3. Introduction
• PUD is the most common cause of non-variceal bleeding.
• Account for 40-50% of UGIB.
• Bleeding is the most common cause of ulcer-related death.
Fortunately 80% of bleeding pud stop spontaneously and not rebleed.
• Most mortality occurred in high risk patients.
• Overall mortality rate 5 to 10%.
• Need for selection of high risk patients.
5. Clinical Presentation
• Hematemesis and melena and sometime hematochezia
• Resting tachycardia(HR> 100bpm), or
• orthostatic changes (HR >20bpm or SBP lower by 20mmHg on standing).
6. Pre-endoscopic Management
• Airway control and protection (in high risk of aspiration).
• Volume resuscitation with crystalloid fluid and blood.
• Gastric lavage using Naso/Orogastric tube which is diagnostic and facilitate future
endoscopic visualization. 15% will have no bloody or coffee ground material on
NGT-aspirates are found to have high risk lesions on endoscopy
• Promotility agent such as iv erythromycin 250mg 30min to 60minutes before
endoscope/metoclopramide prior to endoscope help clearance of upper git.
7. Cont…
• High dose PPI infusion reduces the severity of bleeding and the need
for endoscopic treatment.
• Correct coagulopathy if present INR<1.5 and Platelet>50x109/l.
• Obtain the initial CBC, Electrolytes, RFT and cross-match blood
• Transfusion of Blood product 1:1:1.
8. Cont…
• Most patient the bleeding will stop except for 20% of high risk patients which
predispose to rebleeding.
• Rebleeding rate after endoscopic therapy 5-20%.
• Features for high risk of severe UGIB include:
• Age older than 60 years
• Concomitant liver disease
• Witness hematemesis or hematochezia (ongoing bleeding)
• Hemodynamic unstable during presentation
• Onset in the hospital
• Large PUD > 2 cm
• These patients require early endoscopy.
9. Indications
• After adequate resuscitation and within 24 hour after initial bleeding.
• Emergency endoscopy required if hemodynamically unstable after resuscitation.
10.
11. Risk assessment
1. Rockall score:
Good for prediction of mortality and rebleeding in patient with Upper GI bleeding.
Score of 0 indicate the extremely low risk of rebleed or death and may be suitable
for early discharge or no admission (pre-endoscopic)
Score Value of <3 post-endoscopic have a low risk to rebleeding or death and can be
considered for early discharge
2Score <2 mean low risk of adverse outcome.
13. 2. Glasgow Blatchford score
Glasgow Blatchford score can be used to predict rebleeding and the
need for endoscopic therapy.
The score range from 0-23, with higher scores corresponding to
increasing acuity and mortality.
A score of O indicates the low risk to complications and need to be
discharged or no need for admission.
15. • During endoscopic the lesion may be classified according to stigmata
or recent hemorrhage which predict the rate of rebleeding.
• In patient with major stigmata of recent hemorrhage (active arterial
spurt, oozing and visible nonbleeding vessel have a high risk of
rebleeding
• Need Endoscopic hemostasis treatment , significantly reduces rates of
rebleeding, blood transfusions requirement, and need for surgical
intervention.
16.
17.
18.
19. Endoscopic hemostasis
• Categorized into three:
Injection therapy
Thermal hemostasis
Mechanical hemostasis
• Combination of these method achieve best outcome.
20. Injection therapy
• Most commonly practiced hemostasis.
Include the use of diluted epinephrine, absolute alcohol, thrombin, and
fibrin sealant.
1. Diluted Epinephrine 1:10000-1:100000,injected submucosally;
work by local tamponade on vessel and vasoconstrictive effect.
• Larger volume injection 13-20ml more effective in preventing
rebleeding compared to small volume 5ml.
• It is safe to the tissues systemic complication rare but caution in
patient with Liver disease or ischemic heart disease.
21.
22.
23.
24. 2. Sclerotherapy
Injection of sclerosant:
polidocanol,
ethanolamine,
sodium tetradecyl sulfate (STD), and
absolute ethanol.
• Cause tissue necrosis and ulceration. The effect more with increasing
dose hence they have limited volume.
25. Thrombin and Fibrin sealant
• Fibrin sealant consists of two components: fibrinogen and thrombin
(reconstituted with calcium chloride solution and aprotinin).
26.
27. • In ulcers with active bleeding, preinjection with epinephrine is
required.
• Four quadrants around the bleeding point are injected, each with
0.5mL of fibrinogen and thrombin (a total of 1mL fibrin sealant).
• After each injection, with the needle remaining in tissue, the
reconstituted sealant is immediately followed by 1.0–1.5mL of normal
saline in order to drive the sealant submucosally.
• Following four-quadrant injection, the bleeding point is then injected.
28. Thermal method
• Two methods
• Contact method heater probe and multipolar probe
• Non-contact neodymium: yttrium-aluminum-garnet laser and argon plasma
coagulation.
1. Contact methods using coaptive coagulation involved the use of a hemostat to
tamponade blood flow and coapt the vessel walls, followed by the application of
cautery to thermally seal the vessel.
• Effectively in sealing medium size arteries up to 2 mm in diameter.
29.
30.
31.
32. CONT…
2. Non-contact method Argon plasma coagulation (APC) and laser deliver thermal
energy without contacting the tissue.
• Heating of tissue protein, contraction of the arterial wall, and vessel shrinkage.
However, there is a “heat-sink” effect from flowing arterial blood, leading to the
dissipation of thermal energy.
• Less effective for vessels >0.25mm and deeper bleeding. The burn is superficial
hence less risk for perforation but complications git overdistention.
33. Mechanical
• Endoscopic clip provide direct tissue approximation and superficial vessel closure.
• Clips are loaded through the instrument channel and are generally made of a two-
pronged metal clip attached to a deployment handle that allows opening, closing,
and firing of the clip.
• The handles allow rotation of the clip to facilitate positioning.
34.
35.
36. What is the role of second-look endoscopy in the
treatment of upper gastrointestinal bleeding
(UGIB)?
• A second attempt at endoscopic control is warranted if the initial
endoscopy fails to control the bleeding.
• Some authorities have concerns about the perils of a second
esophagogastroduodenoscopy (EGD), which may result in delayed surgery,
perforation, and increased morbidity and mortality.
• However, this approach has been validated in a large, randomized,
controlled trial that showed decreased morbidity and mortality
• Controversial, may be considered in select group of patients.
• For example obscured vision, inadequate endoscopic therapy.
37. References
• Shackelford surgery of alimentary tract 8th edition
• Gastrointestinal endoscopy in practice
• Gastroenterological endoscope 2nd edition
Notas do Editor
The score less than 2 meaning low rate of bleeding, recurrence and mortality.
