Download 2) Shock

Guideline of Gastrointestinal Bleeding and Peptic ulcer disease
 Definition
Intraluminal blood loss anywhere from the esophagus to the anus .
 Classification :
1) UGI bleeding : Above the ligament of Treitz
2) LGI bleeding : Below the ligament of Treitz
 Term
1) Hematemesis : blood in vomitus
 UGI bleeding
2) Hematochezia : bloody stools
 A) Rapid UGI bleeding B) LGI bleeding
3) Melena : Black , tarry stool from digested blood
 A) UGI bleeding B) anywhere above cecum
 Etiology of bleeding :
1)
2)
3)
4)
5)
6)
alcohol use
liver disease,
coagulation disorders,
bleeding tendencies.
emesis preceding upper GI bleeding  Mallory-Weiss tear.
NSAIDs and aspirin : mucosal damage anywhere in the GI tract.
 Precipitating factors
1)
2)
3)
4)
5)
6)
Coagulopathy
liver disease,
von Willebrand's disease,
vitamin K deficiency
disseminated intravascular coagulation ( DIC )
medications :
A) warfarin,
B) heparin,
C)
D)
E)
F)
G)
aspirin,
NSMDs,
clopidogrel (Plavix),
thrombolytic agents ( tPA )
Newer antithrombotic agents :
a) glycoprotein IIb/IIIa receptor antagonists
tirofiban (Aggrastat)
b) direct thrombin inhibitors : argatroban , bivalirudin
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 Contraindication of endoscopy
1)
2)
3)
4)
Perforated viscus suspected ( PPU )
Shock
Combative or uncooperative patient
Severe inflammation bowel disease
5) Toxic megacolon
 食道靜脈瘤標準
A) Color :
1) Cw : white varice
2) Cb: blue varices
B) Red color sign ( RC ):
1) Red wale marking
2) cherry red spot
3) hematocystic spot
4) diffuse redness
C) Location ( L ) :
1) Ls : ( Locus superior )
2) Lm ( Locus medialis )
3) Li ( Locus inferior )
4) Lg ( Locus gastric varice )
a) Lg-c : near cardia
b) Lg-f : near formix
c) Lg-cf : cardia to formix
D) Form : ( F )
1) F0 : No varice
2) F1 : linear dilatation
3) F2 : Fusiform
4) F3 : nodular varice
 Primary prophylaxia of esophageal varice bleeding
1) ≧ F2
2) Red color sign .
 Tagged red blood cell (TRBC) scanning :
1) RBCs that are labeled with technetium-99m remain in circulation for 48 hours
2) extravasate into the bowel lumen with active bleeding.
3) Detected Bleeding rates :≧0.1 ml/minute
4) accurate in identification of the location of the bleeding source in 80% of
cases.
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5) The false localization rate of approximately 20%
1). Arteriography
1) demonstrating extravasation of the dye into the intestine
2) bleeding rates ≧ 0.5 ml/minute.
3) identify the bleeding lesion, especially bleeding diverticula angiodysplasia.
4) intra-arterial infusion of vasopressin can cause vasoconstriction , stop
bleeding.
5) Embolizatlon of the bleeding artery
small risk of bowel infarction.
 Indication of capsule endoscopy :
1) Crohn's Disease,
2) Celiac disease
3) other malabsorption disorders,
4) benign and malignant tumors of the small
intestine,
5) vascular disorders
6) medication related small bowel injury.
7) obscure gastrointestinal bleeding,
8) iron deficiency anemia,
9) in adults and children from 10 years of age and up.
2). Contraindication of capsule endoscopy :
1)
2)
3)
4)
5)
6)

gastrointestinal obstruction
strictures
fistulas
cardiac pacemakers
swallowing disorders.
in pregnant women
Initial evaluation
Intravascular volume and hemodynamic status :
A) Orthostatic hemodynamic changes :
1)↓systolic BP of >10 mm Hg,
2) ↑pulse rate of >15 beats/minute .
 loss of 10-20% of the circulatory volume
B) Supine hypotension : > 20% blood loss.
C) goals:
1) heart rate <100 beats/min;
2) systolic blood pressure >100 mmHg .
