UpperGastrointestinalBleeding(UGIB)ZhengJianweiDepartmentofGastroenterologyTheFirstAffiliatedHospitalofXiamenUniversityUpperGastrointestinalBleeding(UGIB)abbreviation1.DefinitionWhereisuppergastrointestinal(UGI)tract?WhatisacuteupperGIbleeding?WhatismassiveUGIB?1.DefinitionWhereisuppergastrointestinal(UGI)tract?WhatisacuteupperGIbleeding?WhatismassiveUGIB?DefinitionQ:HowmanypartsoftheGI(gastrointestinal)tract

aredividedinto?Q:Whataretheanatomicaldemarcation(landmark)s?WhereisUGItract?UpperGI(UGI)：proximaltotheligamentofTreitz.LowerGI(LGI)：DistaltotheligamentofTreitz

（OldEdition）.

Mid-GI(MGI)：FromtheligamentofTreitztotheileocecalValve（8thedition）LigamentofTreitzIleocecalValvePapillaofVater

Distaltotheileocecalvalve（NewEdition）Q:Whatistheligamentof

Treitz?

isananatomiclandmarkfortheduodenal-jejunaljunctionQ:WhereisthepapillaofVater?

animportantlandmark,halfwayalongthesecondpartoftheduodenumDefinitionWhereisUGItract?Q:ArethereanyspecialinUGI?

Specialenvironment:

gastricacid,pepsinQ:WhydotheyhavedifferentanatomiclandmarkofUGI,theligamentofTreitz

orthepapillaofVater?Asthelowerbendoftheduodenumisnotalwaysreachedwithstandardgastroscopy,tosettheboundarytothepapillaofVater,allbleedingsitescanbereachedandtreatedendoscopically.StandardgastroscopyDefinitionWhereisUGItract?

DotheybelongtoUpperGastro-intestinalBleeding?Q：Bleedingfrombileduct,pancrease？fromjejunumneargastrointestinalanastomasis？frommouth,pharynxandlarynx？fromrupturedaorticaneurysmintoesophagus？InteractionUpperGastro-intestinalTractThedigestivetractabovetheTreitzligamentorpapillaofVater

esophagus,stomach,duodenum.anatomiclandmarkincludesPancreas,biliarytract&jejunumafter

gastrojejunostomy

arealsointhisrangeSummaryDefinition1.DefinitionWhereisuppergastrointestinal(UGI)tract?WhatisacuteupperGIbleeding?WhatismassiveUGIB?WhatisacuteupperGIbleeding?

UpperGIbleedingisfromasourceproximaltotheligamentofTreitz(orthepapillaofVater)Acutebleedingisdefinedasthethedevelopmentofsuddenbloodloss.Definition1.DefinitionWhereisuppergastrointestinal(UGI)tract?WhatisacuteupperGIbleeding?WhatismassiveUGIB?UpperGImassivebleedinglossofblood(>1000ml)ormorethan20%ofbloodvolumeManifestations:hematemesis,melena,etc

rapid

withinseveralhourstocausehypovolemicshock(hypotension,tachycardia)

Themortalityis10%,misdiagnosisrateofetiologyis20%2.EtiologyWhatarethecausesofUGIB?Whatarethemostcommoncauses?2.EtiologyWhatarethecausesofUGIB?Whatarethemostcommoncauses?TheetiologiescanbeclassifiedasUppergastrointestinaldiseases1.1Esophagealdisorders1.2gastroduodenaldiseases2.Portalhypertension-relatedcauses3.Thediseasesoforganortissueneartheuppergastrointestinaltract4.Systemicdiseases全身性疾病EtiologyTheetiologiescanbeclassifiedasUppergastrointestinaldiseases1.1Esophagealdisorders:esophagitis(refluxesophagitis)esophagealcarcinomaesophagealulceresophagealinjury:physical(Mallory-Weisssyndrome);chemical(strongacidoralkali);radioactive,etc.Etiology

