1、Upper GI Bleeding,Tad Kim, M.D. UF Surgery (c) 682-3793; (p) 413-3222,Overview,Definitions Initial Patient Assessment ABC & Resuscitation Differential Diagnosis Identify the Source & Stop the Bleeding History & Physical Endoscopy & Potential Complications Other diagnostics tes

2、ts Role of Surgery Prevention,Definitions,Upper GI Bleeding = proximal to ligament of Treitz Hematemesis = vomiting blood This is diagnostic of upper GI bleeding Melena = passage of tarry or maroon stool Can be upper or lower (more commonly upper) Hematochezia = Bright red blood per rectum Usually c

3、haracteristic of colonic hemorrhage,Initial Patient Assessment,Get to patients bedside, assess ABC Can the patient protect his airway? Does he need to be intubated? Is the patient hemodynamically unstable? Is he in hemorrhagic shock? 2 large bore IV, Bolus 2L fluids, Type & Cross blood, send CBC & C

4、oags Place patient on O2 & continuous monitor Place an NGT and lavage with NS To confirm if the bleeding source is upper GI,Differential Diagnosis,Peptic Ulcer Disease (PUD) 50% cases Gastritis / Duodenitis (15-30%) Subset due to NSAID use Varices from portal hypertension (10-20%) Mallory-Weiss tear

5、s at GE junction (5%) Esophagitis (3-5%) Malignancy (3%) Dieulafoys lesion (1-3%) Nasopharyngeal bleed swallowed blood Other- Aortoenteric fistula, angiodysplasia, Crohns, hemobilia, hemosuccus pancreaticus,History & Physical,History of prior ulcers, NSAID use, stress History of Helicobacter pylori

6、& treatment Alcohol abuse Retching - Mallory Weiss tear Alcoholic cirrhosis - portal hypertension and varices On Physical Exam, assess hydration Look for stigmata of cirrhosis & portal HTN,Management Acute UGI Bleed,Once again, make sure pt is resuscitated If anemic and symptomatic, give blood Place

7、 NGT/lavage (helps for endoscopy) Perform Upper endoscopy (EGD) For ulcers: if visible clot, visible vessel, or active bleeding, should cauterize/coagulate and inject sclerosing agent For acute variceal bleeding: sclerotherapy + somatostatin or endoscopic band ligation. If fail/rebleed: TIPS vs surg

8、ical shunt. Balloon tamponade is an emergency temporizing measure Start proton pump inhibitor (PPI) infusion,Potential Complications,Perforation of esophagus Aspiration Desaturation or respiratory distress Adverse reaction to conscious sedation risk of complications with: Inadequate resuscitation or

9、 hypotension Comorbidities Consider elective intubation prior to EGD if active bleeding, altered respiratory or mental status,Other Diagnostic Tests,If bleeding is unresolved with endoscopy or endoscopy is contraindicated 1. Angiography (Diagnostic & Therapeutic) Intra-arterial vasopressin Embolizat

10、ion 2. Tagged red blood cell (TRBC) scan Only diagnostic & usually for occult bleeding More sensitive than angiography Can detect bleeding rate of 0.1-0.5 mL/min,Role of Surgery,If medical and endoscopic therapy fail In the event that bleeding source is unidentified - exploratory laparotomy Recurren

11、t bleeding peptic ulcers Anti-ulcer surgery (i.e. vagotomy/antrectomy, or vagotomy/pyloroplasty, or selective vagot),Prevention,After the acute situation is resolved, educate patient on preventive measures Top 2 reasons for ulcers: Hpylori & NSAID 1. Testing for H.pylori (i.e. antral biopsy during e

12、ndoscopy) 2. Treat H.pylori (amoxicill, clarithromycin x1wk plus PPI x4wk) 3. Reduce intake of NSAID,Take Home Points,Always, always perform ABCs first & resuscitate with two #16ga IVs & isotonic crystalloids (blood if pt doesnt respond) NGT/lavage to confirm active bleeding Focused H&P looking for common causes: ulcers, varices, “-itis”, Mallory-Weiss, AVM End