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GI Bleeding PowerPoint Presentation

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Description : Check out this medical PowerPoint presentation titled "GI bleeding”.

This medical PowerPoint presentation talks about Gastrointestinal (GI) bleeding, a medical condition that occurs when there is bleeding in the digestive tract, which includes the esophagus, stomach, small intestine, large intestine, rectum, and anus. GI bleeding can be caused by a variety of factors, such as ulcers, inflammatory bowel disease, hemorrhoids, diverticulosis, and cancer.

Tags : GI bleeding, Gastrointestinal bleeding, digestive tract, esophagus, stomach, small intestine, large intestine, rectum, anus, Gastroenterology, Gastroenterology PowerPoint presentation

Published on : Apr 26, 2023 | Views : 958 | Downloads : 5

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GI bleeding Mackay Memorial Hospital Department of Internal Medicine Division of Gastroenterology R4 陳泓達 97/6/22
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GI Bleeding UGI bleeding Peptic ulcer disease Variceal bleeding LGI bleeding
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UGI bleeding: 5 times more common than LGI bleeding. Men > Women Elderly persons. Despite ongoing advances, fundamental principles are the same !!!!  immediate assessment and stabilization of hemodynamic status
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Determine the source of bleeding Stop active bleeding Treat underlying abnormality Prevent recurrent bleeding
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Resuscitation In hemodynamically unstable… Set up two large-bore IV catheter Colloid solution (NS or lactated Ringer’s) To restore vital sign !! ICU monitor is indicated Central venous monitoring F/U vital sign and urine output
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History taking and physical examination UGI or LGI ? UGI  peptic ulcer disease or portal hypertension related (EV or GV)?
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Differentiate LGI and UGI Melena – upper GI cause in 90% Hematochezia – upper GI cause in 10%
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The intermediate patient Take more time…. Re-examine, Monitor vital signs, Re-check CBC, BUN
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Transfusion ? In hemodynamic unstable, any sign of poor tissue oxygenation, continued bleeding, persistent low Ht level(20-25%) Maintain adequate perfusion Target ?
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Other Blood tests on the bleeding patient… INR, PTT – coagulopathy anyone?
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“There is no single value of hemoglobin concentration that justifies or requires transfusion; an evaluation of the patient’s clinical situation should also be a factor in the decision.”Capital Health Guide to Blood Transfusion
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You’ve decided to give blood… Options?
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O neg Type Specific Full Cross Match – immediately available – 10 – 15 min. – 30 – 60 min.
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What is in a unit of packed cells? 250 mL volume Contains citrate (anticoagulant), and preservative. 1 unit packed cells will increase the Hb concentration by approx. --? 0.5mg/dL
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Massive Transfusion Greater than 1 blood volume( or 10 units ) transfused within 24 hours May dilute platelets and clotting factors
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Dilution coagulopathy Monitor the patient for coagulopathy Follow the resuscitation (CBC, INR, PTT)
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Treatment of dilution coagulopathy Plasma /FFP 10 – 15 mL / kg Usual adult dose 2 units. 5 –8 mL / kg dose for warfarin reversal
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Treatment of dilution coagulopathy Platelets Keep the count greater than 50 ,000 in the bleeding patient 1 unit should increase platelet count by 5 ,000– 10, 000 / L Dose: 6 pack
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Massive TransfusionWhat else can go wrong? Hypothermia Potassium Citrate toxicity (hypocalcemia)
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Vomiting BloodHematemesis Upper GI Bleeding
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Etiology Peptic Ulcer 50 % Gastritis 20% Esophageal varices 10% The rest: Tears, AVM, CA,etc 20%
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More about bleeds…. 80 % of Non – variceal upper GI bleeds will stop spontaneously 60 % of variceal bleeds will stop spontaneously
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What else can I do for GI bleeding, before endoscopy NG lavage Drug ABC Patient and family Agree ( Sign permit first)
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Urgent Endoscopy ? Initial evaluation: 初始出血量是否大量 ? 出血量大者,rebleeding 機會也大觀察重點: vital sign (tachycardia, orthostatic hypotension resting hypotension, shock), 吐血或血便黑便的頻次與量, NG lavage的結果
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NG lavage 15 – 20 % of upper GI bleeds have a negative aspirate Sensitivity 79%, Specificity 55% Cuellar et al, Arch of Int Med Jul 1990 For endoscopic preparation ( not contraindicated in patients with varices)
