ACUTE UPPER GASTROINTESTINAL

HAEMORRHAGE – NON VARICEAL BLEEDING

DR. PURBITA MITRA22.02.2017, MALDA MEDICAL COLLEGE

INTRODUCTION• 80% of all GI bleeding is upper GI bleeding.• Out of all upper GI bleeding, 80% is due to non-variceal causes.• Non-variceal bleeding can also occur in patients who are at high risk of developing variceal bleeding.• Even with the advent of many modern techniques in treatment, the mortality rates remain unchanged.

ETIOLOGY1. Peptic ulcer disease : 30-50% - Gastric ulcer - Duodenal ulcer2. Mallory-Weiss tears : 15-20%3. Gastritis and Duodenitis : 10-15%4. Oesophagitis or Oesophageal ulcer : 5-10%5. Tumors : 2% - Gastric - Oesophageal - Stromal

6. Vascular anomalies : 5% - Angiodysplasia - Dieulafoy’s lesion - Arteriovenous malformations - Gastric antral vascular ectasia (GAVE)7. Others : 5% - Hemophilia - Hemobilia - Purpura - Hemosuccus pancreaticus - Iatrogenic

AN OVERVIEW OF MANAGEMENT OF GASTROINTESTINAL BLEEDING

INITIAL ASSESSMENT AND RESUSCITATION-Assessment of airway, breathing, circulation-Determine severity and volume of blood loss- Laboratory tests-CBC,electrolytes,group and type

HISTORY AND EXAMINATION FINDINGS

-risk factors for bleeding-previous surgical procedures

-relevant medications

LOCALISATION OF THE SOURCE OF BLEEDING

-Aspiration of nasogastric tube-EGD or colonoscopy

-Other studies eg,small bowel investigations

TREATMENT OPTIONS-pharmacologic

-therapeutic endoscopy-angiography and embolization

-surgery

PEPTIC ULCER DISEASE

- Most frequent cause of upper GI bleeding (30-50% of all cases of GI haemorrhage)- Approximately 10-15% of patients with PUD develop bleeding at some point in the course of their disease.-Bleeding develops as a consequence of peptic acid erosion of mucosal surface- Significant bleeding results when there is involvement of a vessel.

- Causes - Helicobacter pylori : 40-50% -NSAIDs : 40-50% -Others

RISK FACTORS FOR MORTALITY AND MORBIDITY IN ACUTE GI HAEMORRHAGE1. Age >60 years2. Comorbid disesae -Renal failure -Liver diseses -Respiratory insufficiency -Cardiac diseases3. Magnitude of haemorrhage4. Persistent or recurrent haemorrhage5. Onset of haemorrhage during hospitalization6. Need for surgery

RISK STRATIFICATION-Predicts mortality and rebleeding

BLEED study identified ongoing Bleeding.•Low blood pressure( SBP < 100 mm Hg),•Elevated prothrombin time(>1.2 times control),•Erratic mental status, and •Unstable comorbid disease

As there is no uniform scoring system,these should be applied with appropriate clinical judgement

AIMS OF MANAGEMENT

- Immediate assessment and resuscitation- Need of blood transfusion- Determine the source of bleeding- Stop active bleeding- Treat the underlying abnormality- Prevent recurrent bleeding

Algorithm for management of peptic ulcer bleeding

MANAGEMENT OF PEPTIC ULCER DISEASE

1. Initial or Non specific management2. Specific management - Medical -Endoscopic - Surgical

INITIAL MANAGEMENT

1. Immediate evaluation2. Resuscitation3. Blood is sent for typing and cross matching,

hematocrit, platelet count, coagulation profile, routine biochemical analysis and LFT

4. Foley’s catheterisation for assessment of end organ perfusion

5. Oxygen supplementation

6. Nasogastric lavage - 15-20% of upper GI bleeding have negative aspirate7. Blood transfusion, if required.

- Patient may need 10 units of blood transfusion in massive bleeding - He/she will also need to maintain adequate platelet count and calcium amount

MEDICAL MANAGEMENT

1. IV Proton pump inhibitors used as a bolus followed by an hourly continuous drip for 72 hours to reduce acidity.

2. Eradication of Helicobacter pylori by using two antibiotics with PPIs. The most common antibiotics used are clarithromycin, amoxycillin and metronidazole.

