Management of acute upper GI haemorrhage

1
Management of acute upper GI haemorrhage
2
Causes

• Peptic ulcer
  35-50
• Gastroduodenal erosions 8-15
• Oesophagitis 5-15
• Varices
  5-10
• Mallory Weiss tear 15
• Upper GI malignancies 1
• Vascular malformations 5
• Rare
  5

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Initial resuscitation

• Two large bore cannulae and take sample
• Normal saline 1-2 lt fall of pulse/improved
  BP/adq urine
• Plasma expander if still shocked
• Blood transfusion - haematemesis/shock
• - Hb lt10

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Severity of bleed

• Current clinical scoring system( Rockall) for
  risk of re-bleed or death involves OGD
• So definition of mild/mod/severe remains a matter
  of clinical judgement

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Mild to moderate bleed

• Pulse/BP normal
• Hb gt10
• Insignificant comorbidity
• Mostly lt60 yrs

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Continued

• Excellent prognosis if no SRH/varices/malignancy
• Subsequent management
• May include H.Pylori eradication
• Use of acid suppressing treatment
• Advice concerning NSAIDs

7
Severe bleed

• Pulsegt100
• SBP lt 100
• Hb lt 10
• Significant comorbidity
• Mostly gt60 yrs

• Preferably HDU
• Hrly BP/pulse/ urine volm
• Fasted
• Urgent endoscopy after resuscitation

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Endoscopy in acute upper GI haemorrhage

• Semi-elective in minor and urgent in major bleed
• Only after initial resuscitation
• Best done in endoscopy unit
• But out of hours ,operating theatre with full
  resus. Equipment and anaesthetist may be better
  option
• Only expert endoscopists
• Consider ET tube to prevent aspiration

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Endoscopic finding subsequent management

• No SRH general ward
• Varices VBL/VScl
• Ulcer with SRH endoscopic haemostasis
  1.adrenaline inj
• 2.heat
  application
• 3.mechanical
  clips

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Drug therpy for non-variceal principally ulcer
bleed

• Evidence suggests following successful endoscopic
  treatment in patient presenting with major ulcer
  bleed high dose omeprazole stabilizes clot and
  prevents rebleed
• omeprazole 80mg iv stat followed by 8mg per hour
  infusion for upto 72 hrs

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After endoscopy

• Close monitor to identify rebleed
• If stable after 6hrs allow light diet ( no data
  suggesting prolong fasting necessary)
• Repeat endoscopy
• If active rebleed
• If concern re optimal initial therapy (after
  12-24 hrs)

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Surgical intervention

• If endoscopic therapy unsuccessful
• In rebleed it is advisable to repeat endoscopy to
  confirm bleed and also try offer one more time of
  endoscopic therapy before considering surgery if
  it was initially successful
• In massive rebleed sometimes surgical
  intervention is needed straightway if initial OGD
  was unfavourable

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Surgical options

• Duodenal ulcers
• Under running ligation of gastroduodenal/rt
  gastroepiploic arteries
• Gastrectomy to include the ulcer with Billroth I
  or II reconstruction
• Gastric ulcers
• Excised
• Parial gastrectomy
• Under running if elderly with poor condition

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Follow up

• For ulcer bleeds standard ulcer healing treatment
• In most cases this also involves H.Pylori
  eradication
• Ulcer associated with NSAID -stop drug or choose
  the least damaging one
• Re-endoscope GU in 6wks to ensure healing. Not
  necessary for DU.

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Additional points for variceal haemorrhage

• For no varix on initial endoscopy repeat 3yrly
• For grade 1 varix yearly F/U
• Primary prophylaxis with propranolol (80-160mg)
  for all grade 2/3 oesophageal varices
• If unsuitable for ppnl, VBL is next option
• ISMN

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Acute management of variceal haemorrhage

• Antiobiotic prophylaxis for all
  patientsciprofloxacin 500mg BD for a week
• VBL is method of choice for OV
• VScl if above difficult or unavailable
• If endoscopy unavailable vasoconstrictor therapy
  or balloon tamponade with Sengstaken tube while
  more definitive therapy is arranged

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continued

• Pharmacological therapy is with two major classes
  of drugs vasopressin or its analogue
  terlipressin (glypressin) and somatostatin or its
  analogue octreotide
• Terlipressin is given as 2mg iv bolus followed by
  1-2mg every 4-6 hrs for up to 72hrs

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OV BLEED

• Controlled banding eradication programme. One
  band /wk. F/U at 3 6 month and then yearly
• Uncontrolled balloon tamponade until further
  endoscopic treatment/ TIPSS/surgical intervention
• Choice of TIPSS or surgical intervention such as
  oesophageal transection depends on centres
  preference

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GV bleed

• If IGV initial sclerotherapy with
  butyl-cyanoacrylate
• If unsuccessful balloon tamponade prior to more
  definitive treatment

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Secondary prophylaxis of variceal haemorrhage

• banding eradication programme
• TIPSS
• Portocaval shunt surgery

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• Thank you