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Upper GI Bleed

Upper GI Bleed. James Peerless April 2011. Introduction. Incidence of 100/100 000 population per year (UK & USA) >80% occur as acute admissions ‘Hospital-acquired’ Critically ill patients Prolonged NG tube Drug Rx Associated with high rate of mortality and long ICU stay. Objectives.

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Upper GI Bleed

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  1. Upper GI Bleed James Peerless April 2011

  2. Introduction • Incidence of 100/100 000 population per year (UK & USA) • >80% occur as acute admissions • ‘Hospital-acquired’ • Critically ill patients • Prolonged NG tube • Drug Rx • Associated with high rate of mortality and long ICU stay

  3. Objectives • Definitions • Anatomy • Sources of Bleeding • Presentation • Assessment • Management

  4. Definitions Upper GI Tract The oral cavity, pharynx, oesophagus, stomach & proximal duodenum Haematemesis The act of vomitting blood; swallowed or that arisen from the bleeding within the upper GI tract Melaena Black discolouredfaeces due to the presence of partly-digested blood from the upper GI tract

  5. Anatomy Coeliac trunk Left gastric a. Splenic a. Hepatic a. Left gastro-epiploic a. Right gastric a. Right gastro-epiploic a.

  6. Azygousv. Portal v. L + R gastric vv.

  7. Causes

  8. Varices • Secondary to portal hypertension • Dilated collateral veins formed at G-Oe junction • These portosystemicanastomoses are superficial and prone to rupture • High pressure veins in a hyperdynamic circulation

  9. Presentation • Active bleeding • History of haematemesis • Melaena • Shock/hypotension/collapse • Anaemia

  10. Acute Management Supportive Corrective Medical Balloon tamponade Endoscopy Surgical • Resuscitation • A B C • History & Examination • Recruit help • Investigations • Continuous monitoring • Blood products • Correction of coagulopathy

  11. Assessment • Acute Assessment • History & Examination • Is the airway safe? • Is the patient at risk of further events?

  12. Identifying Risk • Rockall Score

  13. Rockall Criteria

  14. Rockall Score

  15. Mortality Rates Rockall TA, Logan RF, Devlin HB, Northfield TC (1996) Risk assessment after acute upper gastrointestinal haemorrhage. Gut 38:316 – 21

  16. Scoring Systems • Rockall Score • Forrest Classification • Active haemorrhage • Signs of recent haemorrhage • Lesions without active bleeding • Glasgow-Blatchford Score • Scored on Hb, urea, BP, presentation/comorbidities (no endoscopy)

  17. Management Pathway

  18. Oesophagogastroduodenoscopy • Offers diagnostic information and opportunity for therapeutic intervention • Scoping within 24 hours has a proven reduction in rebleed, mortality and length of admission • For ulcers: • Adrenaline injection (temporary efect) • Diathermy/haemocoagulation • Endocscopic clips

  19. Variceal Bleeding • Endoscopy is the definitive treatment of choice for variceal bleed

  20. Drugs & Secondary MX

  21. Sengstaken-Blakemore Tube

  22. Sengstaken-Blakemore Tube

  23. Linton-Nachlas Tube

  24. TIPSS • TransjugularIntrahepaticPortosystemicShunt • Radiologically guided stent • Drilled through the liver and connects the portal and hepatic vein • Available in specialised units • Complications • Thrombosis (10%) • Bleeding • Infarction

  25. Summary • Hidden clinical picture • Supportive and Corrective Management • Endoscopic therapy mainstay of treatment • Risk of rebleedingremains high – keep monitoring the patient!

  26. The End

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