GI BLEED FOR NURSES.ppt
- 1. Management of Upper Gastrointestinal Bleeding in A&E Basildon and Thurrock University Hospital NHS Trust M Rasool Aljabiri
- 2. Perspective • Integrated care pathway (ICP) • Multidisciplinary • To incorporate latest BSG & JAG guidelines • Evidence Based • Streamline management & admission avoidance • Audit morbidity & mortality Approved • Aim is to update our nurses on management o UGIB • Morbidity • Mortality
- 3. Gastrointestinal Bleeding • Objectives of the Presentation: • A ‘nuts and bolts” review of GI bleeding: presentation approach to the patient, aetiologies • Role of endoscopy in triage of patients with UGI bleeding
- 4. Gastrointestinal Bleeding • Voltaire, 1786 – ……..”the art of medicine is to amuse the patient while nature heals the disease”
- 5. Gastrointestinal Bleeding • Introduction: – GI bleeding is a common disorder that troubles all medical/surgical specialties – UGI bleeding>LGI bleeding – Prevalence: 170 cases/100K adults/yr – Cost estimate: £7B/yr (USA) – 6%-8% mortality (10%) (unchanged since 1945) – Severity: acute/chronic/intermittent/occult
- 6. MWS
- 7. Gastrointestinal Bleeding • UGI bleeding (2225 patients): – Diagnoses: % • DU 24.3 • Gastric erosion, “itis” 23.4 • GU 21.3 • Varices 10.3 • M-W tear 7.2 • Esophagitis 6.3 • Duodenitis 5.8 • Neoplasm 2.9 • Esophageal ulcer 1.7 • Other 8.0
- 8. Gastrointestinal Bleeding • Presentation of bleeding: – Hematemesis-UGI source – Melena-UGI source usually but 5% can be from LGI source – Hematochezia (BRBPR)-LGI source usually but 15% from UGI source – Occult-UGI or LGI source
- 9. Gastrointestinal Bleeding • UGI vs LGI location determined by the Ligament of Treitz: – UGI – proximal to LT • *Oesophagus, *stomach, *duodenal bulb, 2nd/3rd portion of duodenum – LGI – distal to LT • Small bowel, *colon
- 10. Gastrointestinal Bleeding • Determine the urgency of the clinical situation: – Is the patient in shock? • 40% loss of circulating blood volume • Agitation, pallor, tachycardia, hypotension – Is the patient orthostatic? • 20% loss of circulating blood volume • Postural hypotension – Never rely on initial H/H values to asses amount of blood loss (hemoconcentration)
- 11. YOU Believe me am a DOCTOR
- 12. Gastrointestinal Bleeding • Initial management of GI bleeding: – History/physical exam – Replace intravascular volume – Nasogastric intubation – Supplemental nasal oxygen – Laboratory evaluation: CBC/platelets/INR/PTT/BUN/creatinine – Asses need for admission to hospital
- 13. Endoscopic appearance at 17 cm Tongue of tissue at posterior aspect of oesophagus Endoscopic appearance at 34 cm Bx taken
- 14. Management of Upper GI Bleeding in A&E • Triage & Resuscitation • Identifying likely variceal bleeds • Stratifying high from low risk bleeds – Rockall Score
- 15. Gastrointestinal Bleeding • Prognostic factors in UGI bleeding: • severity of initial bleed • age of patient • co-morbidities • onset of bleeding in hospital • giant ulcer seen at endoscopy • endoscopic stgimata present at endoscopy • need for emergency surgery
- 16. Gastrointestinal Bleeding • Diagnostic/therapeutic modalities: – Endoscopy – upper/lower – Radionuclide scanning – Angiography – Capsule endoscopy (not in acute situation) – NEVER EVER USE BARIUM IN ACUTE GI BLEEDING
- 17. VON MIKULICZ SCOPE 1880
- 18. Gastrointestinal Bleeding • UGI bleeding: – Finding % rebleed % mortality • Active bleeding 55 11 • Visible vessel 43 11 • Adherent clot 22 7 • Flat, pigment spot 10 3 • Clean based ulcer <5 2 – Lane, et al. 1994, NEJM, 31: 717-27
- 19. Gastrointestinal Bleeding • Uncommon etiologies of UGI bleeding: – GAVE (gastric antral vascular ectasia) – Dieulafoy’s lesion (vessel without ulcer base) – Portal hypertensive gastropathy – Aorto-enteric fistula Hematobilia – UGI GIST tumor
- 20. GAVE (gastric antral vascular ectasia)
- 21. Dieulafoy’s lesion (vessel without ulcer base)
- 24. Hematobilia
- 25. UGI GIST tumor
- 26. Gastrointestinal Bleeding • UGI bleeding in portal hypertension: Varices – High mortality on first bleed, 70% rebleed rate in next 12 months – Start IV Terlipressin in all suspected PHT bleeds – Endoscopic ligation is procedure of choice (prophylactic banding is standard of care, surveillance for variceal recanalization) – TIPS for endoscopy failures – Surgical (shunts, transection, splenectomy
- 27. Gastrointestinal Bleeding • Special considerations in UGI bleeding: – Evaluate and treat Helicobacter pylori infections in the peptic disorder – Keep Nsaid’s in mind in all patients (the cause of non- healing until proven otherwise) – Stress related mucosal disease (SRMD) in hospitalized patients with non-bleeding illnesses – Suppress gastric acid secretion – Correct coagulopathy in most cases
- 28. Management Non-variceal bleeding Variceal bleeding (Sengstaken Blakemore tubes) Endoscopy Timing Site Staffing/support (Post endoscopic care)
- 29. Resuscitation • Airway • Breathing • Circulation 1. Insert 2 large bore cannulae 2. Correct fluid losses 3. Restore Blood Pressure 4. Send blood for FBC, clotting, U&E & LFTs. 5. Group & Save & Crossmatch • 6 units for suspected variceal bleeding • 4 units if haematemesis/melaena or if BP<100 mmHg systolic • Otherwise group & save
- 30. Identifying possible variceal bleeds Varices develop as a complication of portal venous hypertension & portal venous collateral flow in liver disease • Is there any history of liver disease? • Is there a history of alcoholism or viral hepatitis? • Are there any stigmata of chronic liver disease on examination?
