Description
Upper gastrointestinal (GI) bleeding refers to bleeding that occurs anywhere in the esophagus, the stomach, or the upper part of the small intestine. Upper GI bleeds occur when part of the upper digestive tract becomes injured or inflamed. Acute bleeds are sudden and severe, while chronic bleeding lasts for a longer period and is typically less obvious.
Join us in this session with Dr.C.G Sridhar, Senior Gastroenterologist and Interventional Endocrinologists to know more about Upper GI bleeding and its diagnostic approach.
Résumé
- GI bleeding is a critical healthcare issue with interventions often being the cornerstone of emergency management. Early recognition, diagnosis, and appropriate management are essential for patient survival.
- Initial patient evaluation requires a detailed history, including medication use (especially antiplatelet therapy and NSAIDs), prior GI issues, and alcohol consumption. The presentation can manifest as hematemesis, melena, or hematochezia, each indicative of different severities and locations of bleeding.
- Differentiating between variceal and non-variceal bleeding is crucial. Non-variceal causes include peptic ulcers, erosive gastritis, Mallory-Weiss tears, and malignancies. Variceal bleeding, often associated with chronic liver disease, can be the first sign of the condition.
- Assessing the degree of blood loss is vital. Orthostatic hypotension and tachycardia indicate significant blood loss requiring immediate intervention. Endoscopy within 24 hours after clinical stabilization is the gold standard for diagnosis and therapeutic intervention.
- Endoscopic findings guide treatment. Active bleeding or non-bleeding vessels with stigmata of recent hemorrhage warrant immediate intervention. Options include clipping, ablation with argon plasma coagulation (APC), or injection therapy. Adherent clots may need dislodgement to assess the underlying lesion.
- Variceal bleeding management involves stabilizing the patient, often with intubation, and endoscopic band ligation to occlude the varices. In cases of fundal varices, cyanoacrylate (glue) injection can be performed, potentially with endoscopic ultrasound guidance.
- For uncontrolled variceal bleeding, a self-expanding metal stent can act as a tamponade, serving as a bridge to more definitive therapies like TIPS (transjugular intrahepatic portosystemic shunt) or liver transplantation.
- Interventional radiology offers options like balloon-occluded retrograde transvenous obliteration (BRTO) for gastric varices with a gastrorrenal shunt, but this requires careful patient selection and anatomical assessment.
- Portal hypertension is a key pathophysiological factor. Management includes non-selective beta-blockers (propranolol or carvedilol) to reduce portal pressure and vasoconstrictors like terlipressin or octreotide during acute bleeds.
- Transfusion should be restrictive, targeting a hemoglobin level of 7-8 g/dL to avoid over-transfusion-related complications. INR correction with FFP is generally not recommended in variceal bleeding.
- Post-banding, endoscopic surveillance is crucial to ensure variceal eradication. The Baveno criteria offer non-invasive alternatives to endoscopy for primary prophylaxis in certain patients based on liver stiffness measurements and platelet counts.
- Risk stratification for re-bleeding is essential. Factors like older age, renal failure, severe bleeding, thrombocytopenia, and end-organ damage increase the risk. Patients at high risk require closer monitoring and more aggressive management.
- TIPS is a salvage therapy for uncontrolled variceal bleeding but has a poor prognosis in patients with advanced liver disease. Liver transplantation is often the definitive treatment for variceal bleeding in patients with cirrhosis.
Exemple de certificat
À propos des intervenants
Dr.C.G Sridhar
Chirurgien gastro-intestinal, directeur des cliniques Edusurg | Mumbai et Navi Mumbai
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