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Upper GI bleeding

Upper GI bleeding. UGI bleding. ONE syndrome: a group of diseases. Definitions. Intraluminal, exteriorised bleeding Hematemesis – above the angle of Treitz Melena – above the ileo-cecal valve Hematochezia – bellow the spelnic flexure. A major health problem.

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Upper GI bleeding

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  1. Upper GI bleeding

  2. UGI bleding ONE syndrome: a group of diseases

  3. Definitions • Intraluminal, exteriorised bleeding • Hematemesis – above the angle of Treitz • Melena – above the ileo-cecal valve • Hematochezia – bellow the spelnic flexure

  4. A major health problem • 100-150/100.000 admission/year in US • Mortality is high ~10% even if: • fiberoptic endoscopy - general • better understanding of pathology • high performance medication • POPULATION IS GROWING OLDER • Great variety of pathologies risk of rebleeding very difficult to evaluate

  5. Major cause • Duodenal ulcer 24% • Gastritis 23% • Gastric ulcer 21% • Esophageal varices 10% • Esofagitis 8% • Sdr. M-W 7% • Duodenitis 6% • Tumors 3% Large variations according to region

  6. DIAGNOSTIC VSTRATAMENT • Major emergency • Urgent treatment before ethiological diagnostic • Sequence: • Diagnostic of UGI bleeding • Resuscitation • Empiric treatment • Ethiologic treatment • Specific treatment

  7. Emergency • URGENT EVALUATION • URGENT TREATMENT OF HYPOVOLEMIA • INSSURING A SECURE TRANSPORTATION TO A HOSPITAL

  8. Anamnesis • Describe bleeding • Quantification of blood loss is ridiculous • Other symptoms on onset: ex cough • Past medical history – associated with bleeding: hepatitis, chirrhosis… • Family problems • Alchool intake • Previous bleedings • Medication intake in the last week

  9. FIRST AID • Decubitus • One or two large vein access • Insure vital function • Safe transportation • A sample for blood typing • No macromolecules before sample • Nill per mouth • +/- nasogastric tube + drainage

  10. Haemodynamic evaluation • Hypovolemic shock if: Systolic blood pressure <90 mmHg = 50% circulating volume • NO shock – check for changes in blood pressure and puls in orthostatism • BP<90 - 25-50% loss • BP-10 or puls rate >120/min - 20-25%

  11. EVALUATION BEFORE ETHIOLOGY IS ESTABLISHED • 1. Hemoglobine • 2. Platelets • 3. Hematocrit • 4. Screening test for coagulation • 5. BUN • 6. Screening for live function tests • 7. Abdominal and/or thorax X-Ray for associated pathology that could change protocol

  12. EVALUATION BEFORE ETHIOLOGY IS ESTABLISHED • Patient in ICU under gastroenterology care • Supress HCl secretion (i.v. H2 bloxkers, PPI) • Treat coagulation disfunctions • Blood products • Balance for risks – viral infections • Risks vs benefits in continuous bleeding

  13. SURVEILANCE -MODELES FOR REBLEEDING - • CONTINUOUS BLEEDING • No response • 42% do not present a major episode of rebleeding • Aggressive monitoring = ESSENTIAL • MAJOR EPISODE OF REBLEEDING • 15,2% rebleeding in ICU • 61% sudden onset • ONLY shock is very unusual but possible

  14. REBLEEDINGMAJOR RISK FACTOR • Definition: new bleeding episode after an initial stop and haemodynamic stability • High mortality: 20% (3x more then average for UGU bleeding) • 3 major risk factors for in hospital morbidity and mortality: • Major rebleeding during hospital stay • Old age • Total quantity of transfused blood

  15. ETHIOLOGICAL EVALUATION • Clinical • Rx + US • endoscopy “GOLD DIAGNOSTIC”

  16. ANAMNESIS PATIENT + FAMILY

  17. Clinical Evaluation • Haemodyanmic evaluation and stabilisation • Confirm the dg of UGI bleeding • HEMATEMESIS, MELENA + rectal exam • Ex oral cavity + ENT for swallowed blood • Medicaton • Clinical signs suggestive for liver chirrhosis • Palpable tumors • Other medical problems that can cause UGI bleeding

  18. IMAGISTICS • Can point to a possibel diagnostic • Rx thorax • Pleural efusions • TBC • Primary or secondarty tumors • Abdominal US • Liver chirrhosis + portal hypertension • Abdominal tumors • Rx g-d • Unusual alternative to explore UGI after the remission of signs or when endoscopic examination is incomplete.

