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Upper GI bleeding

Upper GI bleeding. Hematemesis Melena Dizziness Abd. Pain and symptoms of Peptic ulcer disease Hx of NSAID’s use. Pallor Hypotension Orthostasis Jaundice and other stigmatas of chronic liver diseases. UPPER GI BLEEDING Signs and Symptoms. UPPER GI BLEEDING CAUSES. RARE CAUSES

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Upper GI bleeding

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  1. Upper GI bleeding

  2. Hematemesis Melena Dizziness Abd. Pain and symptoms of Peptic ulcer disease Hx of NSAID’s use Pallor Hypotension Orthostasis Jaundice and other stigmatas of chronic liver diseases UPPER GI BLEEDINGSigns and Symptoms

  3. UPPER GI BLEEDINGCAUSES RARE CAUSES Neoplasms AVM/Ectasia Dieulafoy’s Stoma ulcers Esophageal ulcers Deodenitis Hemobilia Aorto-enteric fistulas Unknown 5% Rare GU 5% GU 20% Varices DU 15% Erosions Mallory Weiss Mallory Varices DU Weiss Rare 25% 5% Unknown Erosions 25%

  4. UPPER GI BLEEDINGPeptic Ulcer Disease • Defect in the GI mucosa extending through the muscularis mucosa. • Decreasing incidence. • Caused by imbalance between the aggressive and defensive factors.

  5. UPPER GI BLEEDINGPeptic Ulcer Disease • Helicobacter Pylori • NSAID’s • Acid Hypersecretory state. • Antral G cell Hyperplasia

  6. UPPER GI BLEEDINGPeptic Ulcer Disease

  7. UPPER GI BLEEDINGGastric Ulcers

  8. UPPER GI BLEEDINGDuodenal Ulcers

  9. UPPER GI BLEEDINGMallory - Weiss Laceration around the GE junction Classical presentation as bleeding after episode of vomiting Classical presentation found in 50% only Self- limiting

  10. UPPER GI BLEEDINGDieulafoy’s • Massive And recurrent bleeding • Extramural artery present in the • Submucosa. • Most commonly in the gastric • Cardia, 6 cm from GE junction • High Mortality • Difficult to diagnose

  11. UPPER GI BLEEDINGHemobilia

  12. UPPER GI BLEEDINGHemobilia

  13. UPPER GI BLEEDINGVascular abnormalities Portal HTN Gastropathy Mosiac / Snake skin Body or fundus Antral Vascular Ectesia Multiple punctuated lesions PBC and CREST

  14. UPPER GI BLEEDINGstress ulcers • Caused by Vagal hyperstimulation • and vascular hypoperfusion. • Body and fundus more affected • Multiple • Prophylaxis is indicated in critically • ill ICU patients Curling Extensive burn Cushing Head Injury

  15. UPPER GI BLEEDINGADVERSE PROGNOSTIC FACTORS • Diagnosis • Varices • Malignancy • Older age • Severe initial bleeding • Recurrence during hospitalization • Coincidental diseases • Endoscopic stigmata of recent bleeding • Need for emergency surgery

  16. UPPER GI BLEEDINGMANAGEMENT History Physical NG Tube Labs Resuscitation Assessment Endoscopy Bleeding Stops Bleeding continues Surgery or angiogram/ embolization

  17. UPPER GI BLEEDINGMANAGEMENT Most Have NG Tube Rectal Exam Endoscopy

  18. UPPER GI BLEEDINGMANAGEMENT Most Have NG Tube Rectal Exam Endoscopy

  19. UPPER GI BLEEDINGIMPLICATIONS OF NG ASPIRATE

  20. UPPER GI BLEEDINGIMPLICATION OF A CLEAR NG ASPIRATE

  21. UPPER GI BLEEDINGMANAGEMENT Most Have NG Tube Rectal Exam Endoscopy

  22. UPPER GI BLEEDINGMORTALITY: CORRELATION WITH STOOL AND NG COLOR Stool color NG Aspirate

  23. UPPER GI BLEEDINGMANAGEMENT Most Have NG Tube Rectal Exam Endoscopy

  24. UPPER GI BLEEDINGINFLUENCE OF DIAGNOSIS ON OUTCOME

  25. UPPER GI BLEEDINGMANAGEMENT: Endoscopic Therapy

  26. UPPER GI BLEEDING

  27. UPPER GI BLEEDING

  28. UPPER GI BLEEDING

  29. UPPER GI BLEEDING

  30. UPPER GI BLEEDINGMANAGEMENT:H2 Blockers

  31. UPPER GI BLEEDINGMANAGEMENT: Proton Pump Inhibitors • 10 studies had been published on the use of PPIs for upper GI bleeding since 1990. • Proven benefit in controlling bleeding when 80 mg bolus of Omeprazole followed by infusion for total of 160 mg/day. • Preventing rebleeding when Omeprazole orally at 40 mg twice daily.

  32. UPPER GI BLEEDINGBLEEDINGESOPHAGEAL VARICEAL • Dilated tortuous veins of • the lower and mid • esophagus. • Secondary to portal HTN • 30% mortality after the • first episode. • 60% Rebleeding rate

  33. UPPER GI BLEEDINGEsophageal Varices: Predictors of severity • High Hepatic Gradient • >12 mmHg • Degree of Cirrhosis • (Child Classification ) • Size of Varices • Larger > smaller • Endoscopic Appearance • Cherry red spots • Red wale

  34. UPPER GI BLEEDINGEsophageal Varices: Significance of hepatic gradient

  35. UPPER GI BLEEDINGEsophageal Varices: Influence of endoscopic appearance

  36. UPPER GI BLEEDINGEsophageal Varices: Influence of degree of Cirrhosis

  37. UPPER GI BLEEDINGEsophageal Varices: Influence of degree of Cirrhosis A < 7 points B 7-9 points C >10 points

  38. UPPER GI BLEEDINGEsophageal Varices: Relation of size to bleeding

  39. UPPER GI BLEEDINGEsophageal Varices: Active Bleeding

  40. UPPER GI BLEEDINGEsophageal Varices: Management Assessment / Resuscitation • Pharmacological Therapy • Somatostatin or Octreotide • Vassopressin and Nitroglycerine • Endoscopy for diagnosis and therapy • Variceal Banding • Sclerotherapy Balloon Temponade

  41. UPPER GI BLEEDINGEsophageal Varices: Vassopressin • Splanchnic vasoconstriction and decrease portal blood flow • Controls bleeding in 50%. • High side effects profile with 50% develops chest pain while on treatment. • Nitroglycerin decreases CP but cause hypotension. • 0.2-0.4 U/min Infusion

  42. UPPER GI BLEEDINGEsophageal Varices: Somatostatin and Octreotide • Decrease portal pressure and collateral blood flow. • Equivalent to sclerotherpy in controlling bleeding. • More effective than Vassopressin with less side effects. • Used as initial therapy

  43. UPPER GI BLEEDINGEsophageal Varices: Endoscopic banding • Bleeding control in 90%. • Rebleeding rate reduced to 30%. • Comparing to sclerotherapy • Less rebleeding • Lower mortality • Less complications • Fewer treatment sessions

  44. UPPER GI BLEEDINGEsophageal Varices: TIPS • Technical success in 90% • Control of bleeding in > 90% • Immediate procedural complications around 10%. • Late complications • Encephalopathy 20-30% • Heart failure 40%

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