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Variceal bleeding and massive upper gi bleeding

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Variceal bleeding and massive upper gi bleeding

  1. 1. VARICEAL BLEEDING AND MASSIVE UPPER GI BLEEDING: SURGEON’S ROLE FACEBOOK: HAPPY FRIDAY KNIGHT NOON CONFERENCE FOR INTERNS
  2. 2. VARICEAL UPPER GASTROINTESTINAL BLEEDING
  3. 3. GASTROESOPHAGEAL VARICEAL BLEEDING (GEVB) • Portal hypertensive upper GI bleeding in patients with cirrhosis • Portal hypertension is initial and main consequences of cirrhosis • Cirrhosis: diagnosed by: • Radiological: US, CT, MRI • Pathological: liver biopsy (gold standard)
  4. 4. https://www.otsuka.co.jp/en/health-and-illness/liver-cirrhosis-nutritional-therapy/early-detection/
  5. 5. PORTAL HYPERTENSION: DIAGNOSIS • Invasive test: • Hepatic venous pressure gradient (HVPG) ≥ 5 mmHG • Endoscopy: presents of GEV (portosystemic collaterals) • Non-invasive test: platelet count < 100,000
  6. 6. F https://my.clevelandclinic.org/health/diseases/1 5429-esophageal-varices https://upload.wikimedia.org/wikipedia/comm ons/b/b6/Esophageal_varices_-_wale.jpg
  7. 7. WHEN CIRRHOTIC PATIENTS REQUIRE EGD? • Expert opinion: EGD can be avoided in patients with • Liver stiffness < 20 kPa • Plt cont > 150,000/mm2 • Patients whom do not meet these criteria: EGD for GEV screening is recommended • Frequency: • Q2yrs in ongoing liver injury (active alcoholic drinking) • Q2yrs in presence of small varices • Q3yrs in absence of ongoing injury
  8. 8. • https://www.youtube.com/watch?v=vE0v24- zm4M&has_verified=1
  9. 9. PATIENTS WITH UGIB… • Airway protection and resuscitation • Define as EV or non-EV bleeding • Mortality 20 – 80% • Imaging study for ruling out HCC with portal vein thrombosis • immediate goal of therapy in these patients is to • control bleeding • prevent early recurrence (within 5 days) • prevent 6-week mortality
  10. 10. VARICEAL HEMORRHAGE MANAGEMENT • Restrict PRC transfusion (threshold of Hb 7 g/dL and maintain Hb 7 – 9 g/dL) • Correction of coagulopathy: • NOT recommend to correct INR by FFP or FVII • No recommendation for platelet transfusion • High risk for bacterial infection: antibiotic prophylaxis by ceftriaxone 1 g IV q24h, maximum 7 days (discontinue when UGIB resolved and vasoactive drug discontinued) • Vasoactive drugs: somatostatin, octreotide, terlipressin show benefit
  11. 11. • EGD ASAP (within 12 hours)  if varices present  EVL • Injection sclerotherapy for gastric varices VARICEAL HEMORRHAGE MANAGEMENT
  12. 12. WHAT ABOUT SENGSTAKEN BLAKEMORE TUBE • Control bleeding by tamponade effect • Indications • Active VH with fail med • Active VH with EGD/vasoconstrictor unavailable • contraindications • VH slow down • Recent EGJ surgery • Known esophageal stricture
  13. 13. SENGSTAKEN BLAKEMORE TUBE PLACEMENT • ETT intubation first • Inflate GASTRIC balloon 50 ml  Xray  inflate balloon up to 250 ml • 1-kg traction • Inflate ESOPHAGEAL balloon < 45 mmHg only when failed gastric balloon • Complication: esophageal or gastric rupture
  14. 14. • https://www.youtube.com/watch?v=NHelCd5Jtp4
  15. 15. SURGICAL MANAGEMENT IN NON-VARICEAL HEMORRHAGE
  16. 16. TREATMENT MODALITIES FOR BLEEDING PEPTIC ULCER: ENDOSCOPIC TREATMENT ADRENALINE INJECTION HEAT PROBE
  17. 17. MASSIVE UGIB • Hemodynamically unstable • Require PRC > 4 U in 24 hr
  18. 18. TREATMENT MODALITIES FOR BLEEDING PEPTIC ULCER: ENDOSCOPIC TREATMENT HEMOCLIP
  19. 19. INDICATIONS FOR SURGERY • Uncontrolled bleeding by endoscopy • Rebleeding after repeated endoscopic treatment
  20. 20. FORREST CLASSIFICATION: ENDOSCOPIC FINDING Forrest classificatio n Endoscopic finding Incidence (%) Rebleed without Rx (%) Rebleed after Rx (%) IA Spurting (active bleed) 12 55 15-30 IB Oozing (active bleed) 14 55 15-30 IIA Non-bleeding visible vessel (recent bleed) 22 43 5 IIB Adherent clot (recent bleed) 10 22 IIC Flat pigmented spot (recent bleed) 10 10 III Clean base ulcer (no active bleed) 32 5
  21. 21. TAKE HOME MESSAGE… • When an UGIB patients come to ER  look for emergency condition • Define EV or non-EV • Cause of bleeding can be from oral to ligament of Treitz • EV: only medical and endoscopic • Non-EV: medical  endoscopic  surgical
  22. 22. REFERENCES Garsia-Tsao G, et al. Portal Hypertensive Bleeding in Cirrhosis: Risk Stratification, Diagnosis, and Management: 2016 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatol. 2017:65(1);310-335. Procopet B and Berzigotti A. Diagnosis of cirrhosis and portal hypertension: imaging, non-invasive markers of fibrosis and liver biopsy. Gastroenterology report. 2017:5(2); 79-89. Brunicardi FC et al. Schwartz’s Principles of Surgery. 10th ed. McGraw-Hill Education, 2015.

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