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UPPER GASTROINTESTINAL BLEEDING What Undergraduates should know ?. Prof SM Chandramohan Prof and HOD Department of Surgical Gastroenterology and Center of Excellence for Upper GI Surgery Madras Medical College and Rajiv Gandhi Government General Hospital Chennai.
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UPPER GASTROINTESTINAL BLEEDINGWhat Undergraduates should know ? Prof SM Chandramohan Prof and HOD Department of Surgical Gastroenterology and Center of Excellence for Upper GI Surgery Madras Medical College and Rajiv Gandhi Government General Hospital Chennai
Can download this presentation from www.esoindia.org Prof SM Chandramohan Prof and HOD Department of Surgical Gastroenterology and Center of Excellence for Upper GI Surgery Madras Medical College and Rajiv Gandhi Government General Hospital Chennai
DEFINITION PLAN OF THE TALK CAUSES EVALUATION TREATMENT
DEFINITION PLAN OF THE TALK CAUSES MEDICAL ENDOSCOPIC SURGICAL EVALUATION TREATMENT
DEFINITION Any bleeding from The gastrointestinal Tract above the Level of ligament of Treitz is upper GI Bleeding
DEFINITIONS • Acute GI bleed • < 3 days duration • hemodynamic instability • requires blood transfusion • Overt vs. occult • overt = visible blood (melena, bright red blood, coffee grounds) • occult = only detected by lab tests
NSAID • (1) the risk of gastric ulceration is increased to a greater extent than that of duodenal ulceration • (2) the risk of bleeding varies with the individual NSAID; for example, the relative risk of bleeding is greatest with piroxicam and less with ibuprofen • (3) the risk of bleeding is dose dependent -age greater than 75 years, -history of heart disease, -history of peptic ulcer - history of previous gastrointestinal bleeding RISK FACTORS
A AIRWAY B BREATHING C CIRCULATION
Examination Tell tale signs… Chronic Liver Disease Portal Hypertension
Examination Not to miss…….. Haemodynamic stability Signs of coagulation dysfunction Signs of Liver cell failure PR
As he comes…………. Resuscitate and Examine Simultaneously…….
Form a team………. Wide bore IV line…… preferably central line (take samples at the same time) Naso gastric tube Urinary Catheter ALERT OTHERS IN TEAM…….
Blood Sample for Blood Group Haemogram including platelets Coagulation profile Liver function test Renal function Markers
Blood Sample TRY NOT TO TAKE SAMPLES FREQUENTLY Except for serial evaluation
Naso Gastric Tube or Senstaken tube?
ROLE OF NASOGASTRIC TUBE 10 % of UGIB presents as LGIB Red blood vscoffee grounds NGT clears the gastric field for endoscopic visualization prevent aspiration of gastric content
Endoscopy When to do? What is Possible? When not to do???
Endoscopy One stop Shop Diagnose Assess Treat Reassess
If Hemodynamically stable ENDOSCOPIC EVALUATION Identify Bleeding site Delineate cause Allow endotherapy
ENDOSCOPIC MANAGEMENT VARICEAL NONVARICEAL
ENDOSCOPIC VARICEAL LIGATION A rubber band is placed over the varix which then undergoes thrombosis,sloughing,fibrosis.
ENDOSCOPIC SCLEROTHERAPY Involves injecting a sclerosant Intravariceal/perivariceal Common sclerosants Ethanolamine oleate Absolute alcohol Sodium morrhuate Sodium tetradecyl Hypertonic saline Polidocanol
GLUE THERAPY Cyanoacrylate is a glue that is injected into Gastric varices Acts by forming a Cast over the varix on contact with blood
ULCERS IN POSTERIOR WALL BULB-GDA HIGH RISK ULCER FOR BLEED ULCERS IN THE HIGH LESSER CURVE - LGA DEFINITIVE MANAGEMENT OF NON VARICEAL BLEED SRH/LARGE ULCER >2 cm
Non-Variceal - Modalities • Injection Therapy (a) Adrenaline (b) Sclerosants • Thermal Therapy (a) Monopolar (b) Bicap (c) Heater Probe (d) Argon Plasma Coagulation (e) Laser • Mechanical Therapy (a) Haemoclips Endoscopic Management
Bleeding Peptic Ulcer - Stigmata Forrest Classification Endoscopic Management 1a – Spurting vessel 1b – Oozing from a vessel 2 – Clot in the ulcer base 3 – Ulcer without bleed