1 / 68

OUTLINE

TOPIC:MANAGEMENT OF UPPER GASTROINTESTINAL BLEEDING PRESENTING UNIT:GASTROENTEROLOGY PRESENTER:UGWUNZE E.O DATE:10 MARCH 2014. OUTLINE. INTRODUCTION EPIDEMIOLOGY CLASSIFICATION AETIOLOGY CLINICAL FEATURES[HX AND PHYSICAL EXAMINATION] INVESTIGATIONS TREATMENT PROGNOSIS CONCLUSION.

Download Presentation

OUTLINE

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. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript


  1. TOPIC:MANAGEMENT OF UPPER GASTROINTESTINAL BLEEDINGPRESENTING UNIT:GASTROENTEROLOGYPRESENTER:UGWUNZE E.ODATE:10 MARCH 2014

  2. OUTLINE • INTRODUCTION • EPIDEMIOLOGY • CLASSIFICATION • AETIOLOGY • CLINICAL FEATURES[HX AND PHYSICAL EXAMINATION] • INVESTIGATIONS • TREATMENT • PROGNOSIS • CONCLUSION

  3. INTRODUCTION Upper gastrointestinal bleeding (UGIB) • is a potentially life-threatening abdominal emergency • results in high morbidity and mortality hence requires admission for urgent diagnosis and management. • approximately 4 times as common as bleeding from the lower GI tract • bleeding derived from a source proximal to the ligament of Treitz. • Can be categorized as variceal or non - variceal

  4. EPIDEMIOLOGY • The incidence of UGIB is approximately 100 cases per 100,000 population per year. • England.Wales - 20,000 hospital admission per year. • USA - 100,000 admission per year. • The incidence of UGIB is 2 fold greater in males than in females. • Mortality increases with older age[>60yrs] in males and females.

  5. In Nigeria, a retrospective endoscopic study done on aetiology of UGIB by Mustapha et al in University of Maiduguri TH and FMC Gombe[2003 to 2008] showed : • A preponderance of male affectation[69.8% vs 30.2%]- 2fold increase in M:F. • Oesophagealvarices were the commonest cause of UGIB ffg by erosive mucosal disease ,then PUD. • Mortality rate of 17.9%[all mortality in patients with variceal bleeding] compared with 10% in most western studies.

  6. CLASSIFICATION Nonvariceal bleeding • high pressure arterial haemorrhage - ulcer mucosal, deep tears • low-pressure venous haemorrhage, telangiectasia, and angioectasias vascular malformation that represents an abnormal dilation of mucosal and submucosal vessels

  7. Variceal haemorrhage • elevated portal pressure transmitted to esophageal and gastric varices and resulting in portal gastropathy. • A complication of end stage liver disease. 

  8. AETIOLOGY Common causes of UGIB • Duodenal (DU) and Gastric ulcers (GU) (50% of bleeds),DU>GU. • Varices – Gastric , Oesophageal. • Acute gastric/duodenal erosions. • Mallory weiss tears. • Erosive Oesophagitis.

  9. LESS COMMON CAUSES : • Boerhaave syndrome • GAVE(gastric antral vascular ectasia)(chronic GIB). • Dieulafoy leison • Gastric carcinoma, • Gastrinoma • Stomal Ulcer • Oesophageal Ulcer • Oesophageal carcinoma

  10. Rare causes of UGIB. • Benign gastric tumours • Duodenal tumours • Arterial aneurysms, aorto-enteric fistula • Pseudoxanthoma elasticum. • Hereditary haemorrhagic telangiectasia(Osler- Weber-Rendu syndrome).

  11. Haemangiomas • Bleedingdisorders • Munchausen Syndrome(factitious uppr GIT bleed).

  12. MANAGEMENT • Involves • history taking , • physical examination • investigations • treatment

  13. HISTORY A good and careful history taking • Patient history includes • weakness, • dizziness, • syncope assoc with Haematemesis, (coffee ground vomitus) • melaena (black stools with a rotten odour), • haematochezia (red or maroon stools)- seen in brisk UGIB and suggests a large upper tract hemorrhage.

  14. Previous history of dyspepsia (esp. nocturnal symptoms) • peptic ulcer disease, • early satiety, • nonsteroidal anti-inflammatory drug or aspirin use. • hematemesis or meleana w/out previushx of dyspepsia • Hx of chronic renal disease.

