood group/cross matchwith pulse oximetry,cardiac monitoring, automated BP readings,close monitoring of UO &ideally, CVP

ERABC(shock/airway

compromise)

IVFCrystalloids until blood readyColloids 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 7-8gmsIf no Continuous bleeding or

CVD).

Blood benefits(43% require it

Target Hb 7-8gmsIf 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 & clotsTo 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 needFor endohemostasis

Hematemesis *2 mortalty,rebleed & endohemostasis

Risky statesRisky states

Risk stratification: other than scoring systems

Inpatient at time of bleed *3 mortalityCompared to new admisions

High BU increase need for Endohemostasis

hematochezia *2 mortalty,rebleed & endohemostasis

Risky statesRisky 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 UlcerRisky Ulcer

PREENDOSCOPY:PPI either oral or IV (better)

reducereduce High risk lesions High risk lesions at OGDat OGD ENDO InterventionsENDO Interventions

PH>6Optimal

plat agg clot formation

No effect on mortality, syrgery need or rebleedingNo effect on mortality, syrgery need or rebleeding

Preendoscopy PPI: Most suitable for

Pre OGD PPIPre 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 clinicalendpoints

IV erythro most suitable for patientsMost likely to have blood in stomach at initial OGD.

Plasil if IV eryhthroNo available

IV eryhthroNeed PRIOR ECG

Pre-endoscopic antifibrinolytics /SST,OCT

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.

3not recommended in the routine management of patients with acute NVUGIB.(for VGIB)

?Blee du ncontrollably 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

11 22 33

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 reduced MortalityMortality

In active bleeders& NBVVIn active bleeders& NBVV

Reduce Reduce rebleedrebleed Need forNeed for

surgerysurgery

Postendoscopy Test&treat H Pylori

Treated if +VE

Eradication Reduces rebleed.

Tested to confirmeradication

Tested for HP

All bleeding PUSHOULD

IncreasedFalse –ve testing

Post endoscopy general in-hosp management.

High risk lesions

Add Your Text

If was on asp/NSAIDs

Low risk

Add Your TextTextText

TextText

Evaluate risk/benefir ratioEvaluate risk/benefir ratioReuse within 5 days.Reuse within 5 days.

Fed within 24 hs & discharged onFed within 24 hs & discharged onOral PPI within1-2 days.Oral PPI within1-2 days.

72 hour monitoring for rebleeding72 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.

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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