GI bleeding. GI bleeding

Transcription

1 GI bleeding GI bleeding Term: Hematemesis : bloody vomitus Melena: tarry stool passage Maroon : tarry- bloody stool passage Hematochezia: bloody stool passage 1

2 GI bleeding Bleeding > 5~10ml OB (+) Bleeding > 50~100ml tarry stool Bleeding above Treitz lig. hematemesis Bleeding above ileocecal valve tarry stool Bleeding below ileocecal valve fresh bloody stool 1. R t side colon blood mixed inside the stool 2. L t side colon blood coated outside the stool 3.rectosigmoid fresh bloody discharge Common cause of acute UGI bleeding Erosive, hemorrhagic gastropathy ( aspirin, other NSAIDs) (3~11%) Ulcer: Gastric or duodenal ulcer (35~62%) Mallory-Weiss tear (4~13%) Varices portal hypertensive gastropathy(4~31%) Arteriovenous malformation Maligancy (1~4%) No source identified ( 7~25%) 2

3 Common cause of acute LGI bleeding < 55 y/o 1. Anorectal disease ( hemorrhoid, fissures) 2. Colitis (IBD, infection) 3. Diverticulosis 4. Polys, cancer 5. Angiodysplasia > 55 y/o 1. Anorectal disease (hemorrhoid, fissures) 2. Diverticulosis 3. Angiodysplasia 4. Polys, cancer 5. Enterocolitic (ischemic, infection, IBD, radiation) Evaluated blood loss Blood loss (ml) 0~500 % 0~10% BP No change HR No change S/S None 500~ ~ ~20% 20~35% Posture hypotension 90<SBP<120 <120bpm >120bpm Peripheral cool +oliguria >1750 >35% SBP<90 <60bpm + shock 3

4 Peptic ulcer Phase of GU, DU Active stage: A1: well-defined, deep ulceration; marked bleeding from the ulcer base marginal welling A2: stop bleeding Healing stage (H): H 1,H 2,H 3 Scarred stage (S): S 1 ( red scar), S 2 (white scar) Forrest Grade I 4

5 IIA Forrest Grade IIB Forrest Grade IIC III 5

6 Peptic ulcer Risk of recurrent bleeding SRH: stigmata of recent hemorrhage exposure vessels adherent clots arterial spurting or oozing Endoscopic therapy HSE (hypertonic saline and epinephrine), bipolar electrocoagulation, heat probe, hematoclip, APC Risk factors > 60 y/o age More than one comorbid illness Blood loss > 5 units Shock on admission Bright-red hematemesis with hypotension Coagulopathy Large ( > 2cm) ulcer Recurrent hemorrrhage ( within 72 hrs) Requirement for emergency surgery 6

7 GI bleeding goals of management Hemodynamic stable Active bleeding stopped Recurrent bleeding prevented Hemodynamic stable Pulse pressure > 30 mmhg SBP > 110 mmhg DBP > 70 mmhg HR < 100 bpm Good skin turgor 7

8 UGI bleeding -- management Restoration of intravascular volume Hct: > 25% Hct: > 30% in cardiac or pulmonary dz Vasopressors indicated? Vol resuscitation end-point CVP=15 mmhg Wedge pressure = 10 to 12 mmhg Blood lactate < 4 mmol/ L Base deficit 3 to +3 mmol/l C.I. > 3L/min/m 2 UGI bleeding -- management O2 consumption ( V O2) = Q * Hb * (SaO2-SvO2) Volume deficit = % loss * normal blood volume Males 70 ml / kg or 3.2 L/ M 2 Females 60 ml / kg or 2.9 L/ M 2 8

9 UGI bleeding -- management Correction of coagulopathy Initial infusion: FFP 2~4 u Protamine infusion ( 1mg antagonizes =100 u of heparin) Vit-K (10 mg,im): warfarin, hepatobiliary disease PLT transfusion: > 50000/cumm Airway protection PUD-- treatment Antacids drug interaction Tetracyclines, Quinolone, ketoconazole, Peptic ulcer ( with evidence) H2-blocker: Ranitidine (Zantac, Quicran) side effect: headache, lethargy, confusion, depression drug interaction: Cimetidine β-blockers, Metformin, Phenytoin, Procainamide, Theophylline, TCA and Warfarin. 9

10 PUD -- treatment Peptic ulcer ( with evidence) PPIs: Omeprazole ( Losec) -- elder -- intractable bleeding -- combine with theophylline Raise intragastric ph to 6~7 Enhance clot stablity decreased further bleeding (but not mortality) UGI bleeding -- treatment Variceal hemorrhage 1. Stabilize hemodynamic ( crystal with colloid supply) 2. Airway patent 3. NG decompression of early detect of rebleeding 4. Octreotide: Somatostatine (Somatosan) 2Amp add N/S to 50ml loading 2ml and maintain 2ml/ hr 10

11 UGI bleeding -- treatment Variceal hemorrhage 5. Endoscopic therapy with ligation 6. Sclerotherapy 7. Balloon tamponade Sengstaken-Blakemore tube 8. Avoid hepatic encephalopathy 9. Prophylaxis: reduce portal hypertensoion -- Inderal, nitrates 10. Surgery Recurrent bleeding prevented Eradication of H.P rebleeding rate < 5% Avoid NSAIDs 11

12 acute UGI bleeding if no hemodynamic change and no dropping Hb: routine endoscopy hemodynamic change and dropping Hb: urgent endoscopy ulcer EV Mallory-Weiss tear active bleeding or visible vessel adherent clot or flat,pigmented spot clear base ligation or sclerotherapy active bleeding no active bleeding Endoscopic therapy no Endoscopic therapy no Endoscopic therapy ICU for 1~2 day ward for 2 to 3 days Endoscopic therapy no Endoscopic therapy ICU for 1 day ward for 1 to 2 days ward for 3 days discharge ward for 1~2 days discharge 12