Upper gastrointestinal bleeding
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Upper Gastrointestinal Bleeding. Dr Bernard Stacey Consultant Gastroenterologist. Variceal Known varices Signs of chronic liver disease Prolonged INR Low platelets (Alcohol history). Non-variceal NSAID use Preceding dyspeptic symptoms M-W tear history. Upper GI bleeding.

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Upper gastrointestinal bleeding

Upper Gastrointestinal Bleeding

Dr Bernard Stacey

Consultant Gastroenterologist


Upper gi bleeding

Variceal

Known varices

Signs of chronic liver disease

Prolonged INR

Low platelets

(Alcohol history)

Non-variceal

NSAID use

Preceding dyspeptic symptoms

M-W tear history

Upper GI bleeding


Lower gi bleeding
Lower GI bleeding

  • Previous history of similar events

  • Bright red PR bleed

  • Dark red PR bleed

    • Unless massive upper GI bleed

  • Normal urea


Trials investiging a raised urea as a predictor of ugib v lgib or no bleed
Trials investiging a raised urea as a predictor of UGIB v LGIB (or no bleed)

  • USA 6, Europe 6, Japan 4, SA 1

  • Twice as many retrospective trials

  • 1729 patients

  • Sensitivities 54 – 95%

  • Specificities 27 – 100%

  • 10 trials in favour, 2 against



OGD findings LGIB (or no bleed)

Varices

DU/GU/pyloric ulcer

Gastritis (NSAIDs)

Oesophageal ulcer

Normal

Cancers

Oesophagitis

Dielafoy

Miscellaneous


Acute resuscitation
Acute Resuscitation LGIB (or no bleed)

A B C

not

“OGD”


Acute resuscitation1
Acute Resuscitation LGIB (or no bleed)

  • Airway protection

  • Breathing (oxygenation)

  • Circulation (BP, postural drop)

    • N/Saline, blood

  • (FFP)

  • (Platelets)


Acute resuscitation 2
Acute Resuscitation (2) LGIB (or no bleed)

Endoscopy

  • Allows direct visualisation

  • Heater probe, endoclips

  • Injection with adrenaline, ethanolamine

  • Band ligation

  • Rebleed rate = 15 – 20%


On call endoscopist
On Call Endoscopist LGIB (or no bleed)

  • Aim for OGD within 24 hours of admission

  • Endoscopy at night if:

    • Severe haemodynamic upset (pulse, BP)

    • Varices

  • Otherwise endoscope next morning

  • Discussion of management


Variceal bleeding
Variceal bleeding LGIB (or no bleed)

  • Venous bleeding

  • Usually an associated coagulopathy

  • Drug administration recommended as early as possible (before endoscopic therapy)

  • Combination therapy better than drugs or endoscopy alone


Risk of bleeding
Risk of Bleeding LGIB (or no bleed)

  • Portal pressure - circadian change

  • Highest pressures at night

  •  risk with:

    • severity of liver disease

    • variceal size

    • red markings on varix

    • pressure over 12 mmHg


Pharmacological treatment
Pharmacological treatment LGIB (or no bleed)

  • Similar effectiveness to sclerotherapy

  • Terlipressin (Glypressin) - Synthetic vasopressin

    • bolus administration but may need nitrates if angina provoked

  • Beneficial effects temporary so endoscopy still necessary

  • Antibiotics (cefotaxime)


Blockers
 blockers LGIB (or no bleed)

  • Propranolol, nadolol

    • Lower risk of rebleeding by 40%

    • Lower mortality by 20%

  • Splanchnic haemodynamics unpredictable

  • Not an acute drug


Non variceal bleeding
Non-variceal bleeding LGIB (or no bleed)


Non variceal bleeding1
Non-variceal bleeding LGIB (or no bleed)

  • Endoscopy is the key to effective treatment

  • Proton pump inhibitors / H2 receptor antagonists not effective in stopping active bleeding

    • But: clot stabilisation


The vessel
The Vessel LGIB (or no bleed)

  • Artery protruding above ulcer floor: 33%

  • Clot protruding above ulcer floor: 65%

    •  not simply an acute excess acid problem

  • Aneurysm formation in 51%

    • true 42% false 58%


Proton pump inhibitors
Proton Pump Inhibitors LGIB (or no bleed)

  • Actively bleeding ulcers / visible vessel

     adrenaline injection + thermocoagulation

     IV omeprazole or Placebo

    120120

    8 (6.7%) Rebleeding 27 (22.5%)

    5 In first 3 days 24

    3 Surgery 9

    5 Died 12


Tranexamic acid
Tranexamic acid LGIB (or no bleed)

  • Used as pro-coagulant in other settings

    • cardiac surgery

    • ENT

    • menorrhagia

  • Complications

  • Anecdotal use for portal hypertensive gastropathy and gastric antral vascular ectasia (GAVE)



Think of underlying conditions: prognosis

MI

Pneumonia

GI obstruction


Recurrence rates
Recurrence rates prognosis

Duodenal ulcer

  • Without eradication: 80% in 1 year

  • With eradication: 5% in 1 year


Arterial ulcer v venous variceal bleeding

Arterial prognosis

Physical measures

Excess acid not the main acute problem

IV drugs after OGD (but before also helps)

Venous

Lower pressures involved

Associated coagulopathy

Combination therapy best outcome

IV drugs before and after OGD

Arterial (ulcer) v Venous (variceal) bleeding

Acute ‘ABC’ resuscitation


Any questions
Any Questions? prognosis


Summary
Summary prognosis

  • Basic ‘ABC’ resuscitation is imperative

  • Remember coagulopathy and synthetic vasopressin in variceal bleeds

  • Inform endoscopist

    • At night if unstable

    • Early the next morning if stable

  • Early surgical involvement

  • Acid suppression and eradication regimes


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