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UPPER GASTROINTESTINAL BLEEDING

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.

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UPPER GASTROINTESTINAL BLEEDING

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  1. UPPER GASTROINTESTINAL BLEEDING G.C. Sturniolo Nicoletta Merlini Dipartimento di Scienze Chirurgiche e Gastroenterologiche Sezione di Gastroenterologia

  2. ACUTE UPPER GI BLEEDING INCIDENCE: 50 to 150 cases per 105 per year In UK 25.000 hospital admission each year Palmer, PMJ 2004

  3. AUGIBETIOLOGY • Peptic ulcer disease • Oesophageal/gastric varices • Mallory-Weiss tear • Oesophagitis • Duodenitis/gastritis/erosions • Vascular (Angiodysplasia, Dieulafoy) • Tumours • Aortoenteric fistula

  4. ACUTE UPPER GI BLEEDING Adapted from Palmer, PMJ 2004

  5. MORTALITY 4153 upper GI bleeding Mortality % > 90 21-30 31-40 41-50 51-60 61-70 71-80 81-90 Rockall, BMJ 1995

  6. 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

  7. 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

  8. 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

  9. 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

  10. UGIB:Therapeutic Endoscopy • Only patients with persisten or recurrent bleeding • 80% patients don’t have further bleeding • Optimal utilization IDENTIFY HIGH RISK PATIENTS

  11. 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

  12. 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

  13. 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

  14. UGIBWHICH PATIENTS ARE MORE LIKELY TO REBLEED?

  15. UGIB:Clinical Risk • Large volume bleeding • Shock • Age > 60 years • Bleeding onset after admission • Comorbidity • Variceal Bleeding

  16. Scoring Systems for UGIB • Baylor bleeding score (1993) • Cedars-Sinai predictive index (1996) • Rockall Score (1996) • Blatchford Score (2000) Das, Gastrointest Endosc 2004

  17. 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

  18. BLATCHFORD vs ROCKALL BETTER ROC FOR “CLINICAL INTERVENTION” Blatchford, Lancet 2000

  19. 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

  20. Forrest IIb Forrest IIa

  21. 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

  22. PEPTIC ULCERS:RISK FACTORS? • Male, Advanced age • History of ulcer disease • Helicobacter Pylori • Corticosteroids • NSAIDs • Blood-thinning drugs

  23. MANAGEMENT OF UGIB • Resuscitation • Endoscopy and endoscopic therapy • Drug Therapy

  24. MANAGEMENT OF UGIB • Resuscitation • Endoscopy and endoscopic therapy • Drug Therapy

  25. 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

  26. Blood Transfusion • Cardiologic Evaluation • cTropI Curve WHEN SHOULD WE TRANSFUSE PATIENTS? Age > 60 years Hb < 8.2 g/dL Gastro PD, BLISC

  27. MANAGEMENT OF UGIB • Resuscitation • Endoscopy and endoscopic therapy • Drug Therapy

  28. 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

  29. UGIB: NOT TO SCOPE • No benefit from early endoscopy if the findings do not change patient care

  30. DRUG THERAPY IV PPI vs IV RANITIDINE Time with intragastric pH>4 / 24h 96% 93% p<0,001 67% 43% Merki, Gastroenterology 1996

  31. 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

  32. OESOPHAGEAL VARICES • 80-90% CIRRHOSIS • BLEEDING PREVALENCE: 30-40% • MORTALITY I BLEEDING: 20-45% • PRIMARY PREVENTION • SECONDARY PREVENTION • TREATMENT ACUTE BLEEDING

  33. 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’

  34. 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

  35. EGDS IN 12 HRS • RESUSCITATION • UEC • PLASMA EXPANDERS VARICEAL BLEEDING VASOACTIVE DRUGS ANTIBIOTIC De Franchis, J Hepatol 2000

  36. 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

  37. INFECTIONS •  BLEEDING CONTROL FAILURE •  MORTALITY RELATED BLEEDING • PREDICTIVE FACTOR OF REBLEEDING

  38. 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

  39. 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

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