Upper GI Bleeding - Overview and Management

1. UPPER GASTROINTESTINAL BLEEDING (UGIB) DR. AINIL FATIMA BINTI ZAINODIN DR. AHMAD ZHAFIR BIN ZULKIFLI SUPERVISED BY: DR. MOHD FADHIL BIN DATO HJ AHMAD NAZLAN

2. UGIB : (Proximal to Ligament of Treitz)

3. UGIB : CLINICAL PRESENTATION • Aim – to get diagnosis, to find causes, to elicit complications • Hematemesis:Red Blood, “Cofee- ground” • Malena: Black, Tarry, Foul smelling stool • Sx of Anemia • Occult GI Bleeding : + Iron Deficiency • Abdominal pain

4. UGIB : Risk Factor • Causes • PMh(x) : CLD, Hep B/C , H. Pylori infection, previous PUD, Dyspepsia • Drug history : NSAIDS, aspirin, steroid • Alcohol, smoking • Trauma • Constitutional symptoms

6. CONTENT • ANATOMY(HEPATIC PORTAL VEIN TRIBUTE) • GASTROESOPHAGEAL VARICEAL • PRIMARY PROPHYLAXIS • SCREENING • MANAGEMENT OF ACUTE VARICEAL BLEEDING • MANAGEMNT OF OESOPHAGEAL VARICEAL BLEEDING

7. Gastroesophageal variceal

9. INTRODUCTION • Gastroesophagealvariceal bleeding accounts for 10-30% of UGIB • Majorcause of death in patients withcirrhosis • Variceal bleeding accounts for 6.4% of UGIB in Malaysia. • Etiologyof cirrhosis in Malaysia ismainly due to chronic infection hepatitis B or alcoholic liver disease

10. OESOPHAGEAL VARICES • HVPG (Hepatic Venous Pressure Gradient) -Normal HVPG < 5 mmHg - Varices HVPG >12 mmHg (cause bleeding)

11. Grade: • 1: Small, straight varices • 2: Enlarged, tortuous varices that occupy less than one-third of the lumen • 3: Large, coil-shaped varices that occupy more than one-third of the lumen

13. PRIMARY PROPHYLAXIS 1) Pharmacological Therapy • OESOPHAGEAL VARICES 2) Endoscopic Therapy • - Sodium tetradecyl sulphate (thrombovar) • - Ethanolamine oleate

15. SCREENING • Screening Endoscopy • Patient with small varices on initial endoscopy should screened for enlargement of varicess every 1-2 years .

16. Management Acute Variceal Bleeding Terlipressin: 2mg bolus & 1mg every 6 hr (for 2-5 days) Somatostatin: 250mcg bolus followed by 250mcg/ hr infusion (for 5 days) Octreotide : 50mcg bolus followed by 50mcg/hr (for 5 days) 3rd Generation cephalosporin (iv) or oral quinolone (norfloxacin/ciprofloxacin)

17. Management of Oesophageal Variceal Bleeding • Endoscopic Variceal Ligation (EVL) • Endoscopic Sclerotheraphy • Temporary “bridge” for max 24hr • Consider if not available facilities for endoscopy • TIPS is indicated as a rescue therapy for uncontrolled variceal bleeding after combine pharmacological & endoscopic therapy TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNTS • Oesophageal Transection • Portosystemic shunts • Liver Transplant

19. Non Variceal UGIB

20. The most common cause for non variceal UGIB is peptic ulcer disease.

21. Epidemiology • Male:Female – 2:1 • Incidence of UGIB: 72 per 10,0000 population, peaked around the 4th to 6th decade. [Med J Mal. 2001] • Mortality rate: 10.2% but increased substantially with age • Inpatients who developed UGIB has 5x higher mortality than those came from ED admission for UGIB.

