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Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor
UGI bleed is defined as the bleeding originating proximal to ligament of treitz.90% of patients presenting with GI haemorrhage has an UGI source.
Etiology
Variceal bleed
Gastric
Esophageal
Non variceal bleed
Peptic ulcer disease
Erosive gastritis
Mallory weiss syndrome
Stress ulcer
AV malformation
Malignancy
Clinical Presentation
Hematemesis
Malena
Vitals : Tachycardia, hypotension , decreased pulse pressure may be present.
Cold & clammy skin due to hypotension may be present.
Look for features of CLD.
Vomiting and retching followed by hematemesis suggest Mallory weiss tear.
H/o of glucocorticoids, NSAID's or anticoagulant intake.
Blood urea nitrogen levels are elevated due to GI bleed and absorption of Hb. BUN: Creatinine ratio >30 is suggestive of UGI bleeding.
Variceal Bleeding
It is defined as bleeding from esophageal or gastric varix at the time of endoscopy or presence of large esophageal varices with blood in stomach and no other recognisable cause of bleeding.
Two factors that appear to determine the development of varices are continued hepatic injury and degree of portosystemic shunting.
Portal pressure reflects intravariceal pressure and a hepatic venous pressure gradient greater than 12mm Hg is needed for development and bleeding from esophageal varices.
Management of Active variceal bleed
Airway, Breathing has to addressed.
Circulation :
Secure a two large borer IV cannula
IV fluid resuscitation
Blood products to be transfused.
Endoscopy
As soon as patient is hemodynamically stable preferably within 24hrs is the standard of care.
Variceal band ligation is the method of first choice.
Other methods like sclerotherpy , tissue adhesive like cyanoacrylate or bucrylate are used.
Octerotide
It is a stomatostatin analogue .
It causes selective spalnchic vasoconstriction and reduces portal pressure and portal blood flow.They also reduce secretion of gastric acid & pesin.Stimulates mucus production.
DOSE : 25 - 50 mcg IV stat ; followed by 50 mcg/h IV infusion.
Adverse effect:
Arrythmia, Bradycardia
Vomiting, flatulence, losse stools, abdominal pain
Hypoglycemia & hypergylcemia
Availability : Ampoules 50, 100mcg.
Terlipressin
It is the only agent which have proven to improve survival in acute variceal bleeding.
Antibiotic in variceal bleeding
Bacterial infection occurs in about 20% of patients with cirrhosis with UGI bleed within 48hrs.
The suggested drug is ciplox 1gm/day for seven days orally.
Primary Prophylaxis
Propranolol : It is used as main stay agent in grade2 or grade 3 varices. It reduces portal pressure gradient, reduces azygous blood flow and also variceal pressure. It achieves this by splanchic vasoconstriction and reducing cardiac output. Dose : 40mg BD – 80mg BD.
Alternative drugs : Nadalol or isosorbide mononitrate
Secondary prophylaxis of variceal hemorrhage
TIPSS (Transjugular Intrahepatic Portosystemic Stent Shunting)
This technique uses a stent placed between portal vein & hepatic vein within liver to provide a portosystemic shunt and therefore reduce portal pressure.
It is associated with more chance for hepatic encephalopathy.
It is done when other methods fail to control variceal bleeding & recurent bleeding.
Portosystemic shunt surgery
Surgery prevents recurrent bleeding but carries a high mortality and often leads to encephalopathy.
Management of Non variceal bleed
Proton Pump Inhibitors
They reduce both basal and stimulated acid secretion by inhibiting H+K+ ATPase, the proton pump of parietal cells.
IV PPI achieves more profound and sustained supression.
DOSE
Pantoprazole/omeprazole : 80mg IV bolus followed by 8mg/hr IV infusion for 72hrs. (increased risk of rebleed during 2-3 day)
Reference
UK Guidelines on management of variceal hemorrhage: BMJ
Tintinalli
Davidson
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emmedonline
Dr. Ajith Kumar J MD
Dept. of Emergency Medicne
Travancore Medicity, Kollam
India
editor