INCIDENCE & ETIOLOGIES OF UPPER G.I.

T BLEEDING
NOOR SABIRAH BINTI DAMANHURI NUR NABIHAH BINTI HILMI NUR ASIKIN BINTI AB GHANI

INCIDENCE OF UGIB (MALAYSIA, U.K, U.S.A)

64% : Peptic Ulcer 16.5% : Mucosal Erosive Disease 6.4% : Bleeding varices 3.6% : Malignancies 9% : Idiopathic MINISTRY OF HEALTH MALAYSIA, ACADEMY OF MEDICINE, MALAYSIA MALAYSIAN SOCIETY OF GASTROENTEROLOGY AND HEPATOLOGY

36% : Peptic ulcer 11% : Bleeding varices http://www.ncbi.nlm.nih.gov/pubmed/21490373 http://www.bsg.org.uk/pdf_word_docs/blood_audit_report_07.pdf

20-50%: Peptic ulcer diseases 8-15%: Gastroduodenal erosion 5-20%: Variceal causes 5-15%: Esophagitis 8-15%: Mallory Weiss Tear American Society for Gastrointestinal Endoscopy

ETIOLOGIES
Variceal Non-variceal

1. Esophagus 2. Stomach 3. Duodenum

Oesophageal Varices
Oesophageal varices are abnormal, enlarged veins in the lower part of the esophagus. Bleeding from varices is a complication of portal hypertension; an increase in the pressure within the portal vein due to blockage of blood flow throughout the liver. Causes of portal hypertension:
Liver chirrosis (hepatitis, alcoholic liver disease) Blot clot or thrombosis in portal veins or splenic veis Schistosomiasis Budd-Chiari syndrome

OESOPHAGEAL CAUSES
Oesophageal varices Oesophageal cancer
- >60yr, male, hereditary - Tobacco, alcohol, GERD, Barrets esophagus

Oesophagitis
- in immunocompromised - Infectious causes; candida, herpes, CMV, GERD, hyperacidity, alcohol

Oesophageal ulcers Mallory-Weiss tear

- bleeding from tears in the mucosa at the junction of the stomach and esophagus - alcoholism, retching, coughing, or vomiting.

Stomach causes:
Gastritis Gastric cancer Gastric ulcer Rupture retrogastric aneurysm A-V malformation

Acute Erosive Gastritis

Definition: Diffuse superficial mucosal lesion in body and fundus, may occur in duodenum. Risk of bleeding is increased with: Causes: - Increasing dose NSAID - When two or more drugs taken together. Alcohol - Concomitant anticoagulant or corticosteroid. Long distance running Gastric irradiation

Duodenum
Duodenal ulcer Duodenal carcinoma Hematobilia A-V malformation
aorto-enteric fistula usually secondary to prior vascular surgery usually occur at the proximal anastomosis at the third or fourth portion of the duodenum where it is retroperitoneal and near the aorta

Diverticulum Crohns disease Severe superior mesenteric artery syndrome(rare)

Duodenal ulcer
1st part of duodenum
o Posterosuperior region

Bleeding duodenal ulcer is 10 times more common than bleeding gastric ulcer Etiology:
1. Helicobacter pylori (H. pylori)- 95%
The bacterium produces substances that weaken the stomach's protective mucus and make it more susceptible to the damaging effects of acid and pepsin, as well as produce more acid.

2. Nonsteroidal anti-inflammatory drugs (NSAIDs)

such as aspirin, ibuprofen, and naproxen sodium stomach become vulnerable to the harmful effects of acid and pepsin

3. Hyperacidity 4. Smoking, alcohol

REFFERENCES:
1. http://en.wikipedia.org/wiki/Upper_gastrointes tinal_bleeding#Causes 2. emedicine.medscape.com/article/187857overview 3. http://www.mayoclinic.com/health/medical/IM 02167 4. http://www.lpch.org/DiseaseHealthInfo/Health Library/digest/ulcers.html 5. Lecture notes by Prof. Dr. Farouk Mekky

By: Nurasyikin binti Hanifah (08-6-201) Nurfarahani binti Arpaii (08-6-209) Nor Shahida binti Abu Hanifah (08-6-197)

Presentations of Upper GI Bleeding

Symptoms of anemia

Melena

Hematemesis

Hematochezia

Hypovolemic shock

1) Management of shock

ICU Admission
o Airway : check the patency of airway
- give O2 and intubate if indicated.

o Breathing : chest examination

o Circulation : vital signs (pulse, BP, capillary refill time)

