prof. ibrahim a. al-mofleh professor of medicine, college of medicine & university hospitals,...
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PROF. IBRAHIM A. AL-MOFLEH Professor of Medicine, College of Medicine
& University Hospitals, KSU
PROF. IBRAHIM A. AL-MOFLEH Professor of Medicine, College of Medicine
& University Hospitals, KSU
ACUTE GI – BLEEDING
(AGIB)
Forms
• Upper
• Lower
• Obscure
AGIB
Epidemiology
•Common (e.g. 15000 deaths/yr in USA)
•Upper is 5 x more than lower
•More frequent in men and elderly
•Spontaneous cessation in 80%
•Mortality in general 10%
in elderly 20%
cont. bl/rebleeding >30%
AGIB
A 60 yrs old patient was brought with the ambulance to the emergency room with acute GI-bleeding ; you are asked to care for this patient
What are your plans (objectives)? How would you approach him?
Mention the adverse prognostic factors?
AGIB
Objectives
• Maintain the hemodynamics
• Determine the level
• Determine the cause
• Treat and prevent rebleeding
AGIB
How to approach the patient?
1. Initial assessment
2. Resuscitation
3. History and exam
4. Lab evaluation
5. Localization
6. Treatment
AGIB
Initial assessment – A
How urgent is the situation
stable
or in shock ?
What are the features of shock ?
What is the magnitude of blood loss ?
)1 (
AGIB
Initial assessment – B
What are the features of shock ?
• Agitation
• Pallor
• Hypotension
• Tachycardia
) 1(
AGIB
VS Blood loss (% of total volume)VS Blood loss (% of total volume) Severity of bleed Severity of bleed
Normal < 10% Mild
Postural drop 10 – 20% Moderate
Shock > 20% Severe
How to assess the magnitude of blood loss?
AGIB
How to approach the patient?
1. Initial assessment
2. Resuscitation
3. History and exam
4. Lab evaluation
5. Localization
6. Treatment
AGIB
Resuscitation Hemodynamically unstable patient
• Restore and maintain hemodynamics
• Oxygen
• Monitor VS and urinary output
• Admission to ICU
• Blood transfusion
• ? FFP
) 2(
AGIB
AGIB
Resuscitation Indications for blood transfusion
• Unstable VS
• Continuous bleeding
• Bright blood
• Age > 60
• Concomitant CPD
) 2(
AGIB
How to approach a patient with AGIB?
1. Initial assessment
2. Resuscitation
3. History and exam
4. Lab evaluation
5. Localization
6. Treatment
AGIB
History and examination
HistoryHistory Exam Exam
Age Stigmata of CLD
Dyspepsia Hereditary vascular anomalies
Previous bleeding Scars
Previous PUD Palpable organs / masses
Previous endoscopy Lymphadenopathy
Previous surgery PR
(PUD aortic graft etc..)
Drugs
CLD
Weight loss, Anorexia
Changing bowel habits
) 3( AGIB
How to approach a patient with AGIB?
1. Initial assessment
2. Resuscitation
3. History and exam
4. Lab evaluation
5. Localization
6. Treatment
AGIB
Laboratory parameters
• Type and crossmatchingType and crossmatching
• CBC, PT, PTT,CBC, PT, PTT,
• BUN , BUN / Creatinin ratioBUN , BUN / Creatinin ratio
• LFTLFT
• ABGABG
) 4(
AGIB
How to approach a patient with AGIB?
1. Initial assessment
2. Resuscitation
3. History and exam
4. Lab evaluation
5. Localization
6. Treatment
AGIB
Localization
• Clinical
• Endoscopy
• RBC scan
• Angiography
) 5 (
AGIB
How to approach a patient with AGIB?
1. Initial assessment
2. Resuscitation
3. History and exam
4. Lab evaluation
5. Localization
6. Treatment
AGIB
Treatment
• Medical
• Endoscopic
• Angiographic
• Surgical
) 6(
AGIB
Adverse prognostic factors
ClinicalClinical
• Old age
• Comorbid diseases
• Bright blood (NGA, vomitus, stool)
• Onset of bleeding in the hospital
• Amount of blood lost
• Shock or hypotension on presentation
• Emergency surgery
AGIB
Adverse prognostic factors
EndoscopicEndoscopic
• Vascular bleeding
• Active bleeding
• Visible vessel
• Clot
• Giant ulcer
AGIB
Indications for emergency endoscopy
• Cause
• Severity
• Age
• Cirrhosis
• Persistent bleeding
• Rebleeding
AGIB
Role of endoscopy
• Site of bleeding
• Source of bleeding
• Stigmata of bleeding PUD
−Active bleeding
−Visible vessel
−Clot
−Black spot
• Endoscopic therapy
AGIB
Endoscopic hemostatic methods
• Variceal bleeding
Injection
Banding
• Non-variceal bleeding
Injection
Thermal
Clips
Bleeding Esophageal Varices
EVL
Gastric Varices
GU – Visible Vessel
Sentinel Clot
Gastric Angiodysplasia
Bleeding Angiodysplasia
DU – Bleeding Control
DU – Bleeding
GU Clips
Bleeding GU
Bleeding Diverticulum
Diverticulum Visible Vessel
Bleeding hemorrhoids
Dieulafoy - Colon
Thank you !Thank you !