- 31. Stigmata of chronic liver disease
- 32. If stigmata of chronic liver disease then treat as high risk variceal bleed until proven otherwise Give 2mg terlipressin (glypressin) iv as bolus If evidence of ischaemia on ECG or history of peripheral vascular disease, then give octreotide instead (50 mcg bolus followed by 50 mcg/hour as infusion)
- 34. If initial Rockall Score is ≥ 3 or assumed variceal bleed: High Risk 1. Immediately inform medical SpR on call who should discuss with gastro SpR on call via switchboard. If the bleed is suspected to be from an ulcer, then the surgical SpR should also be informed. 2. Give colloid whilst waiting for blood, if shocked. 3. Insert urinary catheter and consider inserting CVP line. 4. Give 1 pool of platelets if platelet count < 50,000 and 2 units of FFP if INR >1.5. 5. Endoscopy should only be considered once the patient has been suitably resuscitated & only if this can be done in a safe and supported environment.
- 35. If initial Rockall Score is 1 or 2: Low Risk 1. Admit to general medical ward. 2. Regular observations & stool chart. 3. Start oral omeprazole 20mg or lansoprazole 30mg once daily. 4. Plan for endoscopy to be done on the next available ‘in hours’ list.
- 36. If initial Rockall Score is 0 (and Hb >10 g/dl) : Very low risk • Discuss with on-call gastro SpR via switchboard - consider early discharge with outpatient endoscopy where indicated. • Start oral omeprazole 20mg or lansoprazole 30mg once daily.
- 37. Endoscopy: Site • If the patient has a suspected variceal bleed or is unstable the endoscopy should be performed in ICU or theatres (many of the nurses in theatres are trained to assist with endoscopic procedures) with anaesthetic support. • The consultant gastroenterologist on call should be made aware and a suitably trained nurse should be present to assist with any endoscopic interventions.
- 38. Endoscopy: timing The patient should be as optimally resuscitated as possible and the endoscopy arranged within 4 hours if Rockall Score ≥3. In the case of a suspected variceal bleed endoscopy should be done ASAP.
- 39. Endoscopy: support The airway should be protected by elective intubation if there is: • Severe uncontrolled bleeding • Severe encephalopathy • Inability to maintain O2 saturation >90% • Aspiration pneumonia
- 40. Uncontrolled variceal bleeding • If the bleeding is uncontrolled (either pre- or post endoscopy) and presumed to be variceal in origin then a Sengstaken Blakemore tube should be inserted.
- 42. Ideally the patient should be intubated to protect the airway prior to insertion
- 43. Pre/Post Endoscopic Variceal Bleeding Management 1. Patients should be transfused up to a Hb of 7-8 g/dl. Transfusion to Hb >8 can cause further re-bleeding. 2. Give terlipressin 2mg iv every 4 hours. 3. Give empirical iv broad spectrum antibiotics at time of admission eg: iv cefotaxime 2g or ciprofloxacin 400mg iv. 4. Avoid insertion of NG tube within 48 hours of variceal band ligation.
- 45. Treatment options • Inject • Thermal (heat, APC) • GOLD PROBE with high flow flush • Mechanical therapy – Hemo Clip • Band + BB • GLUE • NEW SPRAY --- wait for it-- INCREDIBLE • DO NOT FORGET PPI,BB AND TERLIPRESIN. • IF Rebleeds
- 48. Gastrointestinal Bleeding • LGI bleeding: – Older patient – Presentation • Hematochezia • BRBPR • Maroon stool • Occult+ stool • Iron deficiency anemia (GI blood loss until proven otherwise)
- 49. Gastrointestinal Bleeding • Major LGI bleeding: – Diagnosis %Diagnoses • Diverticulosis 43 • Angiodysplasia (avm’s) 30 • Neoplasia 9 • Colitis 9 • Other 7 • Undetermined 12
- 50. Gastrointestinal Bleeding • Diverticulosis: – Occurs in 3% of pts with diverticulosis – Acute, painless bleeding presenting with bright red blood/maroon stool – Right colon usual site 20% episodes are recurrent/persistent – Colonoscopy after bowel prep – Tagged RBC scans/angiography
- 53. Gastrointestinal Bleeding • Angiodysplasia (avm’s) – Presentation: acute major hemorrhage/slow intermittent bleeding/FOBT+ stool/iron deficiency anemia – Pts with major hemorrhage usually hane a coagulopathy – Colonoscopy/small bowel capsule endoscopy
- 55. Gastrointestinal Bleeding • Neoplasms: – Benign/malignant – Major hemorrhage is rare (iron deficiency anemia, +/- FOBT) – Colonoscopy/capsule endoscopy/angiography
- 58. Gastrointestinal Bleeding • Anorectal/Perianal disease: – Common cause of BRBPR • *hemorrhoids – Minor, intermittent bleeding with defecation – Always a diagnosis of exclusion after more serious lesions in the GI tract have been ruled out (CRC/polyps/colitis)
- 60. Gastrointestinal Bleeding • Role of endoscopy in triage of UGI bleeders: • Accurate identification of the urgency of the clinical situation: hemodynamic compromise/signs of on- going bleeding/coagulopathy/co-morbidities • Who should be hospitalized? • Where to admit? • Diagnosing the cause • Risk stratification