Git GIB Variceal lower 2011 .
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Transcript of Git GIB Variceal lower 2011 .
GIT Bleeding:VGIBLGIB
Dr. Mohamed Shekhani
CABM-FRCP
Variceal bleeding:Variceal bleeding:
Clinical decompensation (i.e., ascites, encephalopathy,a previous
episode of hemorrhage, or jaundice).
Gastric fundal varicesOr GEV
Esophageal varices
Portal hypertensive gastropathy
Common lethal complication of cirrhosis(50% at diagnosis, 7%/year), particularly with:
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Types
Portal hypertensive Biliopathy
Variceal bleeding:Variceal bleeding:
Clinical decompensation (i.e., ascites, encephalopathy,a previous
episode of hemorrhage, or jaundice).
Treatment of the acute bleeding episode:Mortality 15-20%
Primary prophylaxis to prevent a first episode of VH.
Secondary prophylaxis (prevention of recurrent VH).60%/year.
Common lethal complication of cirrhosis(50% at diagnosis, 7%/year), particularly with:
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MANAGEMENT
Small varicesSmall varices Large varicesLarge varicesNo varicesNo varices
7-8%/year7-8%/year 7-8%/year7-8%/year
Varices Increase in Diameter ProgressivelyVarices Increase in Diameter Progressively
Merli et al. J Hepatol 2003;38:266Merli et al. J Hepatol 2003;38:266
VARICES INCREASE IN DIAMETER PROGRESSIVELY
Predictors of hemorrhage: Variceal size Red signs Child B/C
Predictors of hemorrhage: Variceal size Red signs Child B/C
NIEC. N Engl J Med 1988; 319:983NIEC. N Engl J Med 1988; 319:983
Variceal hemorrhageVariceal hemorrhage Varix with red signsVarix with red signs
PROGNOSTIC INDICATORS OF FIRST VARICEAL HEMORRHAGE
Class A: 5-6Class B: 7-9Class C: 10-15
PortalHT
Risk stratification
Varices or colaterlas detected on imaging studies as Abd U/S,EUS,Dopler
Varices on VCE
Fibroscan measuring liver stiffness predicts portal HT
Plateletes/spleen maximal bipolar diameter<909
Decompensated liver cirrhosis:Child-Pough or MELD class
Gastroesophageal varices.
Portal HT Risk stratificationPortal HT Risk stratification 2
HVPG: gold standard&Best predictor of PHT & EV, but invasive ¬ widely available.
>5 mm Hg PHT>10 mm Hg clinically significant
Primary prophylaxis of bleeding eso varices:Primary prophylaxis of bleeding eso varices:
Propranolol
FU OGD afterObliteration:
3 MONTHLYFor 1 year
ThenYearly
Indefintely.
Or
Nadolol
EBLSessions every
4 weeks
PP of EV bleed
Propranolol 20mgm*2 untill PR 55/minIndefinite
Nadolol 40mgm once dailyUntill PR 55/minIndefinite
Endoscopic band ligationEvey 4 weeks untill total obliterationFollow up: 3 /12 for 1 year, yearly
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Management of acute variceal bleeding:Management of acute variceal bleeding:
EndoscopicIntervention
EBLSclerotherapy
SigestakenTube temponade
CyanoacrylateInjection
SclerotherapyFor gastric
Varices.
Antibiotics:Ceftriaxone
Ciprofloxacin5 days
VasoconstrictorOctreotite
SomatostatinTelipresin
5 days
Esophagealstenting
Acute variceal Bleeding.
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Secondary prophylaxis( prevention of recurrent) of bleeding EV:Secondary prophylaxis( prevention of recurrent) of bleeding EV:
propranolo Nadolol
Cyanoacrylate for GV
EBL forEV
InterventionalRadiology for
GV
Isosorbide
Secondary prophylaxis
PropranololSame as for primary prophylaxis.
NadololSame as for primary prophylaxis.
Isosorbide dinitrate10 mgm*10-20 mgm*2
EBL Same as for primary prophylaxis.
Cyanoacrylate injection sclerotherapy or IR for gastric varices not EBL.
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Portal Hypertensive GastropathyPortal Hypertensive Gastropathy
•PHT- related ectatic gastric mucosal vessels mostly in fundus & body of the stomach.
Definition:
GEV , Child class& prior variceal endoscopic therapy
Chronic blood loss leading to IDA rather than acute bleeding
Iron supplementation;BB,Shunt therapy(surgeryorTIPS)
Same.
Predictors of its presence
Prsentation
Treatment:
Prophylaxis
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Acute Lower Gastrointestinal Bleeding Acute Lower Gastrointestinal Bleeding
Bleeding distal to the ligament of Treitz for <less 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.
Causes in Our locality:Perianal diseases(piles/Fissure)IBD(UC>CD)Infectious colitisNeoplasms(adenoma or cancer)Solitary rectal ulcer syndrome
(SRUS)Meckel’s diverticulum.Ischemic colitis.Angiodysplasia
Hemorrhoids/ fissures:Hemorrhoids/ fissures:
Bleeding after/or with defecation
Pain & bleeding with defecation
Careful perianal exam+ anoscopy assist in the diagnosis
Piles Fissure
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Acute LGIB: Management algorythmAcute LGIB: Management algorythmInitial evaluation/ resuscitation
Triage to OP vs Ward vs ICU
Mild scanty bleeding Anorectal pathologysusspected
Rigid Anoscopy or sigmoidoscopy to confirm diagnosis
Outpatient management
Anorectal pathology(piles/fissure) is the most common pathology in our localityBut this should be diagnosed on solid basis not to miss serious pathologies as IBD or cancer.
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.
Acute LGIB: Management algorythmAcute LGIB: Management algorythm
Moderate severe bleeding
Consider NGT aspirate
Bloody NGT aspirateRisk 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.
Acute LGIB: Management algorythmAcute 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.
Acute LGIB: Management algorythmAcute 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
Acute LGIB: Management algorythmAcute 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.
Acute LGIB: Management algorythmAcute LGIB: Management algorythm
Moderate severe bleeding
On colonoscopy bleeding site not identified but bleeding had stopped
OGDOrRepeat colonoscopyOrSI 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/angigraphyIs done fordiagnosis/treatment specially if bleeding recurred.
Acute LGIB: Management algorythmAcute LGIB: Management algorythm
Hope it helps