Mallory–WeisstearUppergastrointestinaldiseases1.2gastroduodenaldiseases:pepticulcer,stomaulceracuteerosive-hemorrhagicgastropathygastriccancerVascularabnormity(VascularEctasia,ArteriovenousMalformations,Dieulafoy’sLesion)Zollinger-EllisonsyndromeProlapseofgastricmucosaacuteerosiveduodenitisgastriclesionsaftergastrectomy,etc.TheetiologiescanbeclassifiedasEtiology

Pepticulcer

Acuteerosivehemorrhagicgastritis

GastricCancer2.Portalhypertension-relatedcausesportalhypertensivegastropathy(PHG)TheetiologiescanbeclassifiedasEtiologyEsophagealvaricesGastricvarices3.ThediseasesoforganortissueneartheuppergastrointestinaltractBiliaryhemorrhagePancreaticdiseasesArterialtumorMediastinaltumororabscess,etc.TheetiologiescanbeclassifiedasEtiology4.Systemicdiseases全身性疾病DiseaseofbloodvesselHematopathy,leukemia,hemophiliaUremiaDiseasesofconnectivetissueStress-relatedgastricmucosalinjury(燒傷Curlingulcer,腦血管意外Cushingulcer)Acuteinfection(Ebolavirus,Denguevirus),

etc.TheetiologiescanbeclassifiedasEtiologyDieulafoy’slesion(杜氏病)hookwormsAllergicPurpuraDuodenalmucosalpurpura2.EtiologyWhatarethecausesofUGIB?Whatarethemostcommoncauses?Themostcommondiseases?

Pepticulcer50%Varicesofesophagus&fundusofstomach25%

Acuteerosivehemorrhagiclesion15~30%

Gastriccancer5%Etiology3.ClinicalPresentation

Hematemesis&Melena(orhematochezia)

Signsandsymptomsofbloodloss

Anemia&hemogramOccultbloodinthestoolfeverElevationintheBUNlevel3.ClinicalPresentation

Hematemesis&Melena(orhematochezia)

Signsandsymptomsofbloodloss

Anemia&hemogramOccultbloodinthestoolfeverElevationintheBUNlevel

Bedefinedasthevomitingofblood.Itmaybeeitherfresh,brightredwithclots,orbeold&takeontheappearanceofcoffeegrounds.Brightredbloodoftenfromvaricesorarteriallesion.Patientswithcoffeegroundemesisarenotusuallybleedingactivelybuthavehadarecentorevenremotebleeding.HematemesisClinicalmanifestationBedefinedaspassageofblack,tarry,sticky,odorousstoolsduetothepresenceofalteredbloodand95%ofcasesoriginatedfromtheupperGItract.

BleedinglesiondistaltoT.Lig.maybeeithermelenaorhematochezia,butnevermanifestshematemesisMelenaClinicalmanifestation

Testforfecaloccultbloodbecomepositivewhenabout5mlbloodislostperday.

Characterofmelenaisduetodegradationofbloodtoferricsulfide(硫化鐵）bybacteria.Referstopassageofbrightredbloodfromtherectumthatmayormaynotbemixedwithstool.HematocheziaClinicalmanifestationItwillhappenifGIbleedingmassivelyasblooddoesn’tremaininbowellongenoughtobecomemelena.HematocheziausuallyrepresentsalowerGIsourcebleeding.HematemesisMelenaHematocheziaMoreproximallesionsproducehematemesisormelena,whereasmoredistallesionsaremorelikelytoproducehematocheziaBleedingformupperGIBleedingformmiddlepartofGIBleedingformlowerGIUpperGIsourcebleeding--hemetemesis&melenaMajorupperGIbleeding---hemetemesis&hemetocheziaThemoredistantfromtherectum,themorelikelythatmelenaoccursThecolonlesion--FOB+orhemetocheziaThesmallbowellesion---melenaorhemetocheziaClinicalmanifestationSummaryofacuteGIbleeding3.ClinicalPresentation

Hematemesis&Melena(orhematochezia)

Signsandsymptomsofbloodloss

Anemia&hemogramOccultbloodinthestoolfeverElevationintheBUNlevel

Patientoftencomplainsoffaintness,sweating,palpitation,fatigue,thirst,andsyncope.

