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Surgical PCT Chomthong hospital 14-07-1011

Upper GI Bleeding
Deffinition
:Bleeding from GI tract proximal to ligam itz. Tr itz. t of

Anatomy
r I tract Esophagus Stomach Duodenum

Etiology
Variceal bleeding
Esophageal bleeding Gastric variceal bleeding
Portal HT Cirrhosis Spleenic vein thrombosis Portal vein thrombosis

Non-variceal bleeding

DU Infection / inflammation GU H.P. infection Cancer Mallory weiss tear Mucosal tear Hemobillia Hemorhagic Gastritis Duodenitis Esophagitis Diuelafoy lesion -Submucosal arterial malfomation

Portal hypertension

Cirrhosis Portal v in thrombosis S l nic v in thrombosis

Cirrhosis and Portal hypertension

H.pylori

Esophagogastric varices

Clinical approach for UGIH

Goal : Determine cause and Treat Confirm bleeding Initial Assessment and Resuscitate Medical Intervention Diagnosis of bleeding site Endoscopic Intervention Surgical Treatment

Confirm bl
History taking Physical exammination NG lavage

ing

Confirm bl

ing

Bleeding 150-200 ml. Stool occult blood positive Melena 75-80%%

Acid Hematin=Hb+Acid Atleast 50 ml bleeding Bleeding 1000 ml melena 5-7 days,stool occult +ve 21 days

Hematemesis 40-50% Coffee Ground Emesis Hematochezia 15-20% Blood streaked stool Fresh blood from rectum

Probabl sourc of I bl
Clinical Hematemesis Melena Blood streaked stool Hematochezia Occult blood I Almost certain Probable Rare Possible Possible

ing

L I Rare Possible Almost certain Propable Possible

LGIH : melena 8

Confirm bl
P r-R ctal Exammination r-

ing

Melena Hematochezia Fresh Blood / bright red blood per rectum Blood coating stool/Within stool Hemorrhoid Anal fissure Tomor

Melena

Initial ass ssm nt

Massive ongoing bleeding with shock Continuous bleeding Intermittent bleeding Recent bleeding

Initial ass ssm nt

V/S
PR BP Postural change Hypoperfusion

NG lavage Co-morbidity Fluid challenge therapy

Clinical as cts of Physical exammination xammination

Pallor Hemodynamic stability Careful abdominal examination Bowel sounds Abdominal tenderness Ascitesshifting dullness Signs of chronic liver disease or portal hypertension Hepatomegaly Splenomegaly Palmar erythema Caput medusa Spider angiomata Peripheral edema icterus

Hemo ynamic instability

Hypotension
SBP <100 Blood loss >40%

Orthostatic hypotension :
SBP>20 mmHg. PR>20 beat/min Blood loss >15%

Tachycardia
PR>100 and Thready pulse Mild to moderate hypovolumia (10-20%)

Hypoperfusion
Cool calmy skin
20% blood loss

Poor mentation
Blood loss >40%

Hypoxia

Class I
loo loss (ml.) % l. loss PR P RR Urine(ml/hr) Mental status <750 <15% 15% <100 Normal

Class II
750750-1500 15-30% 15-30% >100 Normal

Class III
15001500-2000 30-40% 30-40% >120

Class IV
>2000 >40% 40% >140

14-20 14>30 Slight anxiety Normal

Crystalloid

20-30 2020-30 20Mild anxiety Delays

Crystalloid

30-40 305-15 Confusion Delay

Crystalloid and blood

>40 Negligible Lethalgy Delays

Crystalloid and blood

Capillary refill
Flui replacement (3:1 rule)

NG lavage
To detect bleeding To determine type of bleeding To clear stomach before EGD To prevent aspiration

Flui challenge
Fluid challenging therapy shock - crystalloid 2000 ml. 1530% (Class II) - 3040% (Class III) - 40% (Class IV)

NG Aspirate content
Fresh bloo
Current active bleeding

Coffee ground
Recently active bleeding

Clear aspirate
Does not exclude recent bleeding or duodenal bleeding

Bilious non-bloody non Exclude UGIH Stopped bleeding Several hours before

Blood transfusion:PRC
Multifactorial Indication
Hemodynamic status Significant blood loss On going bleeding Comorbidity:Cardiac,renal,cerebral ischemia Patient age