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Endoscopy Diagnostic Therapeutic Prognostic
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Endoscopic features and risk of re-bleeding Active bleeding 55 – 90%
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Endoscopic features and risk of re-bleeding Non bleeding visible vessel 40 – 50 %
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Endoscopic features and risk of re-bleeding Adherent clot 10 – 33%
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Endoscopic features and risk of re-bleeding Flat spot 7 – 10 %
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Endoscopic features and risk of re-bleeding Clean base 3 – 5%
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Variceal bleeding Non-variceal bleeding
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Drugs: Peptic ulcer bleeding Manipulation of gastric pH
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Use of PPI’s Theory : raise gastric pH Better platelet activity Pepsinogen requires acid to become activated to pepsin Clots will form, clots not digested
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High Risk Patients Elderly Co – Morbidity More severe bleeding (hemo-dynamically unstable, ongoing bleeding
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Other helpful medication somatostatin / octreotide  associated with a reduced risk of continued bleeding and rebleeding in PUD
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When endoscopic / pharmacological treatment fail… ◎ angiography  to localize bleeder and hemostasis generally reserved for patient: poor surgical candidates control of bleeding in an unstable patient awaiting surgery
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Surgery Hemodynamic instability despite vigorous resuscitation (more than a three unit transfusion) Recurrent hemorrhage after initial stabilization (attempts at obtaining endoscopic hemostasis) Shock associated with recurrent hemorrhage Continued slow bleeding with a transfusion requirement exceeding three units per day.
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Variceal Bleeding EGD finding: F1-4 Ls-m-i Cb / Cw Red color sign
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Pharmacological treatment: Drug of choice: control bleeding and reduce mortality rate Glypressin (Terlipressin) 1 amp iv stat and q6h. Sandostatin  no evidence 2 amp iv drip stat and 12 amp in 500 c.c. D5W run 24 hours Pitressin: -- Seldom used in recently years
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After endoscopic treatment… Fail to achieve hemostasis or rebleeding Balloon tamponade Transjugular Intrahepatic Portosystemic Shunt (TIPS) Surgery for shunt
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Balloon Tamponade-Buy time Available in MMH S-B tube
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McCormick. British Journal of Hospital Medicine. 43, Apr. 1990 SB tube Gastric ballon Esophageal ballon
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McCormick. British Journal of Hospital Medicine. 43, Apr 1990 never exceed 45mmHg. Volume 200ml
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Tamponade Tube Sengstaken-Blakemore (S-B) tube Radiographic confirmation of the gastric balloon’s position -- 30cc air inflate the gastric balloon Insufflation of the esophageal balloon to 35mmHg
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Compression of varices for not excess 48 hours Deflate the esophageal balloon for about 30 mins every 12 hours Major complications -- aspiration and esophageal perforation Control hemorrhage >90%, but it is temporary
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Bridging procedure buy time Definite therapeutic management must be performed.
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Lower GI Bleeding Hematochezia 90% Melena 10%
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Etiology Most blood passed per rectum is from the upper GI tract. Lower GI Bleeds Diverticulosis, angiodysplasia, CA, colitis, ischemia, hemorrhoids
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More about Lower GI Bleeds 80% resolve spontaneously 25 % will re–bleed Usually painless If painful, r/o mesenteric ischemia
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Investigation of the lower GI bleed The usual suspects: CBC, BUN, Creatinine, INR, PTT, T/S
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Investigation of the lower GI bleed Plain X-rays and abd. CT – not much help unless you clinically suspect perforation, obstruction, ischemia (PAIN)
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Diagnostic procedure Endoscopy : 80% accuracy Poor visibility with heavy bleeding Angiography : 40–80% accuracy Requires heavy bleeding Able to perform embolization or vasopressin infusion
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Diagnostic procedure RBC scans 25–90% accurate Able to do with lower bleeding rates
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What if the patient is really bleeding? Involve your consultants early. Radiologist for angiography Procto. If tumor or ischemic bowel