Powerpoint Tutorial

1
GIT BleedingVGIBLGIB
Dr. Mohamed Shekhani CABM-FRCP
2
(No Transcript)
3
Variceal bleeding
1
Clinical decompensation (i.e., ascites,
encephalopathy,a previous episode of hemorrhage,
or jaundice).
Common lethal complication of cirrhosis(50 at
diagnosis, 7/year), particularly with
Gastric fundal varices Or GEV
Esophageal varices
Types
Portal hypertensive gastropathy
Portal hypertensive Biliopathy
4
Variceal bleeding
1
Clinical decompensation (i.e., ascites,
encephalopathy,a previous episode of hemorrhage,
or jaundice).
Common lethal complication of cirrhosis(50 at
diagnosis, 7/year), particularly with
Treatment of the acute bleeding
episode Mortality 15-20
Primary prophylaxis to prevent a first episode of
VH.
MANAGEMENT
Secondary prophylaxis (prevention of recurrent
VH). 60/year.
5
VARICES INCREASE IN DIAMETER PROGRESSIVELY
Varices Increase in Diameter Progressively
Small varices
No varices
Large varices
7-8/year
7-8/year
Merli et al. J Hepatol 200338266
6
PROGNOSTIC INDICATORS OF FIRST VARICEAL HEMORRHAGE
Varix with red signs
Variceal hemorrhage

• Predictors of hemorrhage
• Variceal size
• Red signs
• Child B/C

NIEC. N Engl J Med 1988 319983
7
Class A 5-6Class B 7-9Class C 10-15
8
Portal HT Risk stratification
2
Varices or colaterlas detected on imaging studies
as Abd U/S,EUS,Dopler
Decompensated liver cirrhosis Child-Pough or
MELD class ( Model of end stage liver disease)
Portal HT Risk stratification
Varices on VCE
Gastroesophageal varices.
Plateletes/spleen maximal bipolar diameterlt909
Fibroscan measuring liver stiffness predicts
portal HT
HVPG gold standardBest predictor of PHT EV,
but invasive not widely available. gt5 mm Hg
PHT gt10 mm Hg clinically significant
9
Primary prophylaxis of bleeding eso varices
3
Propranolol 20mgm2 untill PR 55/min Indefinite
Propranolol
Or
EBL Sessions every 4 weeks
Nadolol 40mgm once daily Untill PR
55/min Indefinite
PP of EV bleed
Endoscopic band ligation Evey 4 weeks untill
total obliteration Follow up 3 /12 for 1 year,
yearly
3 MONTHLY For 1 year Then Yearly Indefintely.
Nadolol
FU OGD after Obliteration
10
Management of acute variceal bleeding
4
Vasoconstrictor Octreotite Somatostatin Telipresin
5 days
Endoscopic Intervention EBL Sclerotherapy
Antibiotics Ceftriaxone Ciprofloxacin 5 days
Acute variceal Bleeding.
Cyanoacrylate Injection Sclerotherapy For
gastric Varices.
Sigestaken Tube temponade
Esophageal stenting
11
Secondary prophylaxis( prevention of recurrent)
of bleeding EV
5
Propranolol Same as for primary prophylaxis.
propranolo
Nadolol
Isosorbide
Nadolol Same as for primary prophylaxis.
Isosorbide dinitrate 10 mgm10-20 mgm2
Secondary prophylaxis
EBL Same as for primary prophylaxis.
Cyanoacrylate for GV
EBL for EV
Interventional Radiology for GV
Cyanoacrylate injection sclerotherapy or IR for
gastric varices not EBL.
12
Portal Hypertensive Gastropathy
14

• PHT- related ectatic gastric mucosal vessels
  mostly in fundus
• body of the stomach.

Definition
GEV , Child class prior variceal endoscopic
therapy
Predictors of its presence
Chronic blood loss leading to IDA rather than
acute bleeding
Prsentation
Iron supplementationBB,Shunt therapy(surgeryorTIP
S)
Treatment
Same.
Prophylaxis
13
Acute Lower Gastrointestinal Bleeding

• Bleeding distal to the ligament of Treitz for
  ltless than 3 days.
• The colon is the most common site of bleeding.
• The incidence increases with age, with mean of
  63-77 years.
• LGIB accounts for 20 of all episodes of GIB.
• Most episodes of LGIB will stop without
  intervention.
• The most common causes of acute LGIB are
  diverticulosis, angiectasia, ischemic colitis,
  perianal disease.
• The most frequent causes of chronic LGIB are
  neoplasms, angiectasia, IBD.

14
Causes in Our locality Perianal
diseases(piles/Fissure) IBD(UCgtCD) Infectious
colitis Neoplasms(adenoma or cancer) Solitary
rectal ulcer syndrome (SRUS) Meckels
diverticulum. Ischemic colitis. Angiodysplasia

15
Hemorrhoids/ fissures
Piles
Fissure
Bleeding after/or with defecation
Pain bleeding with defecation
1
Careful perianal exam anoscopy assist in the
diagnosis
2
16
Acute LGIB Management algorythm
Initial evaluation/ resuscitation Triage to OP
vs Ward vs ICU
Mild scanty bleeding
Anorectal pathology susspected
Rigid Anoscopy or sigmoidoscopy to confirm
diagnosis
Outpatient management
Anorectal pathology(piles/fissure) is the most
common pathology in our locality But this should
be diagnosed on solid basis not to miss serious
pathologies as IBD or cancer.
17
Acute LGIB Management algorythm
Severe bleeding
Severe exanguinating bleeding
Emergency angiography for bleeding control by gel
form or coils Or emergency surgical consult.
If emergency angio succeeded just observe for
recurrence but if fails refer to surgery
SURGERY
Severe exanguinating bleeding needs urgent action
either emergency surgery or emegency therapeutic
interventional radiology.
18
Acute LGIB Management algorythm
Moderate severe bleeding
Consider NGT aspirate
Bloody NGT aspirate Risk for UGIB
OGD
If ve treat accordingly
Most of the cases of LGIB fall in this category
require 1st NGT aspiration if ve bloody
aspirate , urgent upper GIT endoscopy.
19
Acute LGIB Management algorythm
Moderate severe bleeding
NGT not done or ve aspirate
Polyethelene glycol(PEG) solution laxative for
preparation for emergency colonoscopy in few
hours.
Colonoscopy within 12-24 hours
Manage according to colonoscopic findings
If the NGT aspirate is not bloody or NGT was not
inserted, urgent prep with PEG is needed for
urgent colonoscopy within12-24 hours.
20
Acute LGIB Management algorythm
Moderate severe bleeding
On colonoscopy bleeding site cause is identified
so treat as appropriate.
If the colonoscopy identifies the site/cause of
bleeding the problem is solved
21
Acute LGIB Management algorythm
Moderate severe bleeding
If On colonoscopy there is visual impairment
because of ongoing bleeding
Angiography.
If on colonoscopy there was visual impairment due
to bloody field urgent angiography is indicated
fordiagnosis therapy.
22
Acute LGIB Management algorythm
Moderate severe bleeding
On colonoscopy bleeding site not identified but
bleeding had stopped
OGD Or Repeat colonoscopy Or SI evaluation /Or
Others( RBC scan,angiography) for rebleeding.
If on colonoscopy the bleeding had stopped no
lesion was identified, upper GI endoscopy is
considered(if had already been done) or RBC
scan/angigraphy Is done fordiagnosis/treatment
specially if bleeding recurred.
23
(No Transcript)