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Management of acute upper GI haemorrhage

Management of acute upper GI haemorrhage. Causes. Peptic ulcer 35-50% Gastroduodenal erosions 8-15% Oesophagitis 5-15% Varices 5-10% Mallory Weiss tear 15%

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Management of acute upper GI haemorrhage

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  1. Management of acute upper GI haemorrhage

  2. Causes • Peptic ulcer 35-50% • Gastroduodenal erosions 8-15% • Oesophagitis 5-15% • Varices 5-10% • Mallory Weiss tear 15% • Upper GI malignancies 1% • Vascular malformations 5% • Rare 5%

  3. Initial resuscitation • Two large bore cannulae and take sample • Normal saline 1-2 lt fall of pulse/improved BP/adq urine • Plasma expander if still shocked • Blood transfusion - haematemesis/shock - Hb <10

  4. Severity of bleed • Current clinical scoring system( Rockall) for risk of re-bleed or death involves OGD • So definition of mild/mod/severe remains a matter of clinical judgement

  5. Mild to moderate bleed • Pulse/BP normal • Hb >10 • Insignificant comorbidity • Mostly <60 yrs • General ward • Allowed fluid if stable • BP/pulse hourly • Monitor urine volm • Endoscopy next available list • Early discharge

  6. Continued • Excellent prognosis if no SRH/varices/malignancy • Subsequent management • May include H.Pylori eradication • Use of acid suppressing treatment • Advice concerning NSAIDs

  7. Severe bleed • Pulse>100 • SBP < 100 • Hb < 10 • Significant comorbidity • Mostly >60 yrs • Preferably HDU • Hrly BP/pulse/ urine volm • Fasted • Urgent endoscopy after resuscitation

  8. Endoscopy in acute upper GI haemorrhage • Semi-elective in minor and urgent in major bleed • Only after initial resuscitation • Best done in endoscopy unit • But out of hours ,operating theatre with full resus. Equipment and anaesthetist may be better option • Only expert endoscopists • Consider ET tube to prevent aspiration

  9. Endoscopic finding & subsequent management • No SRH : general ward • Varices : VBL/VScl • Ulcer with SRH : endoscopic haemostasis 1.adrenaline inj 2.heat application 3.mechanical clips

  10. Drug therpy for non-variceal principally ulcer bleed • Evidence suggests following successful endoscopic treatment in patient presenting with major ulcer bleed high dose omeprazole stabilizes clot and prevents rebleed • omeprazole 80mg iv stat followed by 8mg per hour infusion for upto 72 hrs

  11. After endoscopy • Close monitor to identify rebleed • If stable after 6hrs allow light diet ( no data suggesting prolong fasting necessary) • Repeat endoscopy • If active rebleed • If concern re optimal initial therapy (after 12-24 hrs)

  12. Surgical intervention • If endoscopic therapy unsuccessful • In rebleed it is advisable to repeat endoscopy to confirm bleed and also try offer one more time of endoscopic therapy before considering surgery if it was initially successful • In massive rebleed sometimes surgical intervention is needed straightway if initial OGD was unfavourable

  13. Surgical options • Duodenal ulcers • Under running ±ligation of gastroduodenal/rt gastroepiploic arteries • Gastrectomy to include the ulcer with Billroth I or II reconstruction • Gastric ulcers • Excised • Parial gastrectomy • Under running if elderly with poor condition

  14. Follow up • For ulcer bleeds standard ulcer healing treatment • In most cases this also involves H.Pylori eradication • Ulcer associated with NSAID -stop drug or choose the least damaging one • Re-endoscope GU in 6wks to ensure healing. Not necessary for DU.

  15. Additional points for variceal haemorrhage • For no varix on initial endoscopy repeat 3yrly • For grade 1 varix yearly F/U • Primary prophylaxis with propranolol (80-160mg) for all grade 2/3 oesophageal varices • If unsuitable for ppnl, VBL is next option • ISMN

  16. Acute management of variceal haemorrhage • Antiobiotic prophylaxis for all patientsciprofloxacin 500mg BD for a week • VBL is method of choice for OV • VScl if above difficult or unavailable • If endoscopy unavailable vasoconstrictor therapy or balloon tamponade with Sengstaken tube while more definitive therapy is arranged

  17. continued • Pharmacological therapy is with two major classes of drugs –vasopressin or its analogue terlipressin (glypressin) and somatostatin or its analogue octreotide • Terlipressin is given as 2mg iv bolus followed by 1-2mg every 4-6 hrs for up to 72hrs

  18. OV BLEED • Controlled – banding eradication programme. One band /wk. F/U at 3& 6 month and then yearly • Uncontrolled –balloon tamponade until further endoscopic treatment/ TIPSS/surgical intervention • Choice of TIPSS or surgical intervention such as oesophageal transection depends on centre’s preference

  19. GV bleed • If IGV initial sclerotherapy with butyl-cyanoacrylate • If unsuccessful balloon tamponade prior to more definitive treatment

  20. Secondary prophylaxis of variceal haemorrhage • banding eradication programme • TIPSS • Portocaval shunt surgery

  21. Thank you

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