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UpperGIBleeding,TadKim,M.D.UFS(c)682-3793;(p)413-3222,Overview,DefinitionsInitialPatientAssessmentABC&ResuscitationDifferentialDiagnosisIdentifytheSource&StoptheBleedingHistory&PhysicalEndoscopy&PotentialComplicationsOtherdiagnosticstestsRoleofSurgeryPrevention,Definitions,UpperGIBleeding=proximaltoligamentofTreitzHematemesis=vomitingbloodThisisdiagnosticofupperGIbleedingMelena=passageoftarryormaroonstoolCanbeupperorlower(morecommonlyupper)Hematochezia=BrightredbloodperrectumUsuallycharacteristicofcolonichemorrhage,InitialPatientAssessment,Gettopatientsbedside,assessABCCanthepatientprotecthisairway?Doesheneedtobeintubated?Isthepatienthemodynamicallyunstable?Isheinhemorrhagicshock?2largeboreIV,Bolus2Lfluids,Type&Crossblood,sendCBC&CoagsPlacepatientonO2&continuousmonitorPlaceanNGTandlavagewithNSToconfirmifthebleedingsourceisupperGI,DifferentialDiagnosis,PepticUlcerDisease(PUD)50%casesGastritis/Duodenitis(15-30%)SubsetduetoNSAIDuseVaricesfromportalhypertension(10-20%)Mallory-WeisstearsatGEjunction(5%)Esophagitis(3-5%)Malignancy(3%)Dieulafoyslesion(1-3%)NasopharyngealbleedswallowedbloodOther-Aortoentericfistula,angiodysplasia,Crohns,hemobilia,hemosuccuspancreaticus,History&Physical,Historyofpriorulcers,NSAIDuse,stressHistoryofHelicobacterpylori&treatmentAlcoholabuseRetching-MalloryWeisstearAlcoholiccirrhosis-portalhypertensionandvaricesOnPhysicalExam,assesshydrationLookforstigmataofcirrhosis&portalHTN,ManagementAcuteUGIBleed,Onceagain,makesureptisresuscitatedIfanemicandsymptomatic,givebloodPlaceNGT/lavage(helpsforendoscopy)PerformUpperendoscopy(EGD)Forulcers:ifvisibleclot,visiblevessel,oractivebleeding,shouldcauterize/coagulateandinjectsclerosingagentForacutevaricealbleeding:sclerotherapy+somatostatinorendoscopicbandligation.Iffail/rebleed:TIPSvssurgicalshunt.BalloontamponadeisanemergencytemporizingmeasureStartprotonpumpinhibitor(PPI)infusion,PotentialComplications,PerforationofesophagusAspirationDesaturationorrespiratorydistressAdversereactiontoconscioussedationriskofcomplicationswith:InadequateresuscitationorhypotensionComorbiditiesConsiderelectiveintubationpriortoEGDifactivebleeding,alteredrespiratoryormentalstatus,OtherDiagnosticTests,Ifbleedingisunresolvedwithendoscopyorendoscopyiscontraindicated1.Angiography(Diagnostic&Therapeutic)Intra-arterialvasopressinEmbolization2.Taggedredbloodcell(TRBC)scanOnlydiagnostic&usuallyforoccultbleedingMoresensitivethanangiographyCandetectbleedingrateof0.1-0.5mL/min,RoleofSurgery,IfmedicalandendoscopictherapyfailIntheeventthatbleedingsourceisunidentified-exploratorylaparotomyRecurrentbleedingpepticulcersAnti-ulcersurgery(i.e.vagotomy/antrectomy,orvagotomy/pyloroplasty,orselectivevagot),Prevention,Aftertheacutesituationisresolved,educatepatientonpreventivemeasuresTop2reasonsforulcers:Hpylori&NSAID1.TestingforH.pylori(i.e.antralbiopsyduringendoscopy)2.TreatH.pylori(amoxicill,clarithromycinx1wkplusPPIx4wk)3.ReduceintakeofNSAID,TakeHomePoints,Always,alwaysperformABCsfirst&resuscitatewithtwo#16gaIVs&isotoniccrystalloids(bloodifptdoesntrespond)NGT/lavagetoconfirmactivebleedingFocusedH&Plookingforcommoncauses:ulcers,var
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