Download upper gastrointestinal bleeding

UPPER GASTROINTESTINAL BLEEDING
I.
Definitions
1.
2.
3.
4.
5.
II.
Normal Circulatory Physiology



III.
Heart: CO = SV x HR (Depends on preload, contractility and afterload)
Blood Vessels: Arteries conduct blood. Veins act as capacitance vessels.
Blood Volume = 5-6 litre
Homeostatic Mechanism following Haemorrhage.





III.
UGIB: Site of bleeding proximal to ligament of Trietz
Haematemesis : Vomiting of blood- frank, clots or coffee ground
Melaena : Passage of black tarry stool (oxidation of haem)
Haematochezia : Bloody stool (brisk upper GI bleed)
Hypovolaemia : Tachycardia (>100/min); low BP ( < 100 mm)
Sympatho-Adrenal : Stimulates inotropic and chronotropic response and selective
vasoconstriction in skin, muscle and splanchnic vessels.
Vasoactive Hormones: Vasopressin constricts vascular sphincters and diverts blood to heart and
brain and potentiates water reabsorption.
Renin-Angiotensin-Aldosterone: Decreases GFR and urine output, causes
salt-water retention and vasoconstriction, which raises BP and vascular volume.
Cortisol, glucagon, adrenaline: Increase glucose concentration.
GRADES OF HYPOVOLAEMIA & CLINICAL CORRELATION
Grade 1
15% blood volume (~750 ml)
Mild resting tachycardia (<100). BP = Normal
Urine >30ml/h
Rx Crystalloids
Grade 2
15 - 30% (750=1500)
Moderate tachycardia (>100) BP = N / , fall in pulse pressure,
delayed capillary return, anxiety.
Urine 20-30ml/h
Grade 3
30 - 40% blood volume (1500 - 2000 ml)
Tachycardia (>120), hypotension, poor capillary return
Anxious, confused,
Urine output 5-10ml/h
Rx Crystalloids
Blood
Grade 4
40 - 50% blood volume (2000 -2500 ml)
Tachycardia (>140), severe hypotension, cold, clammy skin
Confused, lethargic.
Anuria
Rx Crystalloids
Urgent blood
Rx Crystalloids
Rule of 3:1 (3L of Crystalloids = 1L of Blood)
1
AETIOLOGY :
I. LOCAL


Mouth and pharynx: Bleeding tooth socket. Nose bleed. Vascular
malformations
Oesophagus = Inflammatory- Oesophagitis, Barrett’s ulcer

Vascular
- Varices

Neoplastic
- Carcinoma

Other
- Mallory-Weiss tear (postemetic laceration)


Stomach
Inflammatory - Gastric ulcer
-Steroids, NSAIDs– erosions/ulcer
-Dieulafoy lesion (exulceratio simplex)
 Vascular
- Erosions (AML)/Ulcer
- Varices
- Vascular malformations
 = Neoplastic
- Leiomyoma, polyp, carcinoma, lymphoma, KS
Duodenum = Inflammatory - Duodenal ulcer
 Vascular
- Aorto-duodenal fistula
 Neoplastic
- Ca Pancreas or ampulla of Vater
 Other
- Haemobilia
- Pancreatitis
- Post ERCP
II. GENERAL
- Haemophilia, von Willebrand’s disease
- Thrombocytopenia
- Hereditary haemorrhagic telengiectasia
- Anticoagulant or fibrinolytic therapy
- Liver failure. Renal failure
- DIC
COMMON CAUSES OF UPPER GI. BLEEDING
Relative Incidence
Peptic ulcer
Duodenal
Gastric
Erosions
Oesophageal varices
Mallory- Weiss
45%
25%
20%
20%
20%
10%
2
PRIORITY : Resuscitation - Airway. Breathing. Circulation
HISTORY





PRESENTING COMPLAINT: Bleeding
Duration, amount and type of blood: Bright red clots, coffee-ground.
Loose black, tarry stool: Frequency and volume
Frank blood per rectum.
Dizziness and fainting






G.I. System :
Vomiting/Retching : Mallory-Weiss syndrome
Abdominal Pain : Epigastric, ® Upper quadrant : PUD
Dyspepsia/ Heart-burn, regurgitation : Oesophagitis
Recent abdominal trauma (Haemobilia)
Peptic Ulcer / GORD





PAST MEDICAL HISTORY
Blood transfusion. Jaundice, ? Cirrhosis
Resident in Schistosomiasis endemic area
Previous GI bleeding / Endoscopy
Abdominal surgery