Mainphysicalsignsarepallor,sweating,restlessness,tachycardia,hypotensionRecognitionofGIhemorrhageSignsandsymptomsofhypovolemia

Postural(Orthostatic)hypotensionThebloodpressureismaintainedonrecumbencybutfallsmorethan15to20mmHgwhenthepatientsitsup3.ClinicalPresentation

Hematemesis&Melena(orhematochezia)

Signsandsymptomsofbloodloss

Anemia&hemogramOccultbloodinthestoolfeverElevationintheBUNlevelPatientswhobleedsmallamountsofbloodoverlongperiodsoftimedevelopirondeficiencyanemia,alowmeancorpuscularvolume(MCV),hypochromicmicrocyticredbloodcell&detectionofoccultbloodinthestoolwithstandardfecaloccultbloodtestsifbloodlossisacute,hematocritvaluemaynotreflectbloodlossaccuratedly&theMCV,hemoglobinconcentrationisnormal.Becauseequilibrationwithextra-vascularfluid&subsequenthemodilutionrequiresseveralhoursRecognitionofGIhemorrhageAnemia&hemogramHematocritchangesABeforebleedingBImmediatelyafterbleedingC24~72hoursafterbleeding(1)Hb,RBC,red-cellcountandhematocritIntheearlystage,theyarenormal.After3-4h,anemiaappears(tissuefluidfilterintobloodvesselandmaketheblooddilute)Hb:>3~4hRC:<1d；4~7d5~15%,tonormalgraduallyWBC:2~5h10,000~20,000/L;2~3dnormalRecognitionofGIhemorrhageAnemia&hemogramRC:reticulocyte網(wǎng)織紅細(xì)胞(2)ReticulatedcorpusclesWithin24h,itelevates.After4~7days,itelevatesto5%-15%,thengraduallydescentstonormal.Ifthebleedingdoesn’tcease,itcanpersistentlyelevate.Hb:>3~4hRC:<1d；4~7d5~15%,tonormalgraduallyWBC:2~5h10,000~20,000/L;2~3dnormalRecognitionofGIhemorrhageAnemia&hemogram(3)WBC2-5h,WBCelevatesto(10~20)x109/L.Itdescentstonormalafterthebleedingceases2~3days.Ifthepatientwithhypersplenism,WBCcan’televate.Hb:>3~4hRC:<1d；4~7d5~15%,tonormalgraduallyWBC:2~5h10,000~20,000/L;2~3dnormalRecognitionofGIhemorrhageAnemia&hemogram3.ClinicalPresentation

Hematemesis&Melena(orhematochezia)

Signsandsymptomsofbloodloss

Anemia&hemogramOccultbloodinthestoolfeverElevationintheBUNlevel4)occultbloodinthestoolHemoccultispositiveif>5~10mlbloodperdayinstool.5)feverLowgradefever(<38.5℃),persist3~5days

Themechanismisunclear,maybeobstructionofheat-regulatingcentercausingbycirculationvolumereducingandperipheralcirculatoryfailure.RecognitionofGIhemorrhage3.ClinicalPresentation

Hematemesis&Melena(orhematochezia)

