Upper gastrointestinal bleeding
Download
1 / 39

UPPER GASTROINTESTINAL BLEEDING - PowerPoint PPT Presentation


  • 566 Views
  • Uploaded on

UPPER GASTROINTESTINAL BLEEDING. G.C. Sturniolo Nicoletta Merlini Dipartimento di Scienze Chirurgiche e Gastroenterologiche Sezione di Gastroenterologia. ACUTE UPPER GI BLEEDING. INCIDENCE: 50 to 150 cases per 10 5 per year. In UK 25.000 hospital admission each year.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about ' UPPER GASTROINTESTINAL BLEEDING' - zizi


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
Upper gastrointestinal bleeding

UPPER GASTROINTESTINAL BLEEDING

G.C. Sturniolo

Nicoletta Merlini

Dipartimento di

Scienze Chirurgiche e Gastroenterologiche

Sezione di Gastroenterologia


Acute upper gi bleeding
ACUTE UPPER GI BLEEDING

INCIDENCE:

50 to 150 cases per 105 per year

In UK

25.000 hospital admission

each year

Palmer, PMJ 2004


Augib etiology
AUGIBETIOLOGY

  • Peptic ulcer disease

  • Oesophageal/gastric varices

  • Mallory-Weiss tear

  • Oesophagitis

  • Duodenitis/gastritis/erosions

  • Vascular (Angiodysplasia, Dieulafoy)

  • Tumours

  • Aortoenteric fistula


Acute upper gi bleeding1
ACUTE UPPER GI BLEEDING

Adapted from

Palmer, PMJ 2004


Mortality
MORTALITY

4153 upper GI bleeding

Mortality %

> 90

21-30

31-40

41-50

51-60

61-70

71-80

81-90

Rockall, BMJ 1995


Mortality in ugib
MORTALITY in UGIB

Hospital mortality

and mortality related to the source of bleeding

in 362 UGIB

45,5%

29,4%

22,7%

20%

9,1%

5,9%

3,8%

0%

Klebl, Int J Colorectal Dis 2005


Mortality in ugib1
MORTALITY in UGIB

Mortality of patients

during hospitalization

40%

p < 0,05

11%

Bleeding

only before

admission

Bleeding

before + after

admission

Adapted from

Palmer, PMJ 2004


Mortality for ugib time trend
MORTALITY FOR UGIB: Time Trend

1996

19,5%

p=0,05

1996

2000

p=0,03

11,7%

11,1%

2000

7,2%

Fiore, Eur J Gastr Hep 2005


Ugib diagnostic endoscopy
UGIB:Diagnostic Endoscopy

  • Identifies the bleeding lesions >95% of sensitivity and specificity

  • Doesn’t alter patient outcome:

  • Morbidity

  • Mortality

  • Transfusions

  • Length of stay

  • Surgery

Peterson, NEJM 1981

Cappell, Med Clin N Am 2002


Ugib therapeutic endoscopy
UGIB:Therapeutic Endoscopy

  • Only patients with persisten or recurrent bleeding

  • 80% patients don’t have further bleeding

  • Optimal utilization

IDENTIFY HIGH RISK PATIENTS


Ugib rockall score
UGIB: ROCKALL SCORE

Developed in 1996

to assess risk of mortality and rebleeding

in UGIB patients

Rockall, BMJ 1996

Rockall risk score

VariableScore 0 Score 1 Score 2 Score 3

AGE

SHOCK

CO-MORBID

DIAGNOS

MAJOR SRH

< 60

None

None

Mallory-Weiss

No lesions

None or

dark spots

> 80

Fc>100,PAOs <100

Cardiac failure

Malignancy upper GI

Blood in upper

GI tract, blood clot

60-79

Pulse > 100 bpm

-

All other

diagnoses

Renal,liver

failure


Ugib rockall score1
UGIB:ROCKALL SCORE

Retrospective study, 222 patients

Distribution of Rockall Score

7

5

4

6

8

% of patients

9

3

10

2

Bessa, DLD 2006


Ugib rockall score2
UGIB:ROCKALL SCORE

Retrospective study, 222 patients

Rebleeding Risk

Mortality Risk

p < 0,001

p = ns

Rockall < 5

Rockall > 6

Rockall < 5

Rockall > 6

Bessa, DLD 2006


Ugib which patients are more likely to rebleed
UGIBWHICH PATIENTS ARE MORE LIKELY TO REBLEED?


Ugib clinical risk
UGIB:Clinical Risk

  • Large volume bleeding

  • Shock

  • Age > 60 years

  • Bleeding onset after admission

  • Comorbidity

  • Variceal Bleeding


Scoring systems for ugib
Scoring Systems for UGIB

  • Baylor bleeding score (1993)

  • Cedars-Sinai predictive index (1996)

  • Rockall Score (1996)

  • Blatchford Score (2000)

Das, Gastrointest Endosc 2004


Ugib blatchford score
UGIB: Blatchford Score

  • Derived from clinical information at presentation such as:

    • Urea

    • Hb

    • Blood pressure

    • Comorbidity (syncope, melena, heart and/or liver disease)

Blatchford, Lancet 2000


Blatchford vs rockall
BLATCHFORD vs ROCKALL

BETTER ROC FOR

“CLINICAL INTERVENTION”

Blatchford, Lancet 2000


Peptic ulcers classification
PEPTIC ULCERSCLASSIFICATION

FORREST CLASSIFICATION

ACUTE HEMORRHAGE

Forrest I a Arterial, spurting hemorrhage

Forrest I b Oozing hemorrhage

SIGNS OF RECENT HEMORRHAGE

Forrest II a Visible vessel

Forrest II b Adherent clot

Forrest II c Hematin covered lesion

LESIONS WITHOUT RECENT BLEEDING

Forrest III No signs of recent hemorrhage


Forrest IIb

Forrest IIa


Forrest classification
FORREST CLASSIFICATION

Forrest 1a

Spurting bleeding

Forrest 1b

Non-spurting active bleeding

Forrest 2a

Non-bleeding visible vessel

Forrest 2b

Non-bleeding with adherent clot

Forrest 2cForrest 3

Ulcer with haematin-covered base Ulcer with clean base


Peptic ulcers risk factors
PEPTIC ULCERS:RISK FACTORS?

