Management of upper GI bleeding Dr. Emmanuel E. Akpo MBBS

1
Management of upper GI bleeding

• Dr. Emmanuel E. Akpo
• MBBS, FMCS, FICS, DMAS
• Consultant Minimal Access Surgeon
• Department of Surgery, College of MedicineDelta
  State University. Abraka.Delta State. Nigeria
• www.emmanuelakpo.com

2
(No Transcript)
3
Introduction

• Definition Bleeding originating proximal to the
  ligament of Treitz (oesophagus, stomach,
  duodenum)
• Catastrophic upper GI bleed may result in
  massive bleeding per rectum

4
Introduction

• A common medical condition
• 250,000 500,000 admissions/year US
• UGI bleeding incidence 100/100,000 adults
• Incidence increases 20-30 fold from third to
  ninth decade of life
• LGI bleeding incidence 20/100,000 adults
• Overwhelmingly disease of the elderly
• GI bleeding stops spontaneously in 80 cases

5
Morbidity Data

• Majority will receive blood transfusions
• 2 10 require urgent surgery to arrest
  bleeding
• Mortality rates for UGI bleeding 2 15
• Mortality for patients who develop bleeding after
  admission to hospital for another reason is 20
  30

6
UGI bleedingNomenclature

• Hematemesis 25
• Melena alone 25 , 50 100 cc of blood will
  render stool melenic
• Hematochezia 15 , seen in massive UGI hemorrhage
• Red blood hematemesis
• Coffee ground emesis

7
Causes of Upper GI bleeding

• Duodenal ulcer
• Gastric ulcer
• Oesophageal varices
• Erosive gastritis
• Mallory-Weiss syndrome
• Carcinoma of the stomach
• Gastric polyp
• Carcinoma of the oesophagus

8
Causes of Upper GI bleeding

• 9. Leiomyoma
• 10. Gastric lymphomas
• 11. Dieulofoys disease
• 12. Stomal ulcer
• 13. Bleeding disorders
• 14. Pernicious anaemia
• 15. Thrombocythemia

9
Work Up - History

• History of bleeding
• Number of episodes
• Most recent episode
• Hematemesis
• Vomiting prior to hematemesis
• Melaena
• Hematochezia
• Abdominal pain

10
Physical Exam

• Tachycardia at 10 volume loss
• Orthostatic hypotension at 20 loss
• Shock at 30 loss
• Pallor, telangiectesia
• Signs of CLD
• Localized abdominal tenderness/peritonitis
• DRE stool appearance, hemorrhoids etc

11
Urgent management - steps

• Evaluate for shock - BP, PR, RR, SPO2
• Investigations - PCV, GXM, E/U/Cr blood gases,
  LFT, PT, Platelet count, gastroscopy
• BUN/Cr ratio gt 36 in UGI bleed due to GI bllod
  absorption /or prerenal azotemia

12
Urgent management - steps

• Give iv fluids and transfuse blood, fresh frozen
  plasma or platelets
• Catheterize patient - monitor output
• Pass NG tube gastric lavage monitoring
• Insert a CVP line
• Do gastroscopic sclerotherapy, banding, laser or
  haemoclip application
• Pass Sengstaken-Blakemore tube for varices

13
Further treatment

• ICU care
• Antibiotics
• Treatment of complications
• - sepsis
• - DIC
• - MODS

14
Specific treatment

• Open surgery for uncontrolled bleeding
• - ligation of gastrodudenal artery
• - underunning of ulcer bed pyeloplasty
• - gastrectomy
• - ligation of varices with devascularisation

15
Definitive surgery

• Shunt surgery
• Vagotomy gastrojejunostomy
• Gastrectomy
• Splenectomy

16
Indications for Hospitalization and Intensive Care

• Traditional Endoscopy on the day of admission or
  on the day after
• Recent studies Complete endoscopic risk
  stratification PRIOR to admission
• Between 25- 30 of patients with UGI bleeding
  could be discharged from the Emergency Department

17
Modified Forrest Classification for Upper GI
bleeding
18
Risk stratification

• The most important predictors of re-bleeding are
• Age gt 80yrs
• Hb lt 8g/dl
• Endoscopic stigmata of significant hemorrhage
  (SSH)
• Co-morbidities
• These are combined in the risk stratification
  score

19
Rockall risk stratification score
20
Predictors of Outcome in UGI bleeding
21
Ulcer Appearance and Prognosis
22
(No Transcript)
23
(No Transcript)