Signsandsymptomsofbloodloss

Anemia&hemogramOccultbloodinthestoolfeverElevationintheBUNlevelAzotemia(氮質(zhì)血癥）Serumureanitrogenfrequentlyelevatedafterthemassivebleeding,definitedasenterogenousazotemia.Themechanisms:alargeamountbloodenteredintestineanddigestiveproductofbloodisabsorbed(enterogenous)volumeofrenalbloodflowdecreased(prerenal)kidneydiseaseinthepastorlastinglowrenalperfusion(intrarenal)RecognitionofGIhemorrhageWithin24~48h,BUNelevatestopeak,commonlynotmorethan14.3mmol/L(40mg/d),persist3~4days.b.BUNpersistentlyelevatesmorethan3~4daysorobviouslymorethan17.9mmol/L(50mg/dl)theactivebleedinghadnotceased,bloodvolumeisnotcorrectedandtheamountofurineisstilllittle.C.Therenalfailureshouldbeconsideredifthetimeofshockislongandhaskidneydiseaseinthepast.RecognitionofGIhemorrhageAzotemia(氮質(zhì)血癥）Interaction1.HematemesisorMelena?Bleedingsiteaboveorbelowpylorus,amount&speedofbleedingAllpatientsafterbleedinghavemelenaorstoolOB,butnoteveryonehashematemesis.InteractionBelowthepylorus,maybeonlymelena,butabovethepylorus,themelanacanbewithhematemesis.

Verylarge&fastbleedingbelowpylorus,thebloodcanrefluxtostomachhematemesisbesidesmelena.Little&slowbleedingabovepylorus,thepatientlikelyisn’twithhematemesis.Interaction2.Thecolourofthevomitedblood？bloodresidencetimeinstomach:

blood+gastricacidhaematein（正鐵血紅素）Oftendarkbrown,orcoffeegroundsvomiting.Ifbleedingishuge,theblooddoesn’tactwithgastricacid,thehematemesisisbrightred.Interaction3.Thecolourofthestool?

bloodresidencetimeinbowel：Fe(hemoglobin)+SFeS(ironsulfide硫化鐵)

TheironofhemoglobinreactwithsulfideinintestinetoformferricsulfideBlack,tarry,metallic-smellingstools.Ifbleedingishuge,stoolsmaypresentwithdarkredblood.4、ApatientwithGIbleeding,38.5℃ofthebodytemperatureandWBC12X109/L,N92%

Doesheneedantibiotics?Interaction4.DiagnosisDifferentiateddiagnosis

AssessmentofseverityTodeterminewhetherbleedingiscontinuingLocalizationofbleedingPrognosis4.DiagnosisDifferentiateddiagnosis

AssessmentofseverityTodeterminewhetherbleedingiscontinuingLocalizationofbleedingPrognosisThefollowingsituationsmustbenoticed:Toexcludethebleedingfactorsoutsidedigestivetract.

i.bleedingofrespiratorytract.Thedifferentiateddiagnosisofemptysisandhematemesis.ii.Bleedingofmouth,nose,andlarynealpartofpharynxiii.Melenacausedbytakingfoodormedicine.b.EstimationofthebleedingfromupperGItract,midorlowerGItract

i.Hematemesisii.melenaiii.BloodystoolDiagnosisDifferentiateddiagnosis4.DiagnosisDifferentiateddiagnosis

AssessmentofseverityTodeterminewhetherbleedingiscontinuingLocalizationofbleedingPrognosis1.FecalOB(occultblood)

Positive

>5ml/day；

Blackstool

>50ml/day；

Tarrystool

>100ml/day；

2.Hematemesis

>250mlinstomach；3.Signs&symptomsofhypovolemia(systemicsymptoms)>400~500ml;

bloodlose<400ml

Noobvioussigns&symptoms；AssessmentofseverityDiagnosis4.Posturalhypotension體位性低血壓orOrthostatichypotension直位性低血壓Ifthepulserateincreasesmorethan10beatsperminute&thesystolicbloodpressuredropsmorethan15~20mmHgwhenthepatientsitsfromasupinepositon,itislikelythatbloodlosshasexceeded1liter.5.Shock:systolicbloodpressure<90mmHg,pulserate>120/min+signs&symptomsofhypovolemiaAssessmentofseverityDiagnosis4.DiagnosisDifferentiateddiagnosis

