ManagementManagement

Harim MohsinHarim Mohsin

ManagementManagement

Evaluation/ AssessmentEvaluation/ AssessmentStabilizationStabilizationHistoryHistoryPhysical examinationPhysical examinationSpecific TreatmentSpecific TreatmentFollow-upFollow-up

Stabilization & assesmentStabilization & assesment Initial management begins with assessing and Initial management begins with assessing and

addressing the ABCs.addressing the ABCs.

Assessment of hemodynamic statusAssessment of hemodynamic status Severe bleedingSevere bleeding-Systolic bp <100- any HR-Systolic bp <100- any HR Moderate loss-Moderate loss-HR >100 + systolic bp >100HR >100 + systolic bp >100 Mild loss-Mild loss- Normal bp & HR Normal bp & HR

Portal hypertension & tachycardia are useful but Portal hypertension & tachycardia are useful but may be due to other causes. may be due to other causes.

In patients with significant bleeding large bore (16-18-In patients with significant bleeding large bore (16-18-guage) I/v lines should be maintained prior to further guage) I/v lines should be maintained prior to further diagnostic tests.diagnostic tests.

In case of hemodynamic compromise give Ringer’s In case of hemodynamic compromise give Ringer’s lactate or normal saline & cross-matched blood.lactate or normal saline & cross-matched blood.

Plasma substitutes such as Haemaccel may also be Plasma substitutes such as Haemaccel may also be used. used.

Give Oxygen therapy to any patient in shock. Give Oxygen therapy to any patient in shock.

Send blood forSend blood for:: Complete blood countComplete blood count PTPT Serum creatinineSerum creatinine Liver enzymesLiver enzymes Cross-matchingCross-matching

Pass nasogastric tube to perform an aspirate to Pass nasogastric tube to perform an aspirate to determine whether the GI bleeding is emanating determine whether the GI bleeding is emanating from above or below the ligament of Treitz . from above or below the ligament of Treitz .

Aspirate by color:Aspirate by color: Red or coffee ground-Red or coffee ground- active bleeding active bleeding Clear gastric fluid-Clear gastric fluid- duodenal site of bleeding duodenal site of bleeding

possible. possible. Bile without blood-Bile without blood- UGIB less likely UGIB less likely

Rockall Scoring forRockall Scoring for

risk of re-bleeding & risk of re-bleeding & death after hospital death after hospital

admission for acute admission for acute

UGIBUGIB

Baylor Bleeding Score

Pointvalue 0 1 2 3 4 5Age

30 évalatt

30-49 50-59 60-69 -Over 70

Preendoscopyscore

Number ofparalellillnesses

0 1 or 2 - - 3 or 45 or

more

Severity ofparalellillnesses

- - - -Chronic Acute

Postendoscopyscore

Localisationof ulcer

- - - -Posterior

wall ofbulb

-

SRH - Adherentclott

- Visiblevessel -

Activebleeding

History & examinationHistory & examination

Specific managementSpecific management

Medical treatment

Endoscopic treatment

Surgical treatment

Medical treatment

Endoscopic treatment

Surgical treatment

Medical treatment

Reduction of acid production H2RA-Histamine Receptor antagonists (eg

Cimetidine, Ranitidine)- decrease cAMP PPI-Proton pump inhibitors-Inhibit parietal cell

H+/K+- ATPase pump (eg Lansoprazole, Omeprazole)- (I/v 80mg followed by 8mg per hour 80mg followed by 8mg per hour for 72 hours)for 72 hours)

OctreotideOctreotide- continuous Infusion reduces splanchnic - continuous Infusion reduces splanchnic blood flow & portal blood pressure effective blood flow & portal blood pressure effective initially in bleeding due to portal hypertension. initially in bleeding due to portal hypertension.

Medical treatmentMedical treatment

Heamostatic drugs- Transexemic acid(antifibrinolytic agent) - reduction of the Transexemic acid(antifibrinolytic agent) - reduction of the

level of fibrlevel of fibrininogen fragments improving platelet function.ogen fragments improving platelet function. TXA stabilizTXA stabilizeses haemostatic clots by (1) preventing haemostatic clots by (1) preventing

bbininddining of plasmg of plasmininogen to fibrogen to fibrinin inin blood clots blood clots (2)preventing activation of plasm(2)preventing activation of plasmininogen to active plasmogen to active plasmin.in.

