PRESENTER- PRASANNAKUMAR KAMBLE

MODARATOR- DR H M VIJAYKUMAR

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A common ,potentially DEADLY condition . Accounts for 170 cases/100000 1-2% of all admissions Men > women .3:1 Mortality 10%.
Sabiston

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Bleeding from a source proximal to the ligament of Trietz .

Upper: Lower GI bleeding = 5:1 ` Incidence: 50-100 per 100,000 pts. ` 100 per 100,000 hospital admission. ` 30% pts are older than 65 years  80% are self-limited.  20% of pts who have recurrent bleeding (within 48-72 hrs) have poor prognosis.
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` 1) Peptic ulcer disease .most common cause A) duodenal ulcers 29% will rebleed in 10% of cases within 24-48h B) gastric ulcers 16% more likely to rebleed C) stomal ulcers <5% .

ASA.` ` ` 2) Erosive gastritis. esophagitis. NSAID¶s 3) PORTAL HYPERTENSION RELATED esophageal varices gastric varices portal hypertensive gastropathy 4) Mallory-Weiss syndrome ± longitudinal mucosal tear in the cardioesophageal region caused by repeated retching . duodenitis some causes are ETOH.

` ` ` ` ` ` ` ` WATER MELON STOMACH ESOPHAGITIS ±INFECTION DIEULAFOY S LESION AORTODUODENAL FISTULA ANGIODYSPLASIAS CROHN S DISEASE HEMOBILIA HEMORRHAGE FROM PANCREATIC SOURCE. .

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Type & Cross blood.` ` ` ` ` ` Get to patient¶s bedside. send CBC & Coags Place patient on O2 & continuous monitor Place an NGT and lavage with NS To confirm if the bleeding source is upper GI look for need for blood transfusion . assess ABC Can the patient protect his airway? Does he need to be intubated? Is the patient hemodynamically unstable? Is he in hemorrhagic shock? 2 large bore IV. Bolus 2L fluids.

mL/h CNS/Mental Status Fluid Replacement. mL Blood Loss. lethargic Crystalloid and blood Crystalloid Crystalloid .% blood volume Pulse Rate. confused Crystalloid and blood >35 Confused. 3-for-1 rule Up to 750 Class 2 750-1500 Class 3 1500-2000 Class 4 >2000 Up to 15% 15-30% 30-40% >40% <100 Normal Normal or Increased >100 Normal Decreased >120 Decreased Decreased >140 Decreased Decreased 14-20 Slightly anxious 20-30 Mildly anxious 30-40 Anxious.Estimated Fluid and Blood Losses in Shock Class 1 Blood Loss. bpm Blood Pressure Respiratory Rate Urine Output.

Criterion ` Score 0 1 2 0 1 2 0 3 Age ` Shock ` Co-morbidity <60 years 60-79 yrs >80 years None Pulse & sBP >100 sBP <100 None Cardiac/any major 2 Renal/liver/malig. ` Total initial score (max = 7) .

0% 24.6% 11.0% Rockall TA et al Gut 1996.4% 5.6% 48.2% 2. 38: 316-21 .6% 39.9% 50.Initial risk score (pre-endoscopy) Score 0 1 2 3 4 5 6 7 Mortality 0.

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ƒ Signs of shock Cold clammy extremities Poor mentation Rectal examination Occult blood Gross blood Bright red blood per rectum Melena Blood coating stools versus within stools Bloody diarrhea ƒ .

ALT. total protein . GGTP. Cr.` ` CBC. PTT in all cases Others as indicated: Type and crossmatch AST. bilirubin Albumin. PT. BUN. LFT.

Packed cells are the preferred Aim -restore lood volume and pressure and to correct anaemia to maintain the oxygen carrying capacity.5 times higher than the control value. . Platelet transfusion platelet count is elow 50 000/mm3. Fresh frozen plasma given prothrom in time is at least 1.

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` ` ` ` ` ` ` ` ` ` ` ` Age >60 yr Comorbid disease Renal failure Liver disease Respiratory insufficiency Cardiac disease Magnitude of the hemorrhage Systolic blood pressure <100 mm Hg on presentation Transfusion requirement >4 units Persistent or recurrent hemorrhage Onset of hemorrhage during hospitalization Need for surgery .

` ` ` ` ` ` History NG Tube EGD Colonoscopy Tagged RBC Scan Angiography .

HISTORY Probable Source of GI Bleeding Within the Gut Probability of Upper GI Source Almost certain Probable Possible Rare Probability of Lower GI Source Rare Possible Probable Almost certain Possible Clinical Indicator Hematemesis Melena Hematochezia Bloodstreaked stool Occult blood in stool Possible .

Effect of the Color of the Nasogastric Aspirate and of the Stool on UGIB Mortality Rate Nasogastric Aspirate Color Clear Stool Color Brown or red Brown or black Red Red blood Black Brown Red Mortality Rate. % 6 Coffee-ground 8.4 28. .3 19.2 19.1 12.

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` ` ` ` ` ` ` ` PHARMACOLOGICAL ENDOSCOPIC Topical treatment Injection treatment Mechanical treatment Thermal treatment ANGIOGRAPHIC SURGICAL .

. .` ` ` ` ` Most common cause ~ 25 % Mortality rates slight declining ! 5 % initial manifestation. Hemorrhage lethal . 80 % deaths due to acute episode. 20 % at least once.

PYLORI INFECTION NSAID¶S ANTICOAGULANTS CHONIC SYSTEMIC DISEASES HOSPITALISED PATIENTS ETHANOL GLUCOCORTICOIDS COX-2 INHIBITORS ZOLLINGER SYNDROME .` ` ` ` ` ` ` ` ` H.

