胃肠道出血课件.ppt

GIHemorrhage February26 2020DavidHughes Incidence 1 2 ofallhospitaladmissionsMostcommondiagnosisofnewICUadmits5 12 mortality40 forrecurrentbleeders85 stopsponateouslyThosewithmassivebleedingneedurgentinterventionOnly5 10 needoperativeinterventionafterendoscopicinterventions Site UpperEsophagealStomachDoudenumHepaticPancreaticLowerSmallbowelColonAnus Etiology 85 aredueto PepticulcerdiseaseVaricealhemorrhageColonicdiverticulosisAngiodysplasia Chainofevents RecognizeseverityEstablishaccessforresusitationResusitateIdentifysourceIntervention Question 1 JBa30y owithhematemesispresentswithorthostatichypotension clammyhands butwithouttachycardia Howmuchbloodhashelost 40 20 40 10 20 10 Question 1 JBa30y owithhematemesispresentswithorthostatichypotension clammyhands butwithouttachycardia Howmuchbloodhashelost b 20 40 UpperGIhemorrhage Howdoyouknowitsupper 85 ofallGIhemorrhageisupperHematemesisdiagnosticDon tforgetaboutnasalbleedingaspossiblesourceMelenaDegradationofhemoglobintohematinbyacidBowelbacteriaanddigestiveenzymesalsocontributeHematochezia10 ofpatientswithveryrapidUGIsource Gastricvarices Gastricvarices EsophagealVarices Gastricvarices Bleedingulcers EsophagealVarices Gastritis Gastritis Dieulafoy slesion Mallory weiss Watermelonstomach UpperGIhemorrhage EtiologyPepticulcerdisease 50 Varices 10 20 Gastritis 10 25 Mallory weiss 8 10 Esophagitis 3 5 Malignancy 3 Dieulafoy slesion 1 3 Watermelonstomach 1 2 UpperGIhemorrhage CrampyabdominalpaincommonLargecaliberNGTCoffeegroundsorgrossbloodNobloodCanbeusedforlavagepriortoendoscopyUpperendoscopyindicationsMelenaorhematocheziawithhypotensionHematemesisNGTwithguiacpositivefluidShouldbecompletedin24hrsforstablepatients Pepticulcerhemorrhage Pepticulcerdisease20 ofpatientsbleedatleastonceMostlethalcomplicationVesselisusually 1mmdiameterCausesH pylori40 50 NSAID s40 50 Other Z Esyndrome Pepticulcerhemorrhage PredictorsofmortalityRenaldisease29 Acuterenalfailure63 Liverdisease25 Jaundice42 Pulmonarydisease23 Respiratoryfailure57 Cardiacdisease13 Congestiveheartfailure28 Pepticulcerhemorrhage MedicalmanagementAnti ulcermedicationH pyloritreatmentStopNSAIDsFollowupEGDforgastriculcerin6weeks Pepticulcerhemorrhage EndoscopicinterventionsThermalcoagulationInjectedagentsSuccessrate95 initailly80 willnotrebleedRepeattreatmentafter1strebleedsalvages50 Increasedriskofmortality Pepticulcerhemorrhage SurgicalinterventionOnly10 ofpatientsIndicationsFailureofendoscopySignificantrebleedingafter1stendoscopyOngoingtransfusionrequirementNeedfor 6unitsover24hoursEarlierforelderly multipleco morbidities Pepticulcerhemorrhage Anti secretorysurgery IndicatedforNSAIDptswhoneedtocontinuedmedsH pyloriulcerdiseasecontroversialOnly0 2 ofptseveryrequiresurgeryforbleedingulcerSurgeryptshadlowerthanaverageH pyloripositivityOversewingandantibioticsstillleave50 athighriskforrebleedingBottomline stillrecommendedbutwithoutdefinitiveevidence Pepticulcerhemorrhage DoudenalulcerExposeulcerwithduodenotomyorduodenopyloromyotomyDirectsutureligation fourquadrentligation ligationofgastroduodenalarteryAnti secretoryprocedureTruncal parietalcellvagotomyIfunstablecanusemeds Pepticulcerhemorrhage Gastriculcer10 aremaliganant30 willrebleedwithsimpleligationNeedResectionDistalgastrectomywithBilrothIorIISubtotalgastrectomyfor10 highonlessercurve Varicealhemorrhage Cirrhoticsusually25 mortalityforeachbleedingepisode75 willrebleed50 mortalitywithsurgeryBasedonChild sclass Somatostatinorvasopressinw woNTG Shuntprocedures Sugiuraprocedure TIPS OthersourcesofUGIhemorrhage MucosallesionsGastritis ischemia stressulcerationKeyispreventionwithacidsupressionSurgeryoftenrequiresresectionandRoux en Yduetomultiplebleedingsites 50 mortalitywithsurgeryMallory Weiss10 willhavesignificantbleeding90 stopspontaneouslySurgeryrare butgastrotomywithoversewingeffectiveDieulafoy sWedgerxnafterendoscopicmarkingAortoentericfistula1 ofAAArepairpatientsHeraldbleedpreceedsexsangunationbyhourstodaysEndoscopyandifnegativeCTscanandifnegativeangiographySurgery graftremovalandextraanatomicbypass LGIhemorrhage SitesColon 95 97 Smallbowel 3 5 Only15 ofmassiveGIbleedingFindingthesiteIntermittentbleedingcommonUpto42 havemultiplesites Bleedingdiverticulosis Bleedingdiverticulosis Colonicangiodysplasia LGIhemorrhage EtiologyDiverticulosis 40 55 Rightsidedlesions left90 stopspontaneously10 rebleedin1styearand25 at4yearsAngiodysplasia 3 20 MostcommoncauseofSBbleedingin 50y o 50 areinrightcolonNeoplasiaTypicallybleedslowlyInflammatoryconditions15 ofUCpatients 1 ofchron spatientsRadiation infectious AIDSrarelyVascularHemorrhoids 50 havehemorrhoids butonly2 ofbleedingattributedtothemOthers LGIhemorrhage EvaluationSameforUGIbleedIfunstablewithhematochezianeedEGD1stAfterstableRectalAnoscopyforhemorrhoids LGIhemorrhagediagnostics ColonoscopyWithin12hoursinstablepatientswithoutlargeamountsofbleedingSelectiveviseralangiographyNeed 0 5ml minbleeding40 75 sensitiveifbleedingattimeofexamTaggedRBCscanCandetectbleedingat0 1ml min85 sensitiveifbleedingattimeofexamNotaccurateindefiningleftvsrightcolon Meckel sDiverticulum Cecalangiodysplasiawithextravasation SmallbowelulcerationduetoNSAIDS LGIhemorrhagetreatment EndoscopyGreatforangiodysplasiaandpolypectomysitesAngiographicSelectiveembolizationforpoorsurgicalcandidatesCanleadtoischemicsitesrequiringlaterresectionSurgeryOngoinghemorrhage 6unitsorongoingtransfusionrequirementSiteselectionBlindsegmentalwillrebleedin75 BasedonTRBCscanwillrebleedin35 GIhemorrhagefromunknownsource Only2 5 arenotupperorlowerAveragepatient26monthdurationofintermittentbleeding1 20diagnostictestsAverageof20unitstransfused LocalizationofGIHOUS CTscanTumors inflammation diverticuliEnteroclysisUlcerations inflammationOnly