 Restoration of intravascular volume :
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A) Two large-bore IV lines with 14-to 18-gauge catheters
B) Transfusion should be continued until
1) hemodynamic stability
2) Ht > 25%
pulmonary disease : Ht > 30%
3) goals : a) PT <15 seconds;
b) platelets > 50,000/m
cardiac
 Endotracheal intubation to prevent aspiration :
1) altered mental status :
A) shock,
B) hepatic encephalopathy
2) massive hematemesis,
3) active variceal hemorrhage
 Therapy of Peptic ulcer disease (PUD) :
high-dose proton pump inhibitors ( PPIs )
1) omeprazole, 40 mg P0 bid
2) reduces the rate of recurrent bleeding
3) reduces the need for surgery in patients with upper GI bleeding who are
A) awaiting endoscopic treatment or
B) endoscopy is contraindicated or postponed
 Risk factors for increased morbidity and mortality
1) age ＞ 60 years,
2) > one comorbid illness,
3) blood loss of > 5 U,
4) shock on admission,
5) bright-red hematemesis with hypotension,
6) coagulopathy
7) large (>2cm) ulcers,
8) recurrent hemorrhage (within 72 hours),
8) requirement for emergency surgery
 Indications for surgery :
1) Ongoing intractable or recurrent bleeding.
2) transfusion requirements
A) exceeding 4 - 6 U over 24 hours or
B) 10 U overall or
C) ≧ 2-3 recurrent bleeding episodes from the same source .
 Therapy pf Variceal hemorrhage :
A) Octreotide ( Sandostatin ) :
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1) 50 to 100 ug bolus,
2) infusion at 25 - 50 ug/hour .
 2 amp st  12 amp + D5W run 20 cc/hr X 3 days .
3) ↓Glucagon , substance , VIP ( vasoactive intestinal peptide )
 direct splanchnic vasoconstriction
 ↓portal pressures
↓ Collateral blood flow
4) very few side effects,
5) improving the diagnostic yield and therapeutic success of subsequent
endoscopy
B) Terlipressin ( Glypression )
1)
2)
3)
4)
Synthetic analog of vasopressin
Less averse affect
2 amp ( 2 mg ) slow IV st
1 amp ( 1mg ) 4h – q6h IV 無使用天數限制
5) selected vasopressin
 ↓portal veonus pressure
 ↓variceal blood flow
C) Esophageal varices ligation
a) Band ligation as effective as sclerotherapy in
1) controlling acute variceal bleeding
2) preventing rebleeding.
b) fewer complications compared to sclerotherapy
c) Complications of banding :
1) superficial ulceration,
2) dysphagia,
3) transient chest discomfort,
4) esophageal strictures : rarely .
D) Sclerotherapy
a) used less frequently because of complications
1) ulcerations,
2) strictures,
3) perforation ( 1 – 3 % )
4) pleural effusions ( Exudate ) ,
5) adult respiratory distress syndrome ( ARDS ),
6) sepsis
7) aspiration ( 5 – 7 % ) .
b) Recurrent bleeding : up to 50%
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 usually responds to repeat sclerotherapy;
c) Fever : 40% within the first 2 days of therapy;
＞ 2 days  bacteremia.
E) Sengstaken-Blakemore tube
a) guidelines for the use of balloon tamponade:
1). ICU admission is mandatory,
2). endotracheal intubation.
3). NG tube above the esophageal balloon
4). Completed before insertion.
5). intermittent suction to prevent aspiration
6). of oropharyngeal secretions.
7). Gastric balloon :
8). 200 – 300 cc air
9). position confirmed by radiography
10).
11).
12).
13).
14).
15).
Inflating in the esophagus
esophageal rupture.
Esophageal balloon :
35 – 40 mmHg
deflate 30 min q6-12h
Traction : 1.5 – 2.0 lb. ( 1lb. = 453.6 g )
a) β-adrenergic antagonists :
1) reduce portal pressure
2) lower the risk of recurrent bleeding.
3) Propranolol ; nadolol
1) primary prophylaxis :
reduce the resting heart rate by 25%
2) effective prophylactic therapy for recurrent bleeding
3) no benefit in overall survival
b) Nitrates :
1) isosorbide dinitrate
2) reduce portal pressure
3) lower the risk of recurrent bleeding.
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 fever lasts