.e.>1..independent of endoscopy findings .<100 mmhg excluding othostatic measures) Elevated prothrom in time (i.` ` ` ` ` Ongoing leed Low systolic pressure ( i.2 times the control) Altered mental status Presence of co mor id disease ( define) Presence of any one 3 fold risk . e.

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Clean ulcer ase (re leed <1%) Black spots ulcer ase (re leed 5%) Fresh clot (re leed 30%) Visi le vessel (re leed 50%) Bleeding vessel (re leed 80%) .

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1 ml per minute may e detected. images are made over the upper and lower a domen . . Bleeding rates as low as 0.Nuclear Medicine Techniques in the Diagnosis of Gastrointestinal Bleeding After the intravenous injection of either sulfur colloid or la eled red lood cells.

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H. pylori eradication ‡ 1st line x ‡ PPI + clarithromycin (500mg OD) + amoxicillin (1000mg BID) or metronidazole (500mg) if patient has a penicillin allergy ‡ 2nd line x ‡ PPI + ismuth + metronidazole + tetracycline .

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INJECTION THERAPY Adrenaline The ethanol is injected slowly. .1 to 0. in amounts of 0. at three or four sites surrounding the leeding vessel and 1 or 2 mm from the vessel .2 ml per injection.

. A solute alcohol stops leeding y causing rapid dehydration and fixation of the tissue. alcohol and ethanolamine . Polidocanol causes haemostasis y inducing owel wall spasm and early oedema with su sequent inflammation and throm osis of the vessel.Sclerosants 1% polidocanol. thus o literating the leeding vessel.

in 0.2mm working channel) with a disposa le 23 or 25 gauge sclerotherapy needle is recommended.000 adrenaline.7 or 4.5ml aliquots is injected into and around the leeding point until the leeding stops .Procoagulants (Throm ogenic Agents) Human throm in and fi rin sealant Technique video-gastroscope (3. 4-16 ml of 1:10.

The flow of the electrical current is limited thus avoiding pro lems with grounding and a errant current. . . monopolar electrocoagulation is no longer recommended Multipolar electrocoagulation Consists of 3 pairs of electrodes arranged in a linear array at the tip and connected to a power generator.Thermal Modalities Contact and non-contact methods . Monopolar electrocoagulation Due to an unpredicta le depth of coagulation.

. The heater pro e is useful ecause it includes a water jet to wash away any lood.  Practically this requires (i) forceful tamponade using a 3.2mm pro e and (ii) sustained coagulation with 4 consecutive pulses at 30J for at least 8 seconds .Heater probe Consists of a metal tip covered y Teflon heated y a computer-controlled coil to a temperature of 250°C.

Thermal non-contact methods Argon Plasma Coagulation Argon plasma coagulation (APC) is a special electrosurgical modality in which high frequency electric current is conducted µcontact-free¶ through ionized and thus electrically conductive argon (argon plasma) into the tissue to e treated. .

LASER Nd:YAG and argon laser . Have shown excellent results . .

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` FAILED ENDOSCOPY EVIDENCE OF EROSION OF MAJOR VESSEL BLOOD LOSS EXCEEDING HALF A BLOOD VOLUME NO ENDOSCOPY. ` ` ` .

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radycardia decreased cardiac output and coronary vasoconstriction. Nitroglycerin adminstered simultaneously 40 micro g / min .` Vasopressin potent splanchnic vasoconstrictor.1u/min . I v olus 20 u over 20 mins and then continuous infusion of 0. . ` Causes hypertension.then taper to 0.4 u/min .2 to 0.

` Somatostatin 250 micro g I v olus followed y continuous infusion of 250 micro g / hr for 2-4 days. Now octreotide 50 micro g olus plus infusion is eing used . ` .

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respiratory failure.coma following head injury or intracranial operation . acute mucosal ischemia.` ` ` ` Stress gastritis . erosive gastritis or stress ulcer Predominant in ody Distinct from NSAID assoc mucosal erosion Sepsis.

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10 % UGIB Tear in proximal gastric mucosa near esophagogastric junction History vomiting, retching or coughing followed y hemetemesis Mean age >60 years ; 80 % men 90 % stop spontaneously Antisecretory drugs.

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Laporotomy for oversewing of the mucosal tear through high gastrotomy Acid reducing procedure not required.

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Bleed from cancer of the gastrointestinal tract, esophageal cancer, gastric cancer gastric lymphoma, gastrointestinal stromal tumors, and metastatic tumors Source Only 15%

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These lesions are unusually large su mucosal or mucosal vessels Rare cause Superficial erosion usually lesser curvature Sclerotherapy ,electrocoagulation not effective Surgical excision

` ` ` ` Recently recognised When arranged in linear pattern in antrum of the stomach gastric antral vascular ectasia (GAVE)or WATERMELON stomach Pathogenesis unknown. Surgical excision. .

ot ers emergency angiography Emergency laporotomy.or inflammator aortic aneur sms or following aortic replacements ndoscopy mandatory T . .` ` ` ` ` ` ` Uncommon Inflammator tract e elops bet een aorta and IT Infectious aortitis.control of proximal aorta. Extra anatomic ascular bypass.

.Protective role for nitric oxide no Video capsule endoscopy Endoloops detacha le nylon snares.

PillCam SB ± 11 mm x 26 mm ± 1 camera ± 2 frames per second ± Std optics / 1 lens ± Standard lighting control ± Standard angle of view (AOV) 140° ± Depth of field 0-30 mm PillCam SB 2 ± 11 mm x 26 mm ± 1 camera ± 2 frames per second ± New optics / 3 lenses ± Advanced Automatic Light Control ± Extra wide angle of view (AOV) 156° ± Depth of field 0-30 mm .

Bleeding Suspected Crohn¶s Tumors Celiac Disease .

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