AssessmentofseverityTodeterminewhetherbleedingiscontinuingLocalizationofbleedingPrognosisTodeterminewhetherbleedingiscontinuingRepeatinghematemesis,frequencyofmelenaincreasing,orwaterystool,withthehyperactivebowelsounds;

Manifestationsofperipheralcirculatoryfailure

doesn’tobviouslyimproveafteractivetreatment;

Hb,red-cellcount,hematocritpersistentlydecline;

Reticulatedcorpusclespersistentlyelevates;

SerumBUNpersistentlyelevatesorraiseagainintheconditionofenoughfluidinfusionandamountofurineDiagnosis4.DiagnosisDifferentiateddiagnosis

AssessmentofseverityTodeterminewhetherbleedingiscontinuingLocalizationofbleedingPrognosisDiagnosisLocationofthelesionCaseHistory

Priorbleedingepisode?FamilyhistoryofGIdiseaseDosethepatienthavetheillnessofulcer?Cirrhosis?Cancer?Bleedingdisorder?Alcohol?NSAIDs?Anyprecedessymptomsorsigns?Anysignsofjaundice,ascites,spider

angiomas,splenomegaly,etc.DiagnosisLocationofthelesion

Thephysicalexaminationperformedbythephysicianconcentratesonthefollowingthings:

Vitalsigns,inordertodeterminetheseverityofbleeding&thetimingofintervention.

Abdominal&rectalexamination,inordertodeterminepossiblecausesofhemorrhage.

Assessmentforportalhypertension&stigmataofchronicliverdiseaseinordertodetermineifthebleedingisfromavaricealsource.Diagnosis

HematemesisisfromanupperGIsourceofbleeding

MelenaisusuallytheresultofupperGIbleeding

Hematochezia

isusuallytheresultoflowerGIbleedingbutapproximately10%ofthepatientswithrapidbleedingfromanuppersource.Thenasogastriclavage(鼻胃管引流)hasbeenusedextensivelytohelpdifferentiateupperfromlowerGIbleeding,butnow,theuseisdiscouraged.ClinicalPresentationLocationofthelesionUrgentendoscopyrevealedthefollowingfindingonthelessercurvatureofthegastricbody.

UrgentEndoscopy(within24~48hoursafterbleeding）：providediagnosis80%~94%LocationofthelesionDiagnosisSelectiveAngiographyIsadoptedwhenbleedingissomassivethatendoscopycannotbesafelyorsatisfactorilyperformedandsurgeryiscontraindicated.Rateofbleeding

>0.5ml/min。mid-jejunalbranchofsuperiormesentericarteryLocationofthelesionDiagnosisSelectiveAngiographyLeftcolonicarterialbleedingLocationofthelesionDiagnosisanareaofabnormalactivityinthejejunum(arrows)Radionuclideimaging:suchasTaggedRedbloodcellscintigraphy（標(biāo)記紅細(xì)胞掃描）Advantages:sensitivitytolowratesofbleeding(0.1to0.5ml/min);safety;itisnoninvasive;lowcost.Disadvantage:includeitslackoftherapeuticcapabilityanddoubtaboutitsaccuracy.LocationofthelesionDiagnosisCapsuleendoscopyAdvantage:

providediagnosisofsmallbowelDisadvantage:

no

biopsy&endoscopictherapyLocationofthelesionDiagnosisM2A?CapsuleComponentsOpticaldomeLensholderLensIlluminatingLEDs(lightemittingdiodes)CMOS(ComplementaryMetalOxideSemiconductor)imageBatteryASIC(ApplicationSpecificIntegratedCircuit)transmitterAntenna

Dimensions:

Height:11mm Width:27mm Weight:3.7gr1.2.3.4.5.6.7.8.