 2 wide bore cannula

o Fluid transfusion : crystalloid, blood, fresh frozen plasma & platelet transfusion o Blood sample LAB INVESTIGATION

Nasogastic tube (NGT)

o Confirm upper GI bleeding - Red blood suggests currently active bleeding - Coffee grounds suggest recently active bleeding. - Continued aspiration of red blood suggests severe, active hemorrhage o Avoid aspiration (do suction) o Guard against ammoniacal hepatic encephalopathy o Clear the gastric field : to allow better endoscopic visualization

Foleys catheter
o Check for urine output : to assess hypovolemic shock & to avoid fluid overload

Laboratory Investigations
Hemoglobin Coagulation profile Liver function test

Kidney function test

Blood group

2) Measure to avoid hepatic encephalopathy

Gastric lavage
Lactulose enema

Oral neomycin
Antibiotic administration

Avoid hypoglycaemia
Avoid sodium containing fluids

3) Assurance of diagnosis
a) Rapid history & examination
Rapid related history
o Take history from patient, or relatives if not possible.

o Present history (events related)

o Previous similar attack, medical history (liver disease, bleeding tendency, alcohol, analgesics abuse, etc.), surgical history, hospitalization.

Careful abdominal examination

o Bowel sounds o Abdominal tenderness and mass o Ascites (shifting dullness)

b) Emergency endoscopy
Urgent endoscopy is indicated when patients present with hematemesis, melena, or postural changes in blood pressure. Cooper et al have demonstrated a lower rate of rebleeding and shorter length of stay when endoscopy is performed within 24 hours of admission
http://emedicine.medscape.com/article/187857-treatment#a1156

c) Blakemore- Sengstaken tube

Triluminal tube
o Esophageal balloon(air) compress the varices. o Gastric balloon(saline) - fix the tube

o Gastric tube
- Aspiration of blood - To know bleeding stop or not - To introduced ice saline and medications

o Leave the tube inflated for 24hrs, deflate it and leave it foranother 24hrs, if - bleeding occurs again inflate again
- bleeding stop remove the tube

Medical treatment for Upper GIT bleeding

NUR FURQAN MOHD AZLAN NUR SABRINA MOHD AZLI LEE NUR ATIKAH ZAKARIA

Oesophageal varices
Sandostatin (65% control) Glypressin (50% control) -VC splanchnic arteries,restrict portal flow

Propanolol prevention (20% efficacy) -decrease portal pressure by 2: 1-decrease COP 2-blockade B2 VD receptor on splanchnic arteries
Vit K (parentral)

Peptic ulcer
Antibiotics (metronidazole,amoxicillin,clarithromycin,tetracycline) PPI -block acid production

H2 blocker -reduce acid production

Antacid -neutralize stomach acid

Cytoprotective agent: sucralfate,misoprostol,bismuth subsalicylate

Multiple drug regimen

Mallory-Weiss Tear
Control precipitating factor Acid suppression: PPI Anti emetic: prochlorperazine

References:
Clinical medicine 7th edition,Kumar & Clark http://www.mayoclinic.com/health/pepticulcer/DS00242/DSECTION=treatments-anddrugs http://emedicine.medscape.com/article/1871 34-overview#aw2aab6b7 Manual of surgery by Dr Maher el Zeiny,part 1

ENDOSCOPIC TREATMENT OF UPPER GIT BLEEDING

NOR SYUHADA ABDUL HAMID (08-6-196) NURSOLIHAH RAMLY (08-6-199) NOOR ATHIRAH ALI (08-6-204)

TIMING
Urgent endoscopy
Indicated in patient having melena, haematemesis or postural changes of blood pressure

Early endoscopy
Within 24 hours of presentation Most patient presented with upper GIT bleeding

Lower the mortality rate, hospital stay and need of emergency surgery.

TECHNIQUES
Injection of epinephrine or sclerosant Bipolar electrocoagulation Band ligation Heater probe coagulation

Constant probe pressure tamponade

Argon plasma coagulator

Laser photocoagulation

Rubber band ligation

Application of haemostatic material

Application of haemoclip or endoclip

Application of nanopowder

INJECTION THERAPY

Epinepherine

Sclerosant

Vasoconstriction and platelet aggregation Diluted (1:10000), 0.5- to 1-mL aliquots

inducing thrombosis, tissue necrosis, and inflammation at the site of injection ethanol, polidocanol, and sodium tetradecyl sulfate.

