Keterangan
The term "non-variceal upper gastrointestinal bleeding" (UVIB) refers to bleeding close to the ligament of Treitz that is not caused by oesophageal, gastric, or duodenal varices. It might be a life-threatening incident, especially in elderly people with comorbidities. Non-variceal UGIB is mostly brought on by peptic ulcer bleeding. The primary risk factors for UGIB include the use of non-steroidal anti-inflammatory medicines, low-dose aspirin usage, and Helicobacter pylori infections. The therapeutic management of NVUGIB is challenging due to the requirement to balance the risk of gastrointestinal bleeding episodes and adverse cardiovascular events in an older population treated with antiplatelet and/or anticoagulant medicines.
Ringkasan
- The speaker discusses the management of acute upper gastrointestinal (GI) bleeding, focusing on non-variceal bleeds. The definition of acute GI bleed includes visible blood (overt), potential hemodynamic instability, and the need for transfusion. Overt GI bleeding is characterized by visible blood, while occult bleeding is detected only by lab tests and typically managed as an outpatient. Lower GI bleeds originate distal to the ligament of Treitz.
- The incidence of upper GI bleeds is decreasing globally due to improved *H. pylori* treatment, increased use of PPIs, and better management of NSAID use. Mortality rates are higher for upper GI bleeds compared to lower GI bleeds. Peptic ulcer disease remains a common cause, although its prevalence is shifting with decreasing *H. pylori* related cases and increasing NSAID-induced ulcers.
- Initial management involves hemodynamic stabilization, IV access, and resuscitation. A restrictive transfusion strategy, maintaining hemoglobin above 7 g/dL (or 8 g/dL in high-risk patients), is favored over liberal transfusion. Nasogastric (NG) tube placement is crucial for assessment, although a clear aspirate doesn't always rule out bleeding.
- Early risk stratification using scores like the Glasgow-Blatchford score helps determine the urgency of endoscopy. Endoscopy is generally preferred within 24 hours. The speaker details the Forrest classification of ulcer stigmata, guiding treatment decisions. High-dose PPIs are indicated for Forrest Ia, Ib, IIa, and IIb lesions.
- Endoscopic therapy includes injection of epinephrine, thermal coagulation (APC or bipolar cautery), and clipping. Triple therapy (injection, cautery, and clipping) is often used. Adherent clots should be removed before treatment. Doppler-assisted techniques can identify bleeding vessels. Newer techniques include over-the-scope clips and hemostatic sprays like Hemospray, often used for rescue treatment.
- Post-endoscopic care involves PPIs and careful consideration of restarting anticoagulants. A multidisciplinary approach is crucial, involving gastroenterologists, surgeons, medical oncologists, and radiation oncologists. Artificial intelligence and deep learning algorithms are being developed to better predict which patients can be safely discharged after an upper GI bleed.
- The discussion includes the specific challenges of managing GI bleeds in patients with chronic kidney disease, those on antithrombotic agents, and those with gastric cancer. For cancer patients, hemostatic sprays like Hemospray are often used as a palliative measure. Ultimately, the speaker encourages discussion and sharing of management perspectives from participants worldwide.
Contoh Sertifikat
Tentang Pembicara
Dr Sushovan Guha
Professor Of Medicine, McGovern Medical School Division Of Gastroenterology, Hepatology And Nutrition; Depart Of Internal Medicine Co-Director, Center For Interventional Gastroenterology At UTHealth (IGUT)
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