  • Male, Advanced age

  • History of ulcer disease

  • Helicobacter Pylori

  • Corticosteroids

  • NSAIDs

  • Blood-thinning drugs


Management of ugib
MANAGEMENT OF UGIB

  • Resuscitation

  • Endoscopy and endoscopic therapy

  • Drug Therapy


Management of ugib1
MANAGEMENT OF UGIB

  • Resuscitation

  • Endoscopy and endoscopic therapy

  • Drug Therapy


Resuscitation

Shocked

Shocked

Hb < 10 g/dL

Actively

bleeding

RESUSCITATION

  • Airway, Breathing, Circulation

  • Central Venous Pressure (elderly and cardiopathic)

  • Crystalloids (carefully in liver disease!)

  • Colloids in major hypotension

  • Blood transfusion

Palmer, PMJ 2004


When should we transfuse patients

  • Cardiologic Evaluation

  • cTropI Curve

WHEN SHOULD WE TRANSFUSE PATIENTS?

Age > 60 years

Hb < 8.2 g/dL

Gastro PD, BLISC


Management of ugib2
MANAGEMENT OF UGIB

  • Resuscitation

  • Endoscopy and endoscopic therapy

  • Drug Therapy


Ugib to scope
UGIB: TO SCOPE

  • Early endoscopy identifies and treats patients with high risk of rebleed improving patient outcomes

  • PPI therapy alone is not as effective as endoscopic therapy for high risk lesions


Ugib not to scope
UGIB: NOT TO SCOPE

  • No benefit from early endoscopy if the findings do not change patient care


Drug therapy
DRUG THERAPY

IV PPI vs IV RANITIDINE

Time with intragastric pH>4 / 24h

96%

93%

p<0,001

67%

43%

Merki,

Gastroenterology 1996


Management of non variceal bleeding
MANAGEMENT OF NON VARICEAL BLEEDING

Non-variceal, upper GI bleeding

IV PPI bolus + infusion

Upper Endoscopy

High-risk stigmata

Low-risk stigmata

Endo therapy +

IV PPI

Oral PPI therapy

Triadafilopoulos,

Alim Pharm Ther 2005


Oesophageal varices
OESOPHAGEAL VARICES

  • 80-90% CIRRHOSIS

  • BLEEDING PREVALENCE: 30-40%

  • MORTALITY I BLEEDING: 20-45%

  • PRIMARY PREVENTION

  • SECONDARY PREVENTION

  • TREATMENT ACUTE BLEEDING


INCIDENCE/YEAR

5-50%

MORTALITY 30-50%

INCIDENCE/YEAR

5-30%

INCIDENCE/YEAR 5-10%

ACUTE BLEEDING

CIRRHOSIS

SMALL VARICES

LARGE VARICES

REBLEEDING

60% 1 YEAR

PRIMARY PREVENTION

 50% BLEEDING

  • 25-45% MORTALITY’


Risk factors
RISK FACTORS

  • CHILD B-C

  • EXTENSION (63% Ls vs 45% Li)

  • DIMENSION (F1,15%;F2,32%;F3,68%)

  • RED WALL MARK

    (red spots e wall marking 76% vs 17% without)

  • COLOR (blue 80% vs white 45%)

  • PORTAL VEIN PRESSURE (> 12 mmHg)

HIGHER BLEEDING RISK


EGDS IN 12 HRS

  • RESUSCITATION

  • UEC

  • PLASMA EXPANDERS

VARICEAL BLEEDING

VASOACTIVE

DRUGS

ANTIBIOTIC

De Franchis, J Hepatol 2000


Medical treatment antibiotics
MEDICAL TREATMENT ANTIBIOTICS

INFECTIONS

35-66% BLEEDING CIRRHOTICS

  • UTI 12-29% E.Coli + Klebsiella

  • SBP 7-23% Gram -/+

  • PULMONARY INFECTIONS 6-10%

  • SEPSI 4-11%

Dell’Era, APT 2004


INFECTIONS

  •  BLEEDING CONTROL FAILURE

  •  MORTALITY RELATED BLEEDING

  • PREDICTIVE FACTOR OF REBLEEDING


Medical teratment vasoactive drugs
MEDICAL TERATMENTVASOACTIVE DRUGS

TERLIPRESSIN

2 mg e.v. qd 4-6 hrs per 24 hrs

then

1 mg e.v. qd 6 hrs per 4 days


TAKE HOME MESSAGES

VASOACTIVE DRUGS, BLOOD TRASFUSION

RESUSCITATION, COLLOIDS, ANTIBIOTICS

EGDS

VARICEAL BAND LIGATION

SCLEROTHERAPY

MEDICAL TREATMENT

Failure

Vasoactive drugs (5 days long)

II EGDS

Failure

BLAKEMORE

Surgery (child A) TIPS (child B,C)

Lata J et al Dig Dis 2003


ad