Upper GI Bleeding上消化道出血英文版

1、Upper GI BleedingUpper GI BleedingTad Kim, M.D.UF S(c) 682-3793; (p) 413-3222Upper GI BleedingOverview Definitions Initial Patient Assessment ABC & Resuscitation Differential Diagnosis Identify the Source & Stop the Bleeding History & Physical Endoscopy & Potential Compli

2、cations Other diagnostics tests Role of Surgery PreventionUpper GI BleedingDefinitions Upper GI Bleeding = proximal to ligament of Treitz Hematemesis = vomiting blood This is diagnostic of upper GI bleeding Melena = passage of tarry or maroon stool Can be upper or lower (more commonly upper) Hematoc

3、hezia = Bright red blood per rectum Usually characteristic of colonic hemorrhageUpper GI BleedingInitial Patient Assessment Get to patients bedside, assess ABC Can the patient protect his airway? Does he need to be intubated? Is the patient hemodynamically unstable? Is he in hemorrhagic shock? 2 lar

4、ge bore IV, Bolus 2L fluids, Type & Cross blood, send CBC & Coags Place patient on O2 & continuous monitor Place an NGT and lavage with NS To confirm if the bleeding source is upper GIUpper GI BleedingDifferential Diagnosis Peptic Ulcer Disease (PUD) 50% cases Gastritis / Duodenitis (15-30%) Subset

5、due to NSAID use Varices from portal hypertension (10-20%) Mallory-Weiss tears at GE junction (5%) Esophagitis (3-5%) Malignancy (3%) Dieulafoys lesion (1-3%) Nasopharyngeal bleed swallowed blood Other- Aortoenteric fistula, angiodysplasia, Crohns, hemobilia, hemosuccus pancreaticusUpper GI Bleeding

6、History & Physical History of prior ulcers, NSAID use, stress History of Helicobacter pylori & treatment Alcohol abuse Retching - Mallory Weiss tear Alcoholic cirrhosis - portal hypertension and varices On Physical Exam, assess hydration Look for stigmata of cirrhosis & portal HTNUpper GI BleedingMa

7、nagement Acute UGI Bleed Once again, make sure pt is resuscitated If anemic and symptomatic, give blood Place NGT/lavage (helps for endoscopy) Perform Upper endoscopy (EGD) For ulcers: if visible clot, visible vessel, or active bleeding, should cauterize/coagulate and inject sclerosing agent For acu

8、te variceal bleeding: sclerotherapy + somatostatin or endoscopic band ligation. If fail/rebleed: TIPS vs surgical shunt. Balloon tamponade is an emergency temporizing measure Start proton pump inhibitor (PPI) infusionUpper GI BleedingPotential Complications Perforation of esophagus Aspiration Desatu

9、ration or respiratory distress Adverse reaction to conscious sedation risk of complications with: Inadequate resuscitation or hypotension Comorbidities Consider elective intubation prior to EGD if active bleeding, altered respiratory or mental statusUpper GI BleedingOther Diagnostic Tests If bleedin

10、g is unresolved with endoscopy or endoscopy is contraindicated 1. Angiography (Diagnostic & Therapeutic) Intra-arterial vasopressin Embolization 2. Tagged red blood cell (TRBC) scan Only diagnostic & usually for occult bleeding More sensitive than angiography Can detect bleeding rate of 0.1-0.5 mL/m

11、inUpper GI BleedingRole of Surgery If medical and endoscopic therapy fail In the event that bleeding source is unidentified - exploratory laparotomy Recurrent bleeding peptic ulcers Anti-ulcer surgery (i.e. vagotomy/antrectomy, or vagotomy/pyloroplasty, or selective vagot)Upper GI BleedingPrevention

12、 After the acute situation is resolved, educate patient on preventive measures Top 2 reasons for ulcers: Hpylori & NSAID 1. Testing for H.pylori (i.e. antral biopsy during endoscopy) 2. Treat H.pylori (amoxicill, clarithromycin x1wk plus PPI x4wk) 3. Reduce intake of NSAIDUpper GI BleedingTake Home Points Always, always perform ABCs first & resuscitate with two #16ga IVs & isotonic crystalloids (blood if pt doesnt respond) NGT/lavage to confirm active bleeding Focused H&P looking for common causes: u