BAND LIGATION

MULTIPLE ANGIODYSPLASIAS IN A PATIENT WITH HEREDITARY HEMORRHAGIC TELANGIECTASIA. MULIPLE LESIONS WERE LIGATED

SPURTING DIEULAFOY ULCER CONTROLLED WITH RUBBER BAND LIGATION

LASER THERAPY
uses an Nd:YAG laser to create hemostasis by generating heat and direct vessel coagulation. [ noncontact thermal method ] Most commonly used NdYAG Laser good tissue penetration and direct vessel coagulation.

area near the vessel is first injected with epinephri ne

the laser is applied around the vessel, producing a wall of edema

avoid drilling into the vessel with the laser

 Drawbacks it is expensive and cumbersome ; has a higher risk of perforation; 40% of the treated patients need emergency surgery. non-contact method lacks the compression effect to cause tamponade [ not as effective as coaptive coagulation ]

not portable need for specific expertise by the endoscopist and technician special electrical outlets, eye protection Technically difficult in aiming the laser beam

COAPTIVE COAGULATION
uses direct pressure and thermal therapy to achieve hemostasis.

bleeding vessel is isolated, compressed, and tamponaded

coagulation therapy

advantages over laser therapy less expensive Portable easy to use have target irrigation allow tamponade and tangential coagulation. advantages over diathermy: the probe does not stick to the tissue. the procedure is not affected by the size of the coagulum, hence results in better tissue bonding.

Electrocoagulation

Heater probe coagulation

 Thermal electrocoagulation is the classic treatment for bleeding during surgery and has recently been used endoscopically to treat GI bleeding.
Monopolar electrocoagulation associated with tissue adherence problems and tissue injury. Therefore, it is not recommended now. Bipolar (and multipolar) electrocoagulation

ELECTROCOAGULATI ON
Current is concentrated much closer to the tip less depth of tissue injury and lower perforation potential.

Bipolar (and multipolar) diathermy is more widely used procedure because accompanied by lesser damage reduces rebleeding rates reduces need for transfusion reduces length of stay reduces need for surgery and mortality.

HEATER PROBE COAGULATION

The heater probe consists of a resistor electrode enveloped by a titanium capsule and covered by Teflon (to reduce sticking to the mucosa by the probe). The probe temperature rises to 250C (482F). The cylinder transfers heat from its end or sides to tissue when positioned perpendicularly or tangentially. The main disadvantages are chances of This probe may be passed through the biopsy perforation and re-bleed. channels of larger endoscopes and positioned on bleeding lesions to produce tamponade and heat.

ARGON PLASMA COAGULATION

a stream of electrons flows along a stream of argon gas
[ delivers high-frequency energy to the tissue through ionized argon plasma gas, thus causing non-contact electrogoagulation ]. The coagulation is similar to monopolar cautery, with the current flow going from a point of high current density (the point of contact of the gas with the mucosa) to an area of low current density (the conductive pad on the patient's body). the maximal coagulation depth achieved is 3-4 mm which reduces the risk of perforation.

HEMOSTATIC CLIPS AND ENDOCLIPS

Treatment of ulcers in patients who are coagulopathic or who require ongoing anticoagulation; in such patients, electrocoagulation will increase the size, depth, and healing time of treated lesions. With careful placement of the clip, closing the defect in the vessel is possible. Usually, multiple clips are applied. They vary in the size and the strength of the clip.

Endoclips may also be preferable in the retreatment of lesions that rebleed after initial thermal hemostasis.

 Larger endoclips have advantages over smaller hemoclips for the hemostasis of chronic ulcers and the closure of larger lesions.

BIOLOGIC GLUE

Specifically, Fibrin glue (also called fibrin sealant) is a synthetic substance used to create a fibrin clot. It is made up of fibrinogen and thrombin that are injected through one head into the site of a fibrin tear.

Thrombin acts as an enzyme and converts the fibrogen into fibrin between 10 and 60 seconds and acts as a tissue adhesive. It may also contain aprotinin, fibronectin and plasminogen.

NANOPOWDER

Nanopowder also known as hemospray is a single-use device, delivered through the channel of an endoscope and sprayed toward the source of a bleed. When the powder comes in contact with blood, it absorbs water and forms a gel, which acts both cohesively and adhesively to create a stable mechanical barrier that adheres to and covers the bleeding site.

It is a nonthermal, nontraumatic treatment modality for achieving haemostasis

SURGERY
Prepared by:

1.Nurfarizah Binti Ahmad Fauzi 208

2.Nuur Falah Hidayah Binti Mohd Shafie 211 3.Nurliyana Binti Azhar 212

Primary surgical intervention

Perforated viscus (e.g:Boerhaave syndrome).