Blood transfusion:PRC
Young healthy patient
Hb<7 Hct. 25-27%

Elderly or co-morbid patient co Hb<9 Hct<28-30%

Cirrhotic patient
Keep Hct. Only 27% to avoid portal hypertension

Other Blood component transfusion

FFP
INR>1.5 1 U of FFP per 4-6 U of PRC transfusion

Plt concentration
Plt <50,000 with active bleeding When >10 u PRC need

Rockall scoring system

Signs of chronic liver disease/ Portal Hypertension

Hepatomegaly Slenomegaly Caput medusa Spider nevi Palmar erythema Peripheral edema Ascites Jaundice Parotid gland hypertrophy Gynecomastia

Caput medusa

Palmar erythema

Spider nevi

ascites

Parotid gland hypertrophy

Gynecomastia

High Risk Criteria

: Host Factors Age >60yr Co-morbid conditions e.g. renal failure, cirrhosis, cardiovascular disease, COPD Hemodynamic instability; mod to severe shock Coagulopathy include drug-related Bleeding character Active continue red blood from NG after irriagtion and red blood per rectum Patient course massive blood transfution> 4-6 units to maintain Hb in 24 hr re-bleeding in 72 hr return to have hemodynamic instability

Investigation
Lab Chemistry
CBC BUN/Cr
Rising BUN :
Degraded blood absorption Pre-renal azotemia

BUN/Cr >36 Suggest UGIH

LFT Coagulogram(PT,PTT) BS

Imaging study as require:CXR ,U/S Endoscopic exammination Angiography

Diagnosis of bleeding site

EGD
Variceal bleeding Non-variceal bleeding

Angiography

Esophageal Varices

Ulcer

DU

Mallory Weiss tear

Acute Hemorrhagic Gastritis

Dieulafoy lesion
Submucosal arterial malformation Within 5-6 cm. from EGJ

Methods to stop bleeding

Variceal Bleeding Medication Endoscopic Intervention
EVL EIS

Non-variceal bleeding
Medication Endoscopic Intervention
Injection Thermal:Heater probe,Laser,Argon Mechanical :Hemoclips,endoloop,band ligation Combination

Balloon temponade(SB tube) Radiointervention

TIPS Angioembolization

Radiointervention
Angioembolization

Surgery

Surgery

Medication
Suspected variceal bleeding
Somatostatin/Sandostatin(Octreotide ) Somatostatin/Sandostatin(
Splanchnic vasocostriction Reduces Azygos venous blood flow Reduces portal colatteral circulation and decreases portal pressure

Non-variceal bleeding
PPI
Optimization of intragastric PH 7 Improve Hemostatic process

Endoscopic Intervention
Variceal bleeding
EVL Esophageal Variceal Ligation EVL: EIS: Endoscopic Injection sclerotherapy

Non-variceal bleeding
Thermal :Heater probe,Coagulation ,Argon,Laser Injection :Epinephrine(1:10,000),Alcohol,Hypertonic saline Mechanical :Hemoplips,endoloop Combination
Epinephrine+Thermal Epinephrine+Hemoclips Epinephrine+Laser

Sengstaken Brakemore tube

Sengstaken Brakemore Tube

Esophageal balloon Gastric balloon Gastric suction Esophageal suction Pressure :2540 mmHg. Volume:200400 ml.

Traction:200-500 gm. Duration :24-48 hr.

Hemoclips

Endoloop

Heater probe

Surgery for UGIH :Variceal Bleeding

Non shunt procedure
Gastroesophageal devascularization(Hassabb procedure)

Shunt Procedure
Non selective shunt

PortoCaval Shunt Mesocaval shunt Proximal spleenorenal shunt H-shunt

Selective shunt
Warren shunt(Distal splenorenal shunt)

Liver transplantation

Gastroesophageal Devascularization

Portocaval shunt (End to side)

Proximal splenorenal shunt(Linton shunt)

Distal splenorenal shunt (Warren shunt)

TIPS (Transjugula Intrahepatic Portosystemic Shunt )

Surgery for UGIH :Non-Variceal Bleeding

DU surgery
Duodenotomy to suture bleeding ulcer Anti-secretory procedure
TVP:Truncal Vagotomy with Pyloroplasty TVA :Truncal Vagotomy with Antrectomy Proximal gastric Vagotomy

GU surgery

TVP with ulcerectomy Distal gastrectomy include ulcer +/- TV Ulcerectomy Total gastrectomy reoperation

TVP
:TRUNCAL VAGOTOMY WITH PYROLOPLASTY

Truncal Vagotomy with Antrectomy and BI

Truncal Vagotomy with Antrectomy and BI

Proximal gastric vagotomy