Title upper git - URO mainly not GIT.pdf ✅

A 45 year old man has a 4 week history of epigastric discomfort which is relieved by eating. He develops haematemesis and undergoes an upper GI endoscopy. An actively bleeding ulcer is noted in the first part of the duodenum. What is the best management? Whipples procedure Truncal vagotomy and drainage Distal gastrectomy Injection with tranexamic acid Injection with adrenaline Current guidance is that bleeding peptic ulcers should be treated with dual therapeutic modalities. Adrenaline injection should be augmented with an additional therapy such as endoscopic clipping where this is available. Bleeding duodenal ulcers will usually undergo adrenaline injection. This may be augmented by the placement of endoscopic clips or heat therapy with endoscopic heater probes. Following these interventions patients should receive a proton pump inhibitor infusion. Those who re-bleed, may require surgery. For ulcers in this location, laparotomy, duodenotomy and under-running of the ulcer is usually performed. Upper gastrointestinal bleeding Patients may present with the following: Question 1 of 104   Please rate this question:  Discuss and give feedback Next question  gathered by dr. elbarky for free, and not intended for profit by anybody elsewhere.
Haematemesis and/ or malaena Epigastric discomfort Sudden collapse The extent to which these will occur will depend upon the source. Mortality is higher in patients presenting with haematemesis than malaena alone. Oesophageal bleeding Cause Presenting features Oesophagitis Small volume of fresh blood, often streaking vomit. Malaena rare. Often ceases spontaneously. Usually history of antecedent GORD type symptoms. Cancer Usually small volume of blood, except as pre terminal event with erosion of major vessels. Often associated symptoms of dysphagia and constitutional symptoms such as weight loss. May be recurrent until malignancy managed. Mallory Weiss Tear Typically brisk small to moderate volume of bright red blood following bout of repeated vomiting. Malaena rare. Usually ceases spontaneously. Varices Usually large volume of fresh blood. Swallowed blood may cause malaena. Often associated with haemodynamic compromise. May stop spontaneously but re-bleeds are common until appropriately managed. Gastric Bleeding Cause Presenting features Gastric cancer May be frank haematemesis or altered blood mixed with vomit. Usually prodromal features of dyspepsia and may have constitutional symptoms. Amount of bleeding variable but erosion of major vessel may produce considerable haemorrhage. Dieulafoy Lesion Often no prodromal features prior to haematemesis and malaena, but this arteriovenous malformation may produce quite considerable haemorrhage and may be difficult to detect endoscopically. Diffuse erosive gastritis Usually haematemesis and epigastric discomfort. Usually there is an underlying cause such as recent NSAID usage. Large volume haemorrhage may occur with considerable haemodynamic compromise. gathered by dr. elbarky for free, and not intended for profit by anybody elsewhere.
Gastric ulcer Small low volume bleeds more common so would tend to present as iron deficiency anaemia. Erosion into a significant vessel may produce considerable haemorrhage and haematemesis. Duodenum Most common cause of major haemorrhage is a posteriorly sited duodenal ulcer. However, ulcers at any site in the duodenum may present with haematemesis, malaena and epigastric discomfort. The pain of duodenal ulcer is slightly different to that of gastric ulcers and often occurs several hours after eating. Peri ampullary tumours may bleed but these are rare. In patients with previous abdominal aortic aneurysm surgery aorto-enteric fistulation remains a rare but important cause of major haemorrhage associated with high mortality. Management Admission to hospital careful monitoring, cross match blood, check FBC, LFTs, U+E and Clotting (as a minimum) Patients with on-going bleeding and haemodynamic instability are likely to require O negative blood pending cross matched blood Early control of airway is vital (e.g. Drowsy patient with liver failure) Patients with suspected varices should receive terlipressin prior to endoscopy Ideally all patients admitted with upper gastrointestinal haemorrhage should undergo Upper GI endoscopy within 24 hours of admission. In those who are unstable this should occur immediately after resuscitation or in tandem with it. The endoscopy department is a potentially dangerous place for unstable patients and it may be safer to perform the endoscopy in theatre with an anaesthetist present. Varices should be banded or subjected to sclerotherapy. If this is not possible owing to active bleeding then a Sengstaken- Blakemore tube (or Minnesota tube) should be inserted. This should be done with care; gastric balloon should be inflated first and oesophageal balloon second. Remember the balloon will need deflating after 12 hours (ideally sooner) to prevent necrosis. Portal pressure should be lowered by combination of medical therapy +/- TIPSS. Patients with erosive oesophagitis / gastritis should receive a proton pump inhibitor. Mallory Weiss tears will typically resolve spontaneously Identifiable bleeding points should receive combination therapy of injection of adrenaline and either a thermal or mechanical treatment. All who have received intervention should receive a continuous infusion of a proton pump inhibitor (IV omeprazole for 72 hours) to reduce the re-bleeding rate. Patients with diffuse erosive gastritis who cannot be managed endoscopically and continue to bleed may require gastrectomy Bleeding ulcers that cannot be controlled endoscopically may require laparotomy and ulcer underruning gathered by dr. elbarky for free, and not intended for profit by anybody elsewhere.
Indications for surgery Patients > 60 years Continued bleeding despite endoscopic intervention Recurrent bleeding Known cardiovascular disease with poor response to hypotension Surgery Duodenal ulcer Laparotomy, duodenotomy and under running of the ulcer. If bleeding is brisk then the ulcer is almost always posteriorly sited and will have invaded the gastroduodenal artery. Large bites using 0 Vicryl are taken above and below the ulcer base to occlude the vessel. The duodenotomy should be longitudinal but closed transversely to avoid stenosis. For gastric ulcer Under-running of the bleeding site Partial gastrectomy-antral ulcer Partial gastrectomy or under running the ulcer- lesser curve ulcer (involving left gastric artery) Total gastrectomy if bleeding persists Summary of Acute Upper GI bleeding recommendations: The need for admission and timing of endoscopic intervention may be predicted by using the Blatchford score. This considers a patients Hb, serum urea, pulse rate and blood pressure. Those patients with a score of 0 are low risk, all others are considered high risk and require admission and endoscopy. The requirement for pre endoscopic proton pump inhibition is contentious. In the UK the National Institute of Clinical Excellence guidelines suggest the pre endoscopic PPI therapy is unnecessary. Whilst it is accepted that such treatment has no impact on mortality or morbidity a Cochrane review of this practice in 2007 did suggest that it reduced the stigmata of recent haemorrhage at endoscopy. As a result many will still administer PPI to patients prior to endoscopic intervention. Following endoscopy it is important to calculate the Rockall score for patients to determine their risk of rebleeding and mortality. A score of 3 or less is associated with a rebleeding rate of 4% and a very low risk of mortality and identifies a group of patients suitable for early discharge. References 1. http://www.sign.ac.uk/guidelines/fulltext/105/index.html 2. Joint Advisory Group on Endoscopy (JAG) Guidelines - http://www.thejag.org.uk 3. NICE Guideline: Management of acute upper GI bleeding. July 2012. Next question  gathered by dr. elbarky for free, and not intended for profit by anybody elsewhere.