ACUT GI ACUT GI

BLEEDINGBLEEDING

Dr. LDr. Láászlszlóó AndrAndráás, MD. PhDs, MD. PhD

Semmelweis University,Semmelweis University,

KKúútvtvöölgyi lgyi ClinicalClinical CenterCenter

GI BLEEDINGGI BLEEDING

�� UGIBUGIB -- melaenamelaena

�� EsophagusEsophagus

�� EsophagitisEsophagitis

�� RefluxReflux

�� SoorSoor

�� VarixVarix

�� TuTu

�� StomachStomach

�� UlcerUlcer

�� ErosionErosion

�� TuTu

�� DuodenumDuodenum

�� UlcerUlcer

�� TuTu (pancreas?)(pancreas?)

�� LGIBLGIB -- hematochesiahematochesia

�� SmallSmall bowelbowel

�� Large bowelLarge bowel

�� DiverticulumDiverticulum

�� HemorrhoidsHemorrhoids

�� TuTu

�� PolypPolyp

�� CancerCancer

�� ColitisColitis

�� UCUC

�� CDCD

�� RadiationRadiation

�� IschaemieIschaemie

�� InfectionsInfections

�� PostpolypectomyPostpolypectomy

WhyWhy dodo wewe needneed urgenturgent endoscopyendoscopy??

Because the finding of the endoscopy determines the Because the finding of the endoscopy determines the

therapy:therapy:

�� Endoscopic treatment to stop bleedingEndoscopic treatment to stop bleeding

�� SengstakenSengstaken--BlackmooreBlackmoore tubetube

�� Esophageal Esophageal varixvarix bleedingbleeding

�� Conservative therapyConservative therapy

�� Erosions, notErosions, not--bleeding ulcersbleeding ulcers

�� SurgerySurgery

�� Active bleeding, Active bleeding, rebleedingrebleeding

ContraindicationsContraindications toto

emergencyemergency endoscopyendoscopy

�� GI perforationGI perforation

�� Sever hemodynamic instabilitySever hemodynamic instability

�� Uncooperative pt.Uncooperative pt.

�� Lack of informed consentLack of informed consent

EsophagealEsophageal varixvarix bleedingbleeding

TherapyTherapy forfor oesophagealoesophageal

varixvarix bleedingbleeding

�� InjectionInjection therapytherapy withwith aethoxysclerolaethoxysclerol

�� Esophageal Esophageal varixvarix band ligationband ligation

�� SengstakenSengstaken--BlackmooreBlackmoore TubeTube

Esophageal Esophageal varixvarix band ligation band ligation

SengstakenSengstaken TubeTube

NONVARICEAL UGIBNONVARICEAL UGIB

�� > 300.000 > 300.000 hosp.admhosp.adm./year in the US./year in the US

�� Mortality 8 Mortality 8 –– 10 % (no change in the last 50 10 % (no change in the last 50

years years -- age, age, comorbidcomorbid illnesses)illnesses)

�� 8080--85% of bl. stop with supportive 85% of bl. stop with supportive thth..

�� 1515--20 % high risk group, require early 20 % high risk group, require early

identification:identification:enendoscopy,surgary,angigr.thdoscopy,surgary,angigr.th..

Rapid AssessmentRapid Assessment

Hemodynamic statusHemodynamic status

Fluid resuscitationFluid resuscitation

Gastric Gastric lavagelavage??