Emergency surgery in UBIG typically entails oversewing the bleeding vessel in the stomach or duodenum,vagotomy with pyloroplasty, or partial gastrectomy.

Angiographic obliteration of the bleeding vessel in patients with poor prognoses.

Surgery for bleeding peptic ulcer

Severe, life-threatening hemorrhage not responsive to resuscitative efforts A coexisting reason for surgery, such as perforation, obstruction, or malignancy

Prolonged bleeding, with loss of 50% or more of the patient's blood volume

A second hospitalization for peptic ulcer hemorrhage

Failure of medical therapy and endoscopic homeostasis with persistent recurrent bleeding

Complications after Operations for Duodenal Ulcer

Original operation Recurrence PostMortality Antral Liquid rate % gastrectomy rate % innervation emptying syndrome rate % Proximal gastric 10 5 0.71 Preserved Fast vagotomy Truncal 7 20-30 <1 Divided Fast vagotomy Truncal 1 30-50 0-5 Divided Fast vogotomy & drainage (Billroth I & II) Truncal vogotomy & antrectomy (Roux-en-y) 5-10 50-60 0-5 Divided Fast Solid emptying
Normal Slow Fast

Fast

 If a patient with a bleeding ulcer requires surgery, then knowledge of the patient's H pylori status becomes pertinent, because it may help to guide the decision to choose a particular surgical procedure, eg, simply oversewing the ulcer as opposed to performing an antiulcer operation.

Surgery for bleeding gastric ulcer

Indications= hemorrhage, perforation, and obstruction. The goals of surgery are to correct the underlying emergent problem, prevent recurrent bleeding or ulceration, and exclude malignancy. The choice of operation for a bleeding gastric ulcer depends on the location of the ulcer and the hemodynamic stability of the patient to withstand an operation.

Common Operations

Truncal vagotomy and pyloroplasty with a wedge resection of the ulcer

Antrectomy with wedge excision of the proximal ulcer

Distal gastrectomy to include the ulcer, with or without truncal vagotomy

Wedge resection of the ulcer only

Distal gastrectomy with or without truncal vagotomy

Stress Gastritis
Simply oversewing an actively bleeding erosion is to control the bleeding. Life-threatening hemorrhage ,gastric resection with or without vagotomy with reconstruction may be necessary. The type of gastric resection depends on the location of the gastric erosions, ie: whether they are proximal or distal. The options are antrectomy and subtotal, near total, or total gastrectomy.

Surgery for Mallory Weiss tear

In only 10% of cases Surgical intervention is indicated in patients with continued bleeding after failed attempts at nonoperative therapies.

Once the tear is localized, the bleeding is controlled by oversewing the lesion.

Mallory Weiss Syndrome test

Variceal Upper Gastrointestinal Haemorrhage

Active bleeding
If endoscopic methods fail need to consider:
Transection or devascularisation Porto-caval or mesenterico-caval shunting

Shunting can also be performed non-surgically by transjugular intrahepatic porto-systemic shunting (TIPSS) Reduces risk of rebleeding but increases risk of encephalopathy Mortality of the procedure ~1%

Secondary prevention 70% of patients with an variceal haemorrhage will rebleed The following have been shown to be effective in the prevention of rebleeding
Beta-blockers possibly combined with isosorbide mononitrate Endoscopic ligation Sclerotherapy TIPSS Surgical shunting

TIPSS

PRE HEPATIC AND POST HEPATIC CAUSES OF PORTAL HYPERTENSION

Nurfathni binti Mohd Arifin 08-6-210 Noor Fatihah binti Mohd Rusli 08-6-207 Nur Ain Bashariah binti Ahmad Jaafar Sidek 08-6205

 Portal vein thrombosis Extrinsic compression ie ; tumor

Budd chiari syndrome Veno occlusive disease Restrictive pericarditis Right heart failure Sclerosing hyaline necrosis

Portal vein thrombosis

Child Omphalitis Direct injury to Adult 2ry to systemic portal(cancer) vein disease

Cong Cavernous malformation of malformation vascular Congenital portal valves system

Indirect factors that predispose to thrombus formation

Idiopathic

Omphalitis

Extrinsic compression by tumor

Budd chiari syndrome

Heterogenous group of disorder characterized by hepatic venous outflow obstruction at the level of :
hepatic venules, large hepatic veins, inferior vena cava and right atrium.

Veno occlusive disease

Obstruction of hepatic venous outflow at the level of central or lobular hepatic vein or both