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UGIB

my emergency placement presentation on upper gastrointestinal bleed

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Ritsumeikan Latu
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25 views19 pages

UGIB

my emergency placement presentation on upper gastrointestinal bleed

Uploaded by

Ritsumeikan Latu
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PPTX, PDF, TXT or read online on Scribd
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SEPSIS

UGIB Rits.Latu

Rits.Latu (MBBS5)
Case 2
32 yo female presented with GBW , headaches & syncope with associated chills. Patient admits to vomiting out coffee ground content day prior.
ROS: PU/BO okay ,reduced appetite denies syncope , difficulty breathing , chest pain

Nil comorbidities / prev admission / prev surgery / allergies / medication

SHX: denies smoker / ETOH consumer

O/e: Alert & conversant female , generally pale but not in any obvious distress

Ext: pale palms , CR reduced , pulses weak & regular Chest: CLFS Abdo: mild epigastric Abdo: mild epigastric tenderness generally soft

Assessed : Clinically Anemia 2nd to UGIB

Treatment :

1. Discuss with Senior Consultant


2. IV access + bloods ( GnH/FBC/Biochem/INR)
3. Fluids : 500mls IV bolus (NSaline)
4. 1 BTF
5. Referred to medical unit
Blood Supply
Terminology

Hematemesis: vomiting out fresh blood or “coffee ground like material”


Melena: passing black tarry foul smelling stool as a result of oxidation of
haem
Hematochezia: passing fresh blood in stool or BRBPR
Occult bleeding : gastrointestinal bleeding that is not visible to the patient or
physician
Intro to Upper Gastrointestinal Bleed
UGIB refers to GI blood loss having an origin proximal to the ligament of Treitz

More common than lower gastrointestinal bleeding (approximately 70% of GIB) with
hospitalization rate for UGIB estimated to be sixfold higher than for lower GI bleeding

The incidence of UGIB is higher in men than in women (128 versus 65 per 100,000 in one
study) and increases with age.
More recent studies suggest that while still prominent, ulcer disease is now a less common
cause (approximately 20 to 25 percent of cases) other disorders such as esophagitis are
becoming comparatively more common
Causes
UGIB can be classified into several broad categories based on anatomic and
pathophysiologic factors

From a pathophysiologic perspective, ulcerative and erosive lesions (gastric or duodenal


ulcers, esophagitis, and gastritis) are far more common than vascular lesions (varices,
angiodysplasia), mass lesions (adenocarcinoma, polyps), or traumatic lesions (Mallory-
Weiss tear).

The source of bleeding cannot be identified in 10 to 15 percent of patients with UGIB


Peptic Ulcer Disease
Defects in the gastric or duodenal mucosa that extend
through the muscularis mucosae. Gastric ulcers more
common than duodenal ulcer

The four major risk factors for bleeding peptic ulcers are
as follows
● Helicobacter pylori infection
● Nonsteroidal anti-inflammatory drugs (NSAIDs)
● Physiologic stress
● Excess gastric acid
Portal Hypertension

Several causes of UGIB are the result of portal hypertension,


including esophageal varices, PHG, gastric varices, and
ectopic varices. Most commonly caused by hepatic cirrhosis

Due to blocked caval drainage , blood is shunted into


alternative routes (portocaval anastomosis)

Varices may be identified in the esophagus and/or the


stomach. They may also be seen at sites other than the
esophagus or stomach, such as the small bowel (ectopic
varices)
Vascular Lesions
Vascular lesions in the GI tract that may cause bleeding include
angiodysplasias, Dieulafoy's lesions, and GAVE.

Angiodysplasias are the most common vascular anomalies


encountered in the GI tract

Dieulafoy's lesion : A Dieulafoy's lesion is a dilated aberrant


submucosal vessel that erodes the overlying epithelium in the
absence of a primary ulcer

Gastric antral vascular ectasia (GAVE), or watermelon stomach,


results from ectatic mucosal and submucosal capillaries.
Evaluation
The initial evaluation of a patient with a suspected clinically significant acute upper GI bleed
includes a history, physical examination, and laboratory tests

The goal of the evaluation is to assess the severity of the bleed, identify potential sources of the
bleed, and determine if there are conditions present that may affect subsequent management.

Past Medical History : prev UGIB , comorbidity ( chronic liver dxs/malignancy/AAA) , drug
history of NSAID, anticoagulants & SSRI. Smoker & ETOH consumer

Symptom Assessment
Investigation
Labs :
● Full Blood count
● Blood Grouping
● Serum biochemistries
● Liver function tests (AST, ALT)
● Coagulation studies. (prothrombin time with INR)
● BUN

In addition, serial electrocardiograms and cardiac enzymes

Imaging : Endoscopy (gold standard diagnostic modality)


Acute Management
ABC approach is systematically used to assess acutely unwell patient
● Ensure the airway is protected & administer high-flow oxygen if hypoxia is present.
● Establish intravenous access with two large-bore cannulas (> 16 gauge); plus bloods
sent
● Fluid resuscitation : Crystalloid or colloid should be given intravenously while you
are awaiting cross-matched blood. (eg, 500 mL of normal saline or lactated Ringer's
solution over 30 minutes)
○ Vasopressor may be required temporarily
● Blood transfusion : initiate blood transfusion if the hemoglobin is <7 g/dL (<70-g/L)
● Keep NPO
Clotting should be corrected with platelets, fresh frozen plasma and, in patients taking
warfarin, prothrombin complex concentrate (e.g., Octaplex, Beriplex) and vitamin K.
Post resus Management
Pharmacological :
● Acid suppression (eg, PPI)
● Prokinetics (IV erythromycin or
metoclopramide
● Vasoactive medication
● Abx for cirrhosis

Endoscopic treatment Modalities :


● Injection (normal saline solution /dilute
epinephrine / cyanoacrylate glue)
● Cautery (heater probes / electrocautery)
● Mechanical therapy ( bands / clips )
Other
Transjugular Intrahepatic Portosystemic Shunt
● A TIPS functions like side-to-side surgical portacaval shunt
Reference(s)
ACG Clinical Guideline: Upper Gastrointestinal and Ulcer Bleeding

https://www.uptodate.com/contents/methods-to-achieve-hemostasis-in-patients-with-acute-variceal-hemorrhage?sectionName=Somatostatin%20and
%20its%20analogs&topicRef=2548&anchor=H62477672&source=see_link#H4046150407

https://www.uptodate.com/contents/causes-of-upper-gastrointestinal-bleeding-in-adults?search=UGIB&source=search_result&selectedTitle=3%7E15
0&usage_type=default&display_rank=3#topicGraphics

https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults?source=history_widget#H5079922

https://pubmed.ncbi.nlm.nih.gov/11073021/ https://www.clinicalkey.com/student/content/book/3-s2.0-B9780323755764007328#hl0000495

https://www.clinicalkey.com/student/content/book/3-s2.0-B9780323796088000568#hl0000137

https://www.clinicalkey.com/student/content/book/3-s2.0-B9780702083471000247#hl0005356

https://www.asge.org/docs/default-source/education/practice_guidelines/doc-b4349a10-9b72-463e-ac70-f394c7aa20b4.pdf?sfvrsn=6

https://www.clinicalkey.com/student/content/book/3-s2.0-B9780323937863002282#hl0000235

https://www.wikilectures.eu/w/Portocaval_Anastomosis

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