Empirical medical therapyEmpirical medical therapy

Self limited hemorrh.(80%) Self limited hemorrh.(80%)

Elective endoscopyElective endoscopy

(within 12(within 12--24 h)24 h)

Definitive therapyDefinitive therapy

Active or severe hemorrh.(10Active or severe hemorrh.(10--20%)20%)

Urgent endoscopy Urgent endoscopy

(within 6 h)(within 6 h)

Site not localized Site localizedSite not localized Site localized

Further assessment:Further assessment:

Bleeding scan,Bleeding scan,

EnteroscopyEnteroscopy

AngiographyAngiography

SurgerySurgery

Definitive therapyDefinitive therapy

GastroGastro--duodenal ulcerduodenal ulcer

�� Common Common

�� HelHeliicobactercobacter pylori infectionpylori infection

�� NSAID inducedNSAID induced

�� Stress ulcerStress ulcer

�� UncommonUncommon

�� ZollingerZollinger--Ellison syndrome (Ellison syndrome (gastrinomagastrinoma))

�� CrohnCrohn diseasedisease

�� InfectionsInfections

�� Chr. renal failureChr. renal failure

�� Radiation inducedRadiation induced

�� Penetrating tumorPenetrating tumor

HowHow cancan wewe assessassess thethe severityseverity of of

hemorrhagehemorrhage??

�� Orthostatic decrease of 20 mmHgOrthostatic decrease of 20 mmHg

�� Increase in pulse rate of 20 beats/minIncrease in pulse rate of 20 beats/min≥≥ 20% 20% intravascintravasc. volume depletion. volume depletion

HypovolemicHypovolemic shockshock

�� HematocritHematocrit? ? –– misleading! Equivalent loss of plasma & misleading! Equivalent loss of plasma & RBC RBC –– after 72 h is competent.after 72 h is competent.

WhatWhat toto dodo firstfirst??

�� Blood to the lab, typing, Blood to the lab, typing, crossmatchingcrossmatching

�� 2 large intravenous catheters2 large intravenous catheters

�� Fluid replacement Fluid replacement

�� RingerRinger’’s lactates lactate

�� Colloid Colloid –– only in sever only in sever hypoalbuminemiahypoalbuminemia

�� SympathomimeticSympathomimetic agents agents –– only in only in refrrefr. shock. shock

�� Transfusion Transfusion –– not whole blood (fluid overdose, immunoreactions), but PRBC not whole blood (fluid overdose, immunoreactions), but PRBC

�� Hgb:7Hgb:7--10g/l 10g/l

�� 1 U of PRBC 1 U of PRBC HgbHgb 1,0 1,0 g/lg/l in in nonbl.ptnonbl.pt..

�� Massive blood transfusion Massive blood transfusion –– hypocalcemiahypocalcemia, hypothermia, , hypothermia, thrombopeniathrombopenia, ,

coagcoag. . factor(Vfactor(V, VIII) deficiencies (stored blood), VIII) deficiencies (stored blood)

�� FFP, platelets FFP, platelets –– 80.000, but aspirin, 80.000, but aspirin, NSAIDsNSAIDs make make pltplt. dysfunctional. dysfunctional

ClinicalClinical prognosticprognostic factorsfactors

�� Severity of bleedingSeverity of bleeding

�� Hemodynamic instability on initial examinationHemodynamic instability on initial examination

�� Persistent hypotensionPersistent hypotension

�� Transfusion requirements: 4Transfusion requirements: 4--6 U/24h6 U/24h

�� HematemesisHematemesis, , hematocheziahematochezia, bloody gastric asp., bloody gastric asp.

�� Age > 60Age > 60

�� ComorbidComorbid illnessesillnesses

�� Onset of bl. while already hospitalizedOnset of bl. while already hospitalized

�� Recurrent hemorrhage (20%, mortality 30%)Recurrent hemorrhage (20%, mortality 30%)