Other drugs used:Other drugs used: Vasopressin- produces mesenteric vasoconstriction and Vasopressin- produces mesenteric vasoconstriction and

thus decreases portal venous inflow and pressure thus decreases portal venous inflow and pressure SomatostatinSomatostatin

Volume and blood replacement as required

Endoscopic TreatmentEndoscopic Treatment EndoscopyEndoscopy, should be performed immediately after , should be performed immediately after

hemodynamic stabilization & evaluation within 12 hours.hemodynamic stabilization & evaluation within 12 hours.This is useful for:This is useful for: Diagnosing the cause of bleeding Diagnosing the cause of bleeding Estimating prognosis Estimating prognosis Therapeutic haemostasisTherapeutic haemostasis

Contraindications to upper endoscopyContraindications to upper endoscopy Uncooperative patient Uncooperative patient Acute myocardial infarction (unless haemorrhage life-Acute myocardial infarction (unless haemorrhage life-

threatening) threatening) Perforated viscus Perforated viscus

Endoscopy of stomachEndoscopy of stomach

Endoscopic treatmentEndoscopic treatment

The endoscopic appearance of the bleeding lesion The endoscopic appearance of the bleeding lesion has been used to identify patients at high risk for has been used to identify patients at high risk for recurrent bleeding. recurrent bleeding.

High risk-High risk- active bleeding, visible vessels, active bleeding, visible vessels, adherent clots. adherent clots.

Low risk-Low risk- flat, pigmented spots and those that flat, pigmented spots and those that involve a clean ulcer base with no visible vessel. involve a clean ulcer base with no visible vessel.

The indication for endoscopic therapy is based The indication for endoscopic therapy is based on the size, site, and stigmata of recent on the size, site, and stigmata of recent bleeding. bleeding.

Endoscopic treatment

Topical treatment Injection treatmentMechanical treatmentThermal treatment

Topical treatment

Tissue adhesives Blood clotting factors

(throbin,fibrinogen)Vasoconstricting drugs (epinephrine)Collagen (microcrystalline collagen

hemostat (MCH)

Injection therapy

Injection therapy consists of using solutions injected into and around the bleeding lesion to attain hemostasis.

Sclerosant agents (ethanol, polidocanol, and sodium tetradecyl sulfate )-induce thrombosis, tissue necrosis, and inflammation at the site of injection

Epinephrine- Causes vasoconstriction Thrombin/ Fibrin glue- clot producing agents.

Injection therapy consists of using solutions injected into and around the bleeding lesion to attain hemostasis.

Sclerosant agents (ethanol, polidocanol, and sodium tetradecyl sulfate )-induce thrombosis, tissue necrosis, and inflammation at the site of injection

Epinephrine- Causes vasoconstriction Thrombin/ Fibrin glue- clot producing agents.

Mechanical treatment

Loops- Easy, precise and cost-effective variceal ligation. The loop ensures a firm and precise ligation with adjustable ligating force that remains in place for a period of time then leaves the GI tract naturally.

Sutures

Balloon treatment-The 2 most commonly used tubes are the Sengstaken-Blakemore tube and the Minnesota tube. These tubes have an esophageal balloon and a gastric balloon that are inflated to produce a tamponade effect after confirming appropriate anatomical placement

Haemostatic clips- Provide Fast, efficient haemostasis In In addition, maintains the integrity of the surrounding tissue. addition, maintains the integrity of the surrounding tissue.

Thermal treatment Laser photocoagulation-uses an Nd:YAG laser to create hemostasis by uses an Nd:YAG laser to create hemostasis by

generating heat and direct vessel coagulation.generating heat and direct vessel coagulation.

Coaptive coagulationCoaptive coagulation uses direct pressure and heater probe & uses direct pressure and heater probe &

electrocoagulation (monopolar & bipolar) therapy electrocoagulation (monopolar & bipolar) therapy to achieve hemostasis. The bleeding vessel is to achieve hemostasis. The bleeding vessel is isolated, compressed, and tamponaded, isolated, compressed, and tamponaded, minimizing the depth of tissue injury. minimizing the depth of tissue injury.