3. Stop ulcerogenic medications such as NSAIDs, SSRIs, etc.

4. Follow up oesophagogastroduodenoscopy for gastric ulcers.

ENDOSCOPIC INTERVENTIONS

USES : 1)Diagnostic 2)Therapeutic 3)Prognostic

ENDOSCOPY IN TREATMENT OF NON-VARICEAL BLEEDING

1) Laser coagulation - Nd: YAG laser has been used more

commonly - Success rate is around 80%2) Sclerotherapy - Epinephrine (1: 10000) arrests bleeding by

vasoconstriction - Success rate is around 80-90%3) Haemoclip application4) Bipolar electrocoagulogram

HAEMOCLIP APPLICATION

ENDOSCOPY IN DIAGNOSIS AND PROGNOSIS OF PEPTIC ULCER DISEASE

Should be done on an emergency basis within 6 to 36 hours of admission.Endoscopy can determine the risk of rebleeding in PUD and thus determines prognosis.

Forrest Classification for Endoscopic Findings andRebleeding Risks in Peptic Ulcer Disease

GRADE DESCRIPTION RE- BLEEDING RISK

Ia Active,pulsatile bleeding HighIb Active,non-pulsatile bleeding HighII a Non-bleeding visible vessel HighII b Adherent clot IntermediateII c Ulcer with black spot LowIII Clean, non-bleeding ulcer bed Low

SURGICAL MANAGEMENT

INDICATIONS: •Hemodynamic instability despite vigorous resuscitation (>6 U transfusion).•Failure of endoscopic techniques to arrest hemorrhage.•Recurrent hemorrhage after initial stabilization (with up to two attempts at obtaining endoscopic hemostasis).•Shock associated with recurrent hemorrhage.•Continued slow bleeding with a transfusion requirement>3 U/day

SURGICAL MANAGEMENT OF PEPTIC ULCER BLEEDING

- Exposure of the bleeding site- Longitudinal duodenotomy or duodenopyloromyotomy - Hemorrhage is controlled initially with pressure, then direct suture ligation with non-absorbable suture- Anterior ulcers- four quadrant suture ligation.-Posterior ulcer eroding into pancreaticoduodenal or gastroduodenal artery- requires suture ligation of vessel proximal and distal to the ulcer as well as placement of a U stitch- Once bleeding is controlled, a definitive acid reducing operation should be considered.

OPERATIVE PROCEDURES FOR PEPTIC ULCERSBILROTH II GASTRECTOMY :

ROUX-EN-Y GASTROJEJUNOSTOMY :

TRUNCAL VAGOTOMY AND PYLOROPLASTY :Division of the anterior vagus, mobilisation of oesophagus, division of posterior vagusAdvantage : Good drainage

TRUNCAL VAGOTOMY AND ANTRECTOMY : -In addition to truncal vagotomy, the antrum of the stomach is removed and the gastric remnant is joined to the duodenumAdvantage : recurrence rates are exceedingly low

HIGHLY SELECTIVE VAGOTOMY : -The anterior and posterior vagus nerves are preserved but all branches to the fundus and body of the stomach are divided

MALLORY-WEISS TEARS- Longitudinal tear at gastro-oesophageal junction- Cause of hemorrhage : repetitive and strenous vomiting- Presentation : repeated retching , vomiting or coughing followed by hematemesis- Diagnosis : endoscopy- Treatment : stomach is opened by longitudinal gastrotomy , longitudinal mucosal tear is sutured

TUMORS-GI tumors may present as ulcerative lesions that bleed persistently- Persistent bleeding is more characteristic of GI stromal tumors (GISTs) but may occur with other lesions like leiomyomas and lymphomas.

DIEULAFOY’S LESION-Vascular malformations found primarily along the lesser curvature of stomach within 6 cm of gastroesophageal junction-Treatment : application of thermal or sclerosant therapy is effective in 80-100% cases-If fails, Angiographic coil embolization is done-If fails, surgical intervention is needed.

GASTRIC ANTRAL VASCULAR ECTASIA

Also known as watermelon stomach Features of GAVE are as follows :-Women in their 50s are commonly affected- Antrum is commonly involved- Ectasia of antral vessels gives rise to UGI bleeding- Endoscopy is the investigation of choice- Red parallel stripes on mucosal fold are characteristic

-Mucosal fibromuscular hyperplasia and hyalinisation are present-Liver disease in 25% patients – cirrhotic men- No control of bleeding – antrectomy may be required

OTHER CAUSESIATROGENIC : UGI bleeding may follow a therapeutic or diagnostic procedure, for example – bleeding in endoscopic sphincterotomy, percutaneous endoscopic gastrostomy placement, etc.

HEMOBILIA : -Is usually associated with• intraductal neoplasm, • trauma, or • iatrogenic injury such as percutaneous liver biopsy and cystic artery pseudoaneurysm.

-Angiographic therapy is the treatment of choice

Hemobilia

Non variceal upper GI bleeding still constitutes the major bulk of GI bleeding.

Evaluation should be prompt. Upper GI endoscopy is the investigation of

choice. Treatment is mostly non surgical.

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