1 / 21

Management of acute upper GI haemorrhage

Management of acute upper GI haemorrhage. Causes. Peptic ulcer 35-50% Gastroduodenal erosions 8-15% Oesophagitis 5-15% Varices 5-10% Mallory Weiss tear 15%

billy
Download Presentation

Management of acute upper GI haemorrhage

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Management of acute upper GI haemorrhage

  2. Causes • Peptic ulcer 35-50% • Gastroduodenal erosions 8-15% • Oesophagitis 5-15% • Varices 5-10% • Mallory Weiss tear 15% • Upper GI malignancies 1% • Vascular malformations 5% • Rare 5%

  3. Initial resuscitation • Two large bore cannulae and take sample • Normal saline 1-2 lt fall of pulse/improved BP/adq urine • Plasma expander if still shocked • Blood transfusion - haematemesis/shock - Hb <10

  4. Severity of bleed • Current clinical scoring system( Rockall) for risk of re-bleed or death involves OGD • So definition of mild/mod/severe remains a matter of clinical judgement

  5. Mild to moderate bleed • Pulse/BP normal • Hb >10 • Insignificant comorbidity • Mostly <60 yrs • General ward • Allowed fluid if stable • BP/pulse hourly • Monitor urine volm • Endoscopy next available list • Early discharge

  6. Continued • Excellent prognosis if no SRH/varices/malignancy • Subsequent management • May include H.Pylori eradication • Use of acid suppressing treatment • Advice concerning NSAIDs

  7. Severe bleed • Pulse>100 • SBP < 100 • Hb < 10 • Significant comorbidity • Mostly >60 yrs • Preferably HDU • Hrly BP/pulse/ urine volm • Fasted • Urgent endoscopy after resuscitation

  8. Endoscopy in acute upper GI haemorrhage • Semi-elective in minor and urgent in major bleed • Only after initial resuscitation • Best done in endoscopy unit • But out of hours ,operating theatre with full resus. Equipment and anaesthetist may be better option • Only expert endoscopists • Consider ET tube to prevent aspiration

  9. Endoscopic finding & subsequent management • No SRH : general ward • Varices : VBL/VScl • Ulcer with SRH : endoscopic haemostasis 1.adrenaline inj 2.heat application 3.mechanical clips

  10. Drug therpy for non-variceal principally ulcer bleed • Evidence suggests following successful endoscopic treatment in patient presenting with major ulcer bleed high dose omeprazole stabilizes clot and prevents rebleed • omeprazole 80mg iv stat followed by 8mg per hour infusion for upto 72 hrs

  11. After endoscopy • Close monitor to identify rebleed • If stable after 6hrs allow light diet ( no data suggesting prolong fasting necessary) • Repeat endoscopy • If active rebleed • If concern re optimal initial therapy (after 12-24 hrs)

  12. Surgical intervention • If endoscopic therapy unsuccessful • In rebleed it is advisable to repeat endoscopy to confirm bleed and also try offer one more time of endoscopic therapy before considering surgery if it was initially successful • In massive rebleed sometimes surgical intervention is needed straightway if initial OGD was unfavourable

  13. Surgical options • Duodenal ulcers • Under running ±ligation of gastroduodenal/rt gastroepiploic arteries • Gastrectomy to include the ulcer with Billroth I or II reconstruction • Gastric ulcers • Excised • Parial gastrectomy • Under running if elderly with poor condition

  14. Follow up • For ulcer bleeds standard ulcer healing treatment • In most cases this also involves H.Pylori eradication • Ulcer associated with NSAID -stop drug or choose the least damaging one • Re-endoscope GU in 6wks to ensure healing. Not necessary for DU.

  15. Additional points for variceal haemorrhage • For no varix on initial endoscopy repeat 3yrly • For grade 1 varix yearly F/U • Primary prophylaxis with propranolol (80-160mg) for all grade 2/3 oesophageal varices • If unsuitable for ppnl, VBL is next option • ISMN

  16. Acute management of variceal haemorrhage • Antiobiotic prophylaxis for all patientsciprofloxacin 500mg BD for a week • VBL is method of choice for OV • VScl if above difficult or unavailable • If endoscopy unavailable vasoconstrictor therapy or balloon tamponade with Sengstaken tube while more definitive therapy is arranged

  17. continued • Pharmacological therapy is with two major classes of drugs –vasopressin or its analogue terlipressin (glypressin) and somatostatin or its analogue octreotide • Terlipressin is given as 2mg iv bolus followed by 1-2mg every 4-6 hrs for up to 72hrs

  18. OV BLEED • Controlled – banding eradication programme. One band /wk. F/U at 3& 6 month and then yearly • Uncontrolled –balloon tamponade until further endoscopic treatment/ TIPSS/surgical intervention • Choice of TIPSS or surgical intervention such as oesophageal transection depends on centre’s preference

  19. GV bleed • If IGV initial sclerotherapy with butyl-cyanoacrylate • If unsuccessful balloon tamponade prior to more definitive treatment

  20. Secondary prophylaxis of variceal haemorrhage • banding eradication programme • TIPSS • Portocaval shunt surgery

  21. Thank you

More Related