Balloontamponade(Sengstaken-Blakemore)esophagogastrictamponadetubesLocationofthelesionDiagnosisLocationofthelesionDiagnosisExploratorylaparotomy4.DiagnosisDifferentiateddiagnosis

AssessmentofseverityTodeterminewhetherbleedingiscontinuingLocalizationofbleedingPrognosisDiagnosisIncreasingageComorbidityShockPrognosisFactorCommentsRiskincreasesoverage60andespeciallyinveryelderlyAdvancedmalignancy,renal&hepaticfailureareassociatedwithparticularlyhighmortality.Definedaspulse>100/min,BP<100mmHg

DiagnosisVarices&cancerhavetheworstprognosis.EndoscopyActivebleeding&anon-bleedingvisiblevesselatendoscopyareassociatedwithahighriskofcontinuingbleeding.Associatedwith10-foldriseinmortality.

Rebleedingthemostproperandeffectivemethodfordiagnosing&treatingUGIB？gastroscopyInteraction2.ThemostusefulmethodfordiagnosingvascularmalformationinmidorlowerGItract？selectiveangiographycapsuleendoscopyballoonintestinalendoscopycolonoscopyInteraction3.Whatisemergencyendoscopy&whytodothat?Endoscopyisdonewithin24~48hafterbleeding.1.toincreasetheveracityofbleedingetiology,especiallyinacutehemorrhagicgastritis&vascularhemorrhage.2.todetermineifthebleedingispersistentorthedangerousofrebleeding.3.tomakehemostasistreatmentunderendoscopy4.todiagnosisandlocalizethelesionforsurgeonInteraction4.WhatisObscuregastrointestinalbleeding,OGIB?Previousdefinition：Patientswithpersistent,recurrent,orintermittentbleedingfromthegastrointestinal(GI)tractforwhichnodefinitecausehasbeenidentifiedbyinitialesophagogastroduodenoscopy&colonoscopyPresentdefinition：Patientswithpersistent,recurrent,orintermittentbleedingfromthegastrointestinal(GI)tractforwhichnodefinitecausehasbeenidentifiedbyinitialesophagogastroduodenoscopy,capsule

endoscopy&colonoscopyInteraction1.TocheckHbaccuratelyafteracuteGIbleeding?Anemiacouldbeseenin3~4hours，Hbwillbestablearound12hours2.Todecideseverityofanemia?Theamountofbleeding,Hblevelbeforebleeding,Thespeedofthefluidbalance,etc.Interaction3.HowmanydaysdoesthecolourofthestoolrecovernormalafterGIbleedingceaseifthepatienthasbowelmovementeveryday?1~3daysInteraction4.Themaximumblooddonationeachtime?Generally200ml,maximum400ml.Bloodlose<400ml

Noobvioussigns&symptoms5.TreatmentGeneralmeasuresHemostasis

PharmacologicmanagementBalloontamponadeInterventiontreatmentSurgeryEndoscopichemostasis5.TreatmentGeneralmeasuresHemostasis

PharmacologicmanagementBalloontamponadeInterventiontreatmentSurgeryEndoscopichemostasis

1、Generalmeasures

Bedrest

Oxygeninhalation

Monitor:Vitalsigns(BP,P,R,T)

Assessment:Thesituationofbleeding

Bloodsample:hemoglobin,hemotocrit,urea,electrolytes,grouping&cross-matching

History+exam

Fasting(activebleeding)Detectionofbloodgroupandmatchingbloodatonce.Treatment

1、Generalmeasures

I.V.accessToimmediatelyestablishtransfusiontractofveinandsupplementbloodvolume.Ifshortageofblood,insteadofcolloidorotherplasmareplacementagents.Intravenouscrystalloidfluidsorcolloidaregiventorestorethebloodpressure.ThespeedoftransfusionmustbefastatbeginningandamountisbasedontheamountofbleedingTreatment

TheindexofemergencybloodtransfusionWhenthepatientssitsfromasupineposition,theheartrateincreases,thebloodpressuredropsandsyncope2.Theheartrate>120/minorSBP<90mmHg3.Hb<7g/Lorhematocrit<25%4.Notice:anemia,urinevolume5.Cirrhosis:freshblood