Management after endoscopyManagement after endoscopy

Careful monitoring is needed after endoscopy for UGIB Careful monitoring is needed after endoscopy for UGIB (pulse, blood pressure, urine output). It is imperative to (pulse, blood pressure, urine output). It is imperative to identify rebleeding or continuing bleeding. identify rebleeding or continuing bleeding.

If patients are stable 4-6 hours after endoscopy they If patients are stable 4-6 hours after endoscopy they should be put on a light diet as there is no benefit in should be put on a light diet as there is no benefit in continued fasting. continued fasting.

Repeat endoscopy is required if there is evidence of Repeat endoscopy is required if there is evidence of rebleeding (for example with melaena or unstable rebleeding (for example with melaena or unstable observations). observations).

Occasionally major rebleeding may be an indication for Occasionally major rebleeding may be an indication for surgical intervention without further endoscopy. surgical intervention without further endoscopy.

Surgical intervention

Surgical intervention is required Surgical intervention is required when endoscopic techniques fail or are when endoscopic techniques fail or are

contraindicated. Clinical judgement is contraindicated. Clinical judgement is required with expert personnel. required with expert personnel.

In case of continous or rebleeding

Surgery typesSurgery types Transjugular intrahepatic portosystemic

shunt (TIPS)- (TIPS)- A self-expanding metal stent is placed between the A self-expanding metal stent is placed between the

systemic venous system and the portal system.systemic venous system and the portal system. The placement of a TIPS reduces the outflow The placement of a TIPS reduces the outflow

hepatic resistance, lowers portal pressure, and hepatic resistance, lowers portal pressure, and diverts portal blood flow from gastroesophageal diverts portal blood flow from gastroesophageal collaterals through the stent. collaterals through the stent.

Liver transplantation or decompression should be Liver transplantation or decompression should be considered alongside if portal hypertension considered alongside if portal hypertension present. present.

Surgical treatmentSurgical treatment Surgical shunts:Surgical shunts:

(1)(1) decompression of the high-pressure portal venous decompression of the high-pressure portal venous system into a low-pressure systemic venous system and system into a low-pressure systemic venous system and

(2)(2) devascularization of the distal esophagus and proximal devascularization of the distal esophagus and proximal stomach stomach

Non-Selective shuntsNon-Selective shunts-completely divert portal blood flow from -completely divert portal blood flow from the liver the liver

Selective shuntsSelective shunts-decompresses the varices while -decompresses the varices while maintaining hepatopetal blood flow in the remainder of maintaining hepatopetal blood flow in the remainder of the portal system. the portal system.

Partial shunts-Partial shunts- decompresses varices while maintaining decompresses varices while maintaining hepatic portal perfusion. hepatic portal perfusion.

Surgical treatmentSurgical treatment

Local operationSuture

Local operation + vagotomyResection type operation

Variceal bleedingVariceal bleeding

Cirrhosis

-Billiary

-Alcoholic Portal hypertension

(15-30 Hgmm) Rupture of varicose

veins

Treatment of variceal bleeding

Balloon tamponadeSclerotherapy Oesophageal transsectionPorto/caval shuntTIPS (Interventional radiology))

Non-variceal bleedingNon-variceal bleeding

Peptic ulcerPeptic ulcerMallory-Weiss tearMallory-Weiss tearErosive gastritis/duodenitisErosive gastritis/duodenitisEsophagitis/ oesophageal ulcerEsophagitis/ oesophageal ulcerMalignancyMalignancyAngiodysplasia /vascular malformationsAngiodysplasia /vascular malformationsOtherOther

Treatment of Non-variceal bleedingTreatment of Non-variceal bleeding

Repeat endoscopy Repeat endoscopy Emergency surgeryEmergency surgeryTranscatheter arteriography followed by Transcatheter arteriography followed by

transcatheter intervention (usually transcatheter intervention (usually embolization) embolization)

ComplicationsComplications

Specific to the cause of UGIBSpecific to the cause of UGIBMay arise from interventional tools. May arise from interventional tools.

RebleedingRebleeding

ShockShock

AnemiaAnemia

AspirationAspiration

TachycardiaTachycardia

PerforationPerforation

DeathDeath