2012-9-27 Etiology High risk patients GI bleeding lificant GI bleeding olie blood pressure below 100mmHg Vascular malformation Rectal Admitted for other medical problems and developed GI bleeding during hospitalization High risk peptic ulcers RESUSCITATION Localized active bleeding s Vital signs and urine output should be carefully monitored replacemare peripheral drip should be inserted for fluid m A central line would be useful for patients in shock. Evidence of substantial volume loss- blood transfusion s A joint team of gastroenterologists, GI surgeons and tervention radiologists should manage a patient with GI rrhage are important predictors of recurred THERAPY PHARMOCOLOGICAL THEI Pharmacological therapy ceptor antaganists a Radiological therapy mp inhibitors(PPI): omeprazole, est Surgery otide)red ntifibrinolytic agents(recombinant activated factor VIl) n Antibiotics- variceal bleeding halospurin2012-9-27 3 www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 Etiology Upper GI bleeding Lower GI bleeding Common Gastric/duodenal ulcer Esophageal/gastric varices Angiodysplasia Hemorrhoids Less common Gastroduodenal erosions Esophagitis Mallory Weiss tear Colonic neoplasms IBD Ischemic colitis Radiation colitis Diverticular disease Rare Upper GI malignancy Vascular malformation Colonic ulcers Rectal varices www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 High risk patients  Significant GI bleeding – Syncope – Haematemesis – Systolic blood pressure below 100mmHg – Postural hypotension – 4 units of blood have to be transfused in 12 hours to maintain blood pressure  Patients over 60 years old and with multiple underlying diseases  Admitted for other medical problems and developed GI bleeding during hospitalization www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 High risk peptic ulcers  High risk peptic ulcers and those actively bleeding or have bled recently may show stigmata of haemorrhage on endoscopy. – Locoalized active bleeding  Pulsatile  Arteiral spurting  Simple oozing – Have bled recently  Adherent blood clot  Protuberant vessel  Flat pigmented spot on the ulcer base  Stigmata of haemorrhage are important predictors of recurrent bleeding. www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 RESUSCITATION  Irrespective of the underlying cause of gastrointestinal bleeding, a patient should be resuscitated.  Vital signs and urine output should be carefully monitored.  A large bore peripheral drip should be inserted for fluid replacement.  A central line would be useful for patients in shock.  Evidence of substantial volume loss- blood transfusion.  A joint team of gastroenterologists, GI surgeons and intervention radiologists should manage a patient with GI bleeding. www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 THERAPY  Pharmacological therapy  Endoscopic hemostasis  Radiological therapy  Surgery www.zshospital.com Hong Shi, Department of Gastroenterology & Hepatology, Zhongshan Hospital 复 旦 大 学 附 属 中 山 医 院 消 化 科 PHARMOCOLOGICAL THERAPY  Acid-suppressing drugs -effective drugs to promote ulcer healing  H2-receptor antagonists  Proton pump inhibitors (PPI) : omeprazole, esomeprazole and pantoprazole  Vasoactive agents  vasopressin (cardiac ischaemia, worsening coagulopathy)  Terlipressin (used in combination with glyceryl trinitrate)  Somatostatin (octreotide, vapreotide) reduces portal blood pressure and azygous blood flow  Antifibrinolytic agents (recombinant activated factor VII)  Antibiotics- variceal bleeding  Cephalosporin  quinolone