विवरण
With a mortality rate of 2-10%, upper gastrointestinal bleeding (UIB) is a frequent medical emergency. Patients who have been determined to have a very low risk of dying or needing an intervention can be treated as outpatients. Red cell transfusion at a hemoglobin level of 70–80 g/L and intravenous fluids as needed for resuscitation are advised for all other patients. Proton pump inhibitors (PPIs) and the prokinetic drug erythromycin may be delivered when resuscitation is started, with antibiotics and vasoactive medications advised in patients with cirrhosis. Endoscopy should be performed within 24 hours, with early endoscopy being explored in high-risk patients, such as those with hemodynamic instability, following resuscitation.
सारांश
- The presentation focuses on the endoscopic management of acute upper gastrointestinal (GI) bleeds, distinguishing between variceal and non-variceal bleeds. While fluid resuscitation remains a common aspect of the basic management, the pre and post endoscopic procedures are different in both these conditions. It also highlights the importance of differentiating between elective and emergency endoscopy based on the severity and urgency of the bleed.
- The speaker emphasizes the significance of thorough history taking in determining the source and potential causes of the bleed. A good history should include a history of previous GI bleeds, the presence of varices, use of NSAIDs or antithrombotics, or suspicion of malignancy. This information will help in planning the endoscopic procedure and choosing the appropriate accessories.
- Risk stratification is crucial in determining the urgency of the endoscopy and the level of care required, such as ICU admission or blood transfusion. The Glasgow Blatchford score is a commonly used tool for risk assessment, incorporating factors like blood urea nitrogen, blood pressure, and heart rate. Active bleeding, large ulcers, and specific ulcer locations (posterior duodenal bulb, high lesser gastric curvature) are identified as risk factors during endoscopy.
- Management strategies for upper GI bleeds are discussed, including fluid resuscitation, blood transfusions, and the appropriate use of proton pump inhibitors (PPIs). It underscores the need for restrictive blood transfusions and considering anti-thrombotic agents. The speaker clarifies the indications for nasogastric aspiration and endotracheal intubation in massive GI bleeds.
- The timing of endoscopy is crucial, with urgent endoscopy (within 12 hours) recommended for massive GI bleeds with unstable vitals or altered consciousness. The Forrest classification is presented as a guide for endoscopic assessment and treatment decisions. Various endoscopic methods for controlling bleeding are described, including injection sclerotherapy, clipping, and coagulation, tailored to the specific cause and location of the bleed.
- Post-endoscopic management includes continuing PPI therapy, monitoring for rebleeding, and testing for Helicobacter pylori in cases of peptic ulcer bleed. The speaker emphasizes the importance of eradicating H. pylori to prevent recurrent bleeds. Surgical intervention is reserved for cases where endoscopic and medical management fail.
- Variceal bleeds require a distinct approach, including antibiotic prophylaxis with third-generation cephalosporins and the use of vasopressin analogues. Endoscopic banding is the preferred method for esophageal varices, while glue injection is used for gastric varices. In cases of failed endoscopic control, transjugular intrahepatic portosystemic shunt (TIPS) may be considered to reduce portal pressure and control bleeding.
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