1、Generalmeasures6.Bodytemperature:largetransfusionatshorttimeTreatment5.TreatmentGeneralmeasuresHemostasis

PharmacologicmanagementBalloontamponadeInterventiontreatmentSurgeryEndoscopichemostasis2.Hemostasis

Peopleareusuallystratifiedintohavingeithervaricealornon-varicealsourcesofupperGIhemorrhage,asthetwohavedifferenttreatmentalgorithms&prognosis.Earlyendoscopyisrecommended,notonlyasadiagnosticapproach,butalsoasatherapeutictechnique,whichcanbeperformedthroughtheendoscope.Treatment5.TreatmentGeneralmeasuresHemostasis

PharmacologicmanagementBalloontamponadeInterventiontreatmentSurgeryEndoscopichemostasis

ForrestStigmata

PepticUlcer

RebleedingRate(%)

ⅠａActive

bleeding

(噴射樣出血)

55

Ⅰｂ

Oozing

(活動性滲血)

55

ⅡａVisible

vessels

(血管顯露)

43ⅡｂRed

clot(附著血凝塊)

22

ⅡｃFlatspots

(黑色基底)

10ⅢCleanbase(基底潔凈)

5

中華內(nèi)科雜志2005:44(1)

ForrestStigmatainbleedingpepticulcer

EndoscopicHemostasisManagementofNon-varicealUGIBleedingHemostasisTheRecommendationsforEndoscopicTreatmentofBleedingUlcersActivebleedingTreatVisiblevesselTreatClotControversialmosttreatFlatspotsLeaveAloneCleanbasePossibleDischargeBarkumA.AnnInternMed.2010;152:101EndoscopicHemostasisAcombinationofepinephrineinjectionplusthermaltreatmentand/orhaemoclipsisgenerallypreferredtomonotherapyEpinephrineinjectionHaemoclipHeaterprobeBarkumA.AnnInternMed.2010;152:101ManagementofNon-varicealUGIBleedingHemostasishemoclipEndoscopicHemostasisBandingligationManagementofVaricealUGIBleedingSclerotherapy&ligationSclerotherapyHemostasisLigationofesophagusvaricesEndoscopicHemostasisHemostasisSclerotherapyofgastricvaricesEndoscopicHemostasisHemostasis5.TreatmentGeneralmeasuresHemostasis

PharmacologicmanagementBalloontamponadeInterventiontreatmentSurgeryEndoscopichemostasisPharmacologicmanagementHemostasisProtonpumpinhibitors(PPIs)

Which

reduce

gastric

acidproduction&acceleratehealingofcertaingastric,duodenal&esophagealsourcesofhemorrhage.Thesecanbeadministeredorallyorintravenouslyasaninfusiondependingontheriskofrebleeding.WhyAcid-SuppressantTherapy?GastricacidandpepsininhibitclotformationandcauseclotlysisPlateletaggregationandcoagulationoptimalatpH7.4PlateletaggregationimpairedatpH<5.9PepsincausesclotlysisGastricacidimpairsulcerhealingHypersecretionofgastricacidoccursinpatientswithbleedingulcersPharmacologicmanagementHemostasisGastricpHandClinicalEffectGastricpHClinicalEffect>4Pepsininactivated>599%acidneutralized>6Functionalcoagulationandplateletaggregation>7PepsindestructionStressUlcerProphylaxisReductionofrebleedingafterendoscopicinterventionVorderBrueggeW,etal.JClinGastroenterol.1990;12Suppl2:S35-40.PharmacologicmanagementHemostasisTerlipressin

isaVasopressinanalogmostcommonlyusedforvaricealupperGIhemorrhage.PharmacologicmanagementHemostasisSomatostain&itsanalog

toshuntbloodawayfromthesplanchniccirculation.It

has

foundtobeausefulinmanagementofbothvariceal&nonvaricealupperGIbleeding.5.TreatmentGeneralmeasuresHemostasis

PharmacologicmanagementBalloontamponadeInterventiontreatmentSurgery