22. Clinical presentations Coffee ground vomitus Hemetemesis Maelena • Haematochezia • Anemia with or without evidence of visible blood loss

23. Patient assessment • History: • Bleeding from where? How much patient has bled? • Risk factor: NSAID, blood thinning agents, traditional meds, alcohol, PUD, hepatitis • Physical examination: • General examination • PR: “fresh” vs “stale” malena

24. Resus, resus, resus! (ABC) • Aim to stabilize hemodynamic status • Insert at least 2 large bore branula into large peripheral veins • Give supportive O2: NPO2, VM, HFM • Take bloods: FBC, RP, LFT, COAG, BG, GXM/GSH • Fluid resus with crystalloids or packed cell • Correct coagulopathy • Monitoring: Ryles tube*, CVP, CBD, strict I/O

25. Resus, resus, resus! (ABC) • Start PPI • Consider intubation when: • severe uncontrollable bleeding • encephalopathic • inability to maintain O2 saturation adequately • to prevent aspiration • ICU bed and facilities should be made available • Close monitoring in ward • Once patient stable -> OGDS within 24H if indicated

26. When to transfuse blood or blood products? • Why transfuse? • To restore blood volume, BP and to correct anemia to maintain oxygen carrying capacity • Indication for packed cell transfusion: • Systolic BP < 110 mmHg • Postural hypotension • Pulse > 110/min • Hb <7g/dl • Angina or cardiovascular disease with a hb<10g/dl • Maintain Hb ~10g/dL • Transfuse platelet if patient actively bleeding and PLT count is <50,000/mm3 • Give FFP if PT is at least 1.5x higher than control value

27. When to scope? • Offer endoscopy to unstable patients with severe acute UGIB immediately after resuscitation. • Offer endoscopy within 24 hours of admission to all other patients with UGIB Source: NICE Clinical Guideline: Acute upper gastrointestinal bleeding: management, 2012.

28. Oesophago Gastro DuodenoScopy (OGDS) Indication: • Diagnostic • Therapeutic Complications (1 in 1000): • Aspiration pneumonia • Bleeding • Perforation • Cardiopulmonary problems

29. Risk scoring: The Rockall score A score of 2 or less is associated with a low risk of further bleeding or death.

30. Forrest classification for bleeding peptic ulcer: Source: Jain V, Agarwal P N, Singh R, Mishra A, Chugh A, Meena M. Management of Upper Gastrointestinal Bleed. MAMC J Med Sci 2015;1:69-79

31. Forrest classification for bleeding peptic ulcer:

32. Therapeutics procedure during OGDS • Mechanical • Hemoclips • Injection • Injection therapy with diluted epinephrine • Results in local tamponade and vasospasm • Thermal • Unipolar diathermy • Thermal coagulation uses argon plasma coagulation (APC)

33. Impact of nasogastric tube insertion on outcomes in acute GI bleeding. Huang ES, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel BM  Gastrointest Endosc. 2011 Nov;74(5):971-80. Epub 2011 Jul 7.  Retrospective analysis. A total of 632 patients admitted with GI bleeding. RESULTS: Patients receiving NGT were more likely to take nonsteroidal anti-inflammatory drugs and be admitted to intensive care, but less likely to have metastatic disease or tachycardia, be taking warfarin, or present on weekdays. After propensity matching, NGT did not affect mortality (odds ratio [OR]0.84; 95% confidence interval [CI], 0.37-1.92), length of hospital stay (7.3 vs 8.1 days, P = .57), surgery (OR 1.51; 95% CI, 0.42-5.43), or transfusions (3.2 vs 3.0 units, P = .94). However, NGT was associated with earlier time to endoscopy (hazard ratio 1.49; 95% CI, 1.09-2.04), and bloody aspirates were associated high-risk lesions (OR 2.69; 95% CI, 1.08-6.73). CONCLUSIONS: Performing NGT is associated with the earlier performance of endoscopy, but does not affect clinical outcomes. Performing NGL at initial triage may promote more timely process of care, but further studies will be needed to confirm these findings.

35. References: • Malaysian CPG: Management of Acute Non Variceal Upper GI Bleeding, 2003. • NICE Clinical Guideline: Acute upper gastrointestinal bleeding: management, 2012. • Jain V, Agarwal P N, Singh R, Mishra A, Chugh A, Meena M. Management of Upper Gastrointestinal Bleed. MAMC J Med Sci2015;1:69-79 • Approach to acute upper gastrointestinal bleeding in adults, UpToDate 2017. • Huang ES, Karsan S, Kanwal F, Singh I, Makhani M, Spiegel BM: Gastrointest Endosc. 2011 Nov;74(5):971-80. Epub 2011 Jul 7.

36. THANK YOU! • Special thanks to our mentor DrMohdFadhil in guiding us to prepare this slide. • Alas, thank you all for lending your precious time to listen to our presentation. Your presence are greatly appreciated!