  15. Vomiting may point to Mallory weiss tears. • Weight loss, dysphagia, anorexia may be associated with malignancy .

  16. PHYSICAL EXAMINATION • Objectives of the physical exam. • Assess the Haemodynamic state of patient and Determine the degree of shock. • Pulse and Bp should be checked supine and Upright positions to note effect of blood loss. • A systolic Bp < 100mmHg and pulse > 100/min indicate a 20% depletion of blood volume or more. • Tachycardia and Hypotension, indicate hypovolaemia.

  17. Other signs of shock include • cool extremities, • oliguria, • chest pain, • presyncope, • confusion, • delirium. • Haematemesis and malaena to be noted. • Anaemia – indicates chronic blood loss

  18. Signs of chronic liver disease should be noted – • spider angiomata. • gynaecomastia. • splenomegaly. • ascites. • pedal oedema. • Asterixis.

  19. Signs of malignancy should be noted and portend a poor progress – • nodular liver, • abdominal mass, • firm lymphadenopathy suggestive. • Subcutaneous emphysema with a history of vomiting suggestive of Boerhaave syndrome (Oesophageal perforation). • Telangiectasias – may indicate rare Osler Weber-Rendu Syndrome.

  20. INVESTIGATIONS • FBC: Hb may be normal or low. • Grouping and crossmatching of blood based on the rate of active bleeding(e.g 2 – 6 units). • BUN-to-creatinine ratio: value > 36 in a pxt without renal insufficiency is suggestive of UGIB.

  21. Coagulation profile: PT, APTT,INR(coagulopathy, advanced liver disease) • Platelet count. • LFT. • Serum calcium:hypercalcemia increases acid secretion. • Gastrin level.

  22. ENDOSCOPY • Early endoscopy within 24hrs and after resuscitation. • Urgent in patients with shock, liver disease, continued bleeding. • Cause of bleeding detected in > 80% • Can detect more likely cases to rebleed. • Varices can be injected at first endoscopy • Bleeding ulcers may be injected or vessels coagulated. • Improve rebleed but do not significantly improve mortality rebleed . Other Investigations. • Chest radiographs, Abd-x-Ray < supine, upright. • Barium studies – can affect endoscopy

  23. Bleeding pud

  24. Mallory-Weiss tear

  25. Oesophageal varices

  26. CT scan and ultrasonography – cirrhosis, cholecystitis, pancreatitis, with pseudocyst and haemorrh, aorto- enteric fisfula, etc. • Nuclear medicine scan - areas of active bleeding • Angiography – Important as salvage therapy, embolization of bleeding vessel in failed endoscopic therapy. • Nasogastric lavage ; • confirm recent bleeding, active bleeding etc • Can reduce patient’s need to vomit • Character of nasogastric lavage fluid > severity of bleeding

  27. HISTOLOGICAL FINDINGS. • Bleeding vessel in ulcer. • Fibrinoid necrosis, pseudoaneurysmal dilation of vessel. • Take biopsy samples from edge of gastric ulcer to rule out cancer. • H pylori lesion – chronic active gastritis with organisms in stained sample

  28. PRINCIPLES OF MANAGEMENT1.Assessment *Brief and essential history *Physical examination2.Resuscitation *I.V. fluids – crystalloids, colloids, blood *Urethral catheterisation *C.V.P. line3.Re-assessment4.Endoscopy – OGD (diagnostic/therapeutic)5.Other investigations6.Definitive treatment7.Follow - up

  29. RESUSCITATION

  30. Endoscopy • Injection of epinephrine or sclerosants, • heater-probe coagulation, • bipolar electrode coagulation, • laser coagulation • endoscopic application of clips, • use of banding devices, • argon plasma coagulation.

  31. surgery • The indications for surgery in patients with bleeding peptic ulcers are as follows: • Severe, life-threatening hemorrhage not responsive to resuscitative efforts • Failure of medical therapy and endoscopic hemostasis with persistent recurrent bleeding • A coexisting reason for surgery, such as perforation, obstruction, or malignancy • Prolonged bleeding, with loss of 50% or more of the patient's blood volume • A second hospitalization for peptic ulcer hemorrhage

More Related