DRUGS & OTHER RISKS FACTORS
Ulcerogenic drugs: Steroids, aspirin and other NSAIDs
Alcohol : acute erosions; severe retching > Mallory-Weiss tear
Severe stress: Major trauma/surgery/sepsis/ burns = erosions/ulcer
Anticoagulants
Chronic alcoholism: Cirrhosis
Cardiovascular System: Pre-existing heart disease.
Respiratory System: Chronic cough, chest pain
Nervous System: Confusion, coma (Encephalopathy)
EXAMINATION (ASSESS RAPIDLY)

AIRWAY OBSTRUCTION ( Due to coma or vomitus)

RESPIRATION- Shallow, rapid

HAEMODYNAMIC STATE – P.BP. T. , capillary refill, cold , clammy skin


SKIN AND MUCOSA : Pallor, jaundice, pigmentation, petichiae, ecchymosis, lymph nodes,
palmar erythema, spider naevi, caput medussa. (gynaecomastia and testicular atrophy)

ABDOMEN- Scars, tenderness, hepatosplenomegaly, mass, ascitis.

RECTAL EXAMINATION- Stool, haemorrhoids, fissure, mass
3
MANAGEMENT- RESUSCITATION : (Remember 3 Tubes)
AIRWAY OBSTRUCTION
Suction
Oxygen (40-60%)
Endotracheal Intubation
VASCULAR ACCESS – IV Fluids / Blood
The Routine Case
Cannula ( Size 12-14) in one or both forearm veins
Central Venous Line
Unstable
Elderly
Cardiac
Profoundly Shocked
Venous cutdown / catheter
Urinary catheter
NASOGASTRIC TUBE & LAVAGE
URINARY CATHETER (Unstable patient)
MONITOR AND FLOW CHART
= Time of Admission
= Initial & subsequent vital signs. ECG, pulse oximetry, CVP
= Fluids IN
= Urine OUTPUT
= Serial Hb/Hct q4h-q8h
= NGT aspirate and stool
INVESTIGATIONS: (Take blood at initial venepuncture)

LABORATORY

CBC, BLOOD GROUP & CROSS MATCH (4 – 6 units, immediately)

SERIAL Hb / Hct 4-6 hourly

PLATELET COUNT

LFTs, Albumin. PT/ PTT - Reveal abnormal liver function or coagulopathy
o

Useful in PHT: Modified Child’s Classification : A B C
CREATININE & ELECTROLYTES
4
DIAGNOSTIC
UPPER GI ENDOSCOPY (OGD)
 Accuracy 95%
 Early (<24 hours)
 Stable patient
 Empty stomach (NGT & Lavage)
 Predicts Prognosis (Stigmata of recent haemorrhage)
 Also therapeutic: Sclerotherapy / Cauterisation
BARIUM STUDY (Rarely useful and may interfere with endoscopy)
 Accuracy - Ulcer: 85%
 Varices : 50%
 -Gastritis : 28%
ANGIOGRAPHY
 Requires brisk bleeding (> 0.5 ml / min)
 Useful for therapy – embolization
TECHNETIUM LABELLED RBC SCAN
 Sensitive but not very specific (requires 0.1 ml/min bleeding
 May identify location but not cause of bleeding
FLUID RESUSCITATION & BLOOD TRANSFUSION
What, how much and how fast?
STABLE PATIENT
(Blood group & X match 2 units)
1.
2.
3L of crystalloid (Ringer Lactate or Normal Saline) / 24 hrs.
Transfuse if Hb < 8 gm / dl; use clinical judgement
- 1 unit over 4 hrs for each gram below 8 gm / dl
UNSTABLE PATIENT
- (Blood group & X match 4 units. Active bleeding: 6-8 units.)
1.
2L of crystalloid (Ringer Lactate or Normal Saline- Rapidly)
2.
Assess clinical response:

Rapid response : Reduce rate

Transient response: Continue fluids. Initiate B/T.