EndoscopicEndoscopic diagnosticdiagnostic factorsfactors

�� Ulcer location Ulcer location –– close large vessels close large vessels

�� Posterior duodenal bulbPosterior duodenal bulb

�� Higher lesser gastric curvatureHigher lesser gastric curvature

�� Ulcer size Ulcer size –– 11--2 cm diameter2 cm diameter

�� Adherent clotAdherent clot

�� Visible vesselVisible vessel

�� Active bleedingActive bleeding

INCREASED LIKELIHOOD OF REBLEEDING & DEATHINCREASED LIKELIHOOD OF REBLEEDING & DEATH

MedicalMedical treatmenttreatment of UGIBof UGIB

�� Gastric Gastric lavagelavage

�� Iced salineIced saline

�� VasoconstrictingVasoconstricting agentsagents

�� AntifibrinolyticsAntifibrinolytics

�� Pharmacologic agentsPharmacologic agents

�� H2RAH2RA

�� PPIPPI

�� ProstoglandinProstoglandin analoguesanalogues

�� VasoconstrictorsVasoconstrictors

NO MEDICAL THERAPY CAN BE STRONGLY RECOMMENDEDNO MEDICAL THERAPY CAN BE STRONGLY RECOMMENDED

TherapeuticTherapeutic endoscopyendoscopy forfor

acuteacute nonvaricealnonvariceal UGIBUGIB

�� Thermally active methodsThermally active methods

�� Laser photocoagulationLaser photocoagulation

�� Topical or injection methodsTopical or injection methods

�� SclerotherapySclerotherapy

�� Tissue gluesTissue glues

�� Clotting factorsClotting factors

�� Mechanical methodsMechanical methods

�� Band ligationBand ligation

�� Endoscopic staplingEndoscopic stapling

AngiographicAngiographic interventionintervention inin UGIBUGIB

�� UncommonUncommon

�� Severe, persistent bleeding, if surgery confers a Severe, persistent bleeding, if surgery confers a

high risk, and endoscopic high risk, and endoscopic thth. is not available or . is not available or

unsuccessful.unsuccessful.

�� Art.embArt.emb. with absorbable gelatin sponge, or with . with absorbable gelatin sponge, or with

nonadsorbnonadsorb. . polyvinilpolyvinil alcohol, or alcohol, or spongspong--wire coils wire coils

–– 7575--80 % success80 % success

SurgicalSurgical treatmenttreatment of UGIBof UGIB

�� Failure to control bl. with Failure to control bl. with nonoperativenonoperative meansmeans

�� Severe Severe rebleedingrebleeding despite of 2 attempts of endoscopic despite of 2 attempts of endoscopic hemostasishemostasis

�� A lesion inaccessible to endoscopyA lesion inaccessible to endoscopy�� Prior surgeryPrior surgery

�� Anatomic anomalyAnatomic anomaly

�� Pyloric Pyloric stenosisstenosis

�� Sever shockSever shock

�� Severe complication of endoscopic therapySevere complication of endoscopic therapy�� PerforationPerforation

�� Worsening bleedingWorsening bleeding

Prevention of ulcer Prevention of ulcer rebleedingrebleeding

�� Acid suppressive medications: H2RA, PPIAcid suppressive medications: H2RA, PPI

�� Eradication of Helicobacter pyloriEradication of Helicobacter pylori

�� Cessation of NSAID useCessation of NSAID use

SpecificSpecific cousescouses of UGIBof UGIB

�� Stress related mucosal injuryStress related mucosal injury

�� Congestive Congestive gastropathygastropathy

�� MalloryMallory--Weiss Weiss sysy

�� TumorsTumors

�� Vascular Vascular malformmalform..�� AngiodysplasiaAngiodysplasia

�� OslerOsler--WeberWeber--RenduRendu diseasedisease

�� General General antralantral vascvasc. . ectasiaectasia

(watermelon stomach(watermelon stomach))

�� HemobiliaHemobilia

�� DieulafoyDieulafoy’’ss lesion (caliber lesion (caliber persist.artpersist.art.).)

�� AortoentericAortoenteric fistulafistula

LargeLarge bowelbowel diverticulumdiverticulum

HemorrhoidsHemorrhoids

UlcerativeUlcerative colitiscolitis

CrohnCrohn’’ss diseasedisease

RadiationRadiation colitiscolitis, , ischemicischemic colitiscolitis

AngiodysplasiaAngiodysplasia

LargeLarge bowelbowel polyppolyp

LargeLarge bowelbowel cancercancer

Thank you for your attention!Thank you for your attention!