  19. ENDOSCOPY • Establishes SOURCE OR SOURCES of bleeding • Evaluation of risk of rebleeding • THERAPEUTIC acces directly to the lesion ENDOSCOPY - in emergency - not after 24 hourse SHORT LIVED LESIONS

  20. PREPARE FOR ENDOSCOPY • Patient should be stable / in OR • Empty stomach if possible • +/- sedation – risk of aspiration • Patient in left lateral position – prevent aspiration

  21. ENDOSCOPIC DIAGNOSTIC • Portal hypertension: varices YES/NO • Significant in massive bleeding • Diagnostic for all lesions with potential of bleeding • Evaluation of RISK of rebleeding • Type of ACTIVE bleeding • Complete vs incomplete examination: which areas not evaluated

  22. MIRAGE – the first lesion ? the most significant lesion?

  23. TREATMENT • Stabilise and monitor patient • STOP THE BLEEDING • Prevent recurrent bleeding • Treat the disease CAUSE • Treat complications and associated diseases

  24. TRATAMENTaccording to cause • ENDOSCOPY: Oclude the vessel the least aggressive for patient immediate after diagnosis very efficient required in all cases with major risk of rebleeding • Medication • Surgical • Interventional radiology

  25. a. Congenital Weber-Rendu-Osler Blue rubber bleb nevus Bullous epidermolisis Esophageal duplication b. Inflamatory GERD Barrett disease Infectious esophagitis Caustic lesions RT induced lesions CHT induced lesions Crohn disease Behcet disease pemfigoid ESOPHAGIAN CAUSES - 4%

  26. b. Traumatic or mechanic Hiatus hernia Mallory-Weiss syndrome Boerhaave syndrome Foreign body Iatrogenic c. Neoplasia malignant benign d. Vascular Varices Aortic aneurism After cardiac surgery e. Hematological anticoagulants coagulation disorders

  27. ESOPHAGIAN CAUSES • Esophagus varices • Mallory-Weiss sundrome • Hiatus hernia and GERD • Tumors

  28. Varices • 10% of cases • Associated with alcohol abuse and hepatitis: clinical signs of chirrhosis • ESSENTIAL to exclude variceal haemorrhage • Endoscopy may be difficult but very important

  29. VARICELE ESOFAGIENE • Endoscopic difficulties • Important bleeding • Stomach full of cloths • Gastric varices • Encephalopathy • BUT ONLY 60% of patients with chirrhosis bleed from varices

  30. DIAGNOSTIC

  31. TRATAMENT • MEDICATION - OCTREOCTIDE: decreases portal flux and pressure in varices • TAMPONDE – Segstaken Blackmore tube • Not a first choice • SURGICAL SHUNT • ~70% mortality in emergency cases • TIPS • ~50% mortality on emergency

  32. M-W SYNDROM • Diagnostic only with endoscopy in emergency • Short lived lesions • Usually with small quantity of blood but may produce shock • Short monitoring • ~0% risk of rebleeding • Conservative treatment ~ 100%

  33. Mallory Weiss

  34. HIATUS HERNIA AND GERD • dg+ EDS – stigmata of recent bleeding • HH very frequent encounter • Treatment: H2 blockers, PPI

  35. TUMORS of ESOPHAGUS • Very unusual cause of clinical manifest bleeding: occult • Endoscopic hemostasis • Laser YAG • Argon plasma

  36. GASTRIC ORIGINE • Hemorrhagic gastritis • Gastric ulcer • Benign tumors • Malignant tumors

  37. HEMORRHAGIC GASTRITIS • Morfologic criteria • EDS aspect may vary • Radiology useless and pointless • EDS: if late may not show anything

  38. HEMORRHAGIC GASTRITIS • H2 blockers and PPI – routine but doubtful benefit • Rebleeding extremely rare • Endoscopic treatment: not recommended (numerous lesions with small risk of rebleeding) • SURGICAL(unusual: doubtfull diagnostic + hemodynamic instability) • In situ hemostasissutura in situ • Vagotomy + gastrectomy

  39. GASTRIC ULCER • Some localisations are difficult to see • EDS needs to evaluate • Stigmata of bleeding • Risk of rebleeding

  40. H2, IPP +/- i.v route Endoscopic direct treatment Treatment • Sclerosis • Thermocoagulation • Clips

  41. Surgical treatment • If so, resection of lesion is better • Frozen section pathology: malignnancy always in doubt • Limited resections for bening disease

  42. Benign gastric tumors • Bleding is RARE • Polipoid lesions can be resected endoscopically • Surgical excision

  43. Malignant gastric tumors • 6% • Special characteristics • High mortality 9% • Frequently non-resectable • Large costs little benefit in survival

  44. ENDOSCOPY • Examination: advanced lesion • Hemostasis (laser or argon plasma) Ex. Echografic • Ultrasound: MTS and large LN: inoperable

  45. Laparotomy or laparoscopy: confirm advanced disease vs operability Massive bleeding: most often advanced lesions Paliation ~25% bypass gastrostomy jejunostomy Surgical treatment

  46. ~5% Congenital anomaly Abnormal artery protruding in submucoasa Vascular malformations Dielafoy (exulceratio simplex)

  47. Echoendoscopy

  48. Treatment • Mechanic destruction of the vascular anomaly • Surgery: in situ hemostasis • Endoscopy – GOLD STANDARD • Correct diagnostic • Banding • Hemoclips • Laser thermocoagulation

  49. Bading

  50. DUODENAL ORIGIN • Very frequent • Justifies the empiric treatment with PPI

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