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UPPER GI BLEEDING

UPPER GI BLEEDING. Busara Charoenwat , MD. Pediatric Gastroenterology and Hepatology Department of Pediatric, KKU. Upper GI Bleeding. Epidemiology. Pediatric Endoscopy Database System - Clinical Outcomes Research Intensive (PEDS-CORI) 5 % hematemesis (327 from 6337 patients) PICU

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UPPER GI BLEEDING

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  1. UPPER GI BLEEDING BusaraCharoenwat, MD. Pediatric Gastroenterology and Hepatology Department of Pediatric, KKU

  2. Upper GI Bleeding

  3. Epidemiology • Pediatric Endoscopy Database System - Clinical Outcomes ResearchIntensive (PEDS-CORI) • 5 % hematemesis (327 from 6337patients) • PICU • 6-25 % hematemesis • Mortality rate 0.4% • Bancroft J, et al. gastrointest endosoc 2003;57:AB121. • Chaibou M, et al. Pediatrics 1998;102:933-8. • Cochran EB et al. Crit Care Med 1992;20:1519-23.

  4. Is it blood? Is it blood? Is the bleeding GI? Nasopharynx Respiratory (hemoptysis) GI • Red color food • Tomato, strawberry, spinach, beetroot, iron

  5. GI bleeding site UGIB/ LGIB UGIB/ MGIB/ LGIB UGIB UGIB MGIB LGIB Ligament of Triez LGIB • สุพจน์ นิ่มอนงค์. Classification of gastrointestinal bleeding. • เลือดออดในทางเดินอาหาร 2553. หน้า 1-3.

  6. GI bleeding site

  7. Modalities EGD Colonoscopy Capsule enteroscopy

  8. Characteristics of the bleeding Hematemesis Coffee ground Melena Hematochezia

  9. Etiology of UGIB by age group • Gilger M, Whitfield K. Upper gastrointestinal bleeding. • Walker's Pediatric Gastrointestinal Disease: 5th ed; 2008. p. 1285-90. • Romano C, et al. World J Gastroenterol 2017;23:1328-37.

  10. UGIB: esophagus • (A) (B) (C) • Reflux esophagitis Esophageal varices Candida esophagitis

  11. UGIB: stomach (F) H.pylori infection (D) Stress gastritis (E) Gastric varices (G) Fundic gland polyp

  12. UGIB: duodenum (H) Duodenitis/ duodenal ulcer

  13. UGIB: others (I) (J) (K) Dieulafoy lesion Gastric Crohn’s disease hemangioma

  14. Diagnosis Varices Non-varices Extrahepatic Intrahepatic Pre-sinusoid Sinusoid Post-sinusoid Swallowed maternal blood CMPA Esophagitis Gastritis Biecker E. World J Gastroenterol 2013;19:5035-50.

  15. Portal hypertension Wyllie R. et al, Pediatric Gastrointestinal and Liver Disease. 2015;9:928-43.

  16. Variceal bleeding Signs of portal hypertension

  17. Non-variceal bleeding Romano C, et al. World J Gastroenterol 2017;23:1328-37.

  18. Management • Supportive treatment • Specific treatment • Variceal bleeding • Non - variceal bleeding

  19. Supportive treatment • Airway, Breathing, Circulation • Volumn status • NG/ SBBT • Blood components (keep Hb 7-8 g/dL) • Correct coagulopathy

  20. Specific treatment • Romano C, et al. World J Gastroenterol 2017;23:1328-37. • Laine L. N Engl J Med 2016;374:2367-76. • Bozic MA , et al. Curr Gastroenterol Rep 2015;17:1-8.

  21. Acid secretion

  22. Transjugular intrahepatic portosystemic shunt (TIPS)

  23. Need for endoscopy? Thomson MA, et al. JPGN 2015;60: 632–36

  24. Sheffield Scoring System Thomson MA, et al. JPGN 2015;60: 632–36.

  25. ESPGHAN guideline Thomson MA, et al. JPGN 2017;64: 133–53.

  26. ESPGHAN guideline Thomson MA, et al. JPGN 2017;64: 133–53.

  27. ESPGHAN guideline ESPGHAN guideline Thomson MA, et al. JPGN 2017;64: 133–53.

  28. ESPGHAN guideline Thomson MA, et al. JPGN 2017;64: 133–53.

  29. EVS/ EVL EVS/ EVL EVS EVL Pre - EVS Post - EVS Pre - EVL Post - EVL

  30. Mechanical device Hemoclips Thermocoagulation

  31. Prophylaxis

  32. Meso-Rex bypass shunt Shneider BL, et al. Hepatology 2016;63:1368-80.

  33. Take home messages • Required prompt attention • Recognition • Always remember: ABCD • Required urgent co-operation • Doctors management • Nursing care • Laboratory investigations • Supportive/ specific treatment

  34. Thank you!

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