Minimal or no response: Rapid Blood Transfusion.
-
Consider O –ve blood in urgent situation
-
Transfuse 1 unit of blood over each 15 min.
-
Increase rate if BP fails to rise or falls.
5
o
Stop blood if patient stable and maintain IV fluids.
(Massive transfusion – citrate toxicity/ K+ toxicity / coagulation disorders)
Aim Maintain vital signs : P, BP, CVP
Maintain urinary catheter output > 30 ml/hr
Maintain Hct at over 30%


If CVP is measured
Infuse until CVP > 5 cm water

If CVP > 12 cm & BP > 100 mm Hg – Stop infusion/ Frusemide

o
o
o
If CVP > 12 cm & BP < 100 mm Hg - Transfer to ICU
Dopamine 5mcg/kg/min or
Dobutamine 2.5-5 mcg/kg/min
Involve physician
SPECIFIC THERAPY
A. PEPTIC ULCER DISEASE.
1.



Conservative ( 80% stop spontaneously)
Gastric Lavage (clears stomach).
No effectiveness
Antacids.
No effectiveness
H2R Antagonists/PP Inhibitors.
No effectiveness
 (Antacids/PPInh. Prophylaxis for stress ulcers)
 Secretin, somatostatin-Arrest bleeding in 80-90%
2.






Endoscopic therapy
Electrocoagulation.
Control 86%. Rec. 29%
Laser coagulation.
Control 95%. Rec. 22%
Injection Therapy
(1:10,000 Adrenaline)
Control 95%. Rec. 17%
Combination: Inj. Adrenaline and electrocoagulation
Haemoclips
3.




Surgery
Massive, prolonged or recurrent bleed.
Age > 60 years, chronic ulcer, co-morbid conditions (risk is higher)
Forrest Type 1a & 1b (Active bleeding)
Failed conservative/ Endoscopic therapy
 DU: Local Undersewing & Vagotomy + GJ
 GU: a) 2/3 Gastric resection
b) Excision of ulcer & Vagotomy + GJ
c) Biopsy. Undersewing & Vagotomy + GJ
6
RISK FACTORS FOR REBLEEDING
Variable
Relative Risk
Age > than 60 years
Taking Medications
Shock
HB< 10 gm
Major Endoscopic Criteria
Gastric Ulcer
p
1.7
1.7
2.0
2.0
6.1
1.7
<0.05
<0,05
<0.002
<0.002
<0.0001
<0.008
FORREST’S CLASSIFICATION
Endoscopic Stigmata of Recent Haemorrhage
CLASS
STATUS
ACTIVITY
Ia
Active Bleeding
Arterial Spurt
Ib
Active Bleeding
II
Bleeding Ceased
III
Bleeding Ceased
Oozing
RISK
RECOMMENDATIONS
80-100%
90% Early Surgery
60-80%
Endoscopic Rx
Clot on base
Visible vessel
40-60%
Clean base
0-4%
90% Endoscopic Control
Observation
B. OESOPHAGEAL VARICES
1. Conservative









Vasoconstrictor Therapy (Control 50-60%)
Vasopressin. Bolus : 20 u in 200 ml over 20 minutes.
 IVI : 0.4u / min.
Glypressin (Terlipressin) Bolus : 2mg stat; 1mg q6h
(Side effects: coronary, cerebral vasoconstriction. Use GTN)
Somatostatin. IVI : 250mcg/hr
Octreotide.
Bolus : 100mcg, then mcg/h IVI for 120 hours
Baloon Tamponade (Initial control: 70-80%. Recurrence: 50%)
Sangstaken-Blakemore / Minnesota Tube
(Complications: Aspiration pneumonia, rupture of oesophagus)
2. Endoscopic therapy (Control 80%. Recurrence: 30%)
 Injection sclerotherapy eg. 5% Ethanolamine oleate.
 Rubber band ligation (EVBL), probably superior
3. Surgery (CHILD’s Classification: A, B = Shunt; C = Transplant)
 Oesophageal transection and anastomosis (Stapled)
 Oesophagogastric devascularization (Sugiura/Hassab)
 Suture ligation of varices
 Porto-systemic shunts (eg. H graft portocaval shunt)
 Transjugular porto-systemic shunt (TIPS)
 Liver transplant. (Child’s C)
7
Secondary Prevention: EVBL + Propranolol (Pulse<25%) +Isosorbide Mononitrate
* Child- Pugh Classification
Parameter
1 Point
2 Points
Bilirubin
<2
2-3
Albumin
>3.5
2.8-3.5
Increase in PT
1-3
4-6
Ascites
None
Slight
Encephalopathy
None
1-2
3 Points
>3
<2.8
>6
Moderate
3-4
*Risk of the first variceal bleed is predicted based on:
1. variceal size, 2. the presence of red wales, 3 Child-Pugh score > 8 points
8