Git GIB Variceal lower 2011

GIT Bleeding:VGIBLGIB

Dr. Mohamed Shekhani

CABM-FRCP

Variceal bleeding:Variceal bleeding:

Clinical decompensation (i.e., ascites, encephalopathy,a previous

episode of hemorrhage, or jaundice).

Gastric fundal varicesOr GEV

Esophageal varices

Portal hypertensive gastropathy

Common lethal complication of cirrhosis(50% at diagnosis, 7%/year), particularly with:

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Types

Portal hypertensive Biliopathy

Variceal bleeding:Variceal bleeding:

Clinical decompensation (i.e., ascites, encephalopathy,a previous

episode of hemorrhage, or jaundice).

Treatment of the acute bleeding episode:Mortality 15-20%

Primary prophylaxis to prevent a first episode of VH.

Secondary prophylaxis (prevention of recurrent VH).60%/year.

Common lethal complication of cirrhosis(50% at diagnosis, 7%/year), particularly with:

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MANAGEMENT

Small varicesSmall varices Large varicesLarge varicesNo varicesNo varices

7-8%/year7-8%/year 7-8%/year7-8%/year

Varices Increase in Diameter ProgressivelyVarices Increase in Diameter Progressively

Merli et al. J Hepatol 2003;38:266Merli et al. J Hepatol 2003;38:266

VARICES INCREASE IN DIAMETER PROGRESSIVELY

Predictors of hemorrhage: Variceal size Red signs Child B/C

Predictors of hemorrhage: Variceal size Red signs Child B/C

NIEC. N Engl J Med 1988; 319:983NIEC. N Engl J Med 1988; 319:983

Variceal hemorrhageVariceal hemorrhage Varix with red signsVarix with red signs

PROGNOSTIC INDICATORS OF FIRST VARICEAL HEMORRHAGE

Class A: 5-6Class B: 7-9Class C: 10-15

PortalHT

Risk stratification

Varices or colaterlas detected on imaging studies as Abd U/S,EUS,Dopler

Varices on VCE

Fibroscan measuring liver stiffness predicts portal HT

Plateletes/spleen maximal bipolar diameter<909

Decompensated liver cirrhosis:Child-Pough or MELD class

Gastroesophageal varices.

Portal HT Risk stratificationPortal HT Risk stratification 2

HVPG: gold standard&Best predictor of PHT & EV, but invasive &not widely available.

>5 mm Hg PHT>10 mm Hg clinically significant

Primary prophylaxis of bleeding eso varices:Primary prophylaxis of bleeding eso varices:

Propranolol

FU OGD afterObliteration:

3 MONTHLYFor 1 year

ThenYearly

Indefintely.

Or

Nadolol

EBLSessions every

4 weeks

PP of EV bleed

Propranolol 20mgm*2 untill PR 55/minIndefinite

Nadolol 40mgm once dailyUntill PR 55/minIndefinite

Endoscopic band ligationEvey 4 weeks untill total obliterationFollow up: 3 /12 for 1 year, yearly

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Management of acute variceal bleeding:Management of acute variceal bleeding:

EndoscopicIntervention

EBLSclerotherapy

SigestakenTube temponade

CyanoacrylateInjection

SclerotherapyFor gastric

Varices.

Antibiotics:Ceftriaxone

Ciprofloxacin5 days

VasoconstrictorOctreotite

SomatostatinTelipresin

5 days

Esophagealstenting

Acute variceal Bleeding.

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Secondary prophylaxis( prevention of recurrent) of bleeding EV:Secondary prophylaxis( prevention of recurrent) of bleeding EV:

propranolo Nadolol

Cyanoacrylate for GV

EBL forEV

InterventionalRadiology for

GV

Isosorbide

Secondary prophylaxis

PropranololSame as for primary prophylaxis.

NadololSame as for primary prophylaxis.

Isosorbide dinitrate10 mgm*10-20 mgm*2

EBL Same as for primary prophylaxis.

Cyanoacrylate injection sclerotherapy or IR for gastric varices not EBL.

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Portal Hypertensive GastropathyPortal Hypertensive Gastropathy

•PHT- related ectatic gastric mucosal vessels mostly in fundus & body of the stomach.

Definition:

GEV , Child class& prior variceal endoscopic therapy

Chronic blood loss leading to IDA rather than acute bleeding

Iron supplementation;BB,Shunt therapy(surgeryorTIPS)

Same.

Predictors of its presence

Prsentation

Treatment:

Prophylaxis

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Acute Lower Gastrointestinal Bleeding Acute Lower Gastrointestinal Bleeding

Bleeding distal to the ligament of Treitz for <less than 3 days. The colon is the most common site of bleeding.The incidence increases with age, with mean of 63-77 years. LGIB accounts for 20% of all episodes of GIB. Most episodes of LGIB will stop without intervention. The most common causes of acute LGIB are diverticulosis, angiectasia,

ischemic colitis, perianal disease.The most frequent causes of chronic LGIB are neoplasms, angiectasia, IBD.

Causes in Our locality:Perianal diseases(piles/Fissure)IBD(UC>CD)Infectious colitisNeoplasms(adenoma or cancer)Solitary rectal ulcer syndrome

(SRUS)Meckel’s diverticulum.Ischemic colitis.Angiodysplasia

Hemorrhoids/ fissures:Hemorrhoids/ fissures:

Bleeding after/or with defecation

Pain & bleeding with defecation

Careful perianal exam+ anoscopy assist in the diagnosis

Piles Fissure

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2

Acute LGIB: Management algorythmAcute LGIB: Management algorythmInitial evaluation/ resuscitation

Triage to OP vs Ward vs ICU

Mild scanty bleeding Anorectal pathologysusspected

Rigid Anoscopy or sigmoidoscopy to confirm diagnosis

Outpatient management

Anorectal pathology(piles/fissure) is the most common pathology in our localityBut this should be diagnosed on solid basis not to miss serious pathologies as IBD or cancer.

Severe bleeding

Severe exanguinating bleeding

Emergency angiography for bleeding control by gel form or coils

Or emergency surgical consult.

If emergency angio succeeded just observe for recurrence but if fails refer to surgery

SURGERY

Severe exanguinating bleeding needs urgent action either emergency surgery or emegency therapeutic interventional radiology.

Acute LGIB: Management algorythmAcute LGIB: Management algorythm

Moderate severe bleeding

Consider NGT aspirate

Bloody NGT aspirateRisk for UGIB

OGD If +ve treat accordingly

Most of the cases of LGIB fall in this category & require 1st NGT aspiration & if +ve bloody aspirate , urgent upper GIT endoscopy.

Acute LGIB: Management algorythmAcute LGIB: Management algorythm

Moderate severe bleeding

NGT not done or –ve aspirate

Polyethelene glycol(PEG) solution laxative for preparation for emergency colonoscopy in few hours.

Colonoscopy within 12-24 hours

Manage according to colonoscopic findings

If the NGT aspirate is not bloody or NGT was not inserted, urgent prep with PEG is needed for urgent colonoscopy within12-24 hours.

Acute LGIB: Management algorythmAcute LGIB: Management algorythm

Moderate severe bleeding

On colonoscopy bleeding site & cause is identified

so treat as appropriate.

If the colonoscopy identifies the site/cause of bleeding the problem is solved

Acute LGIB: Management algorythmAcute LGIB: Management algorythm

Moderate severe bleeding

If On colonoscopy there is visual impairment because of ongoing bleeding

Angiography.

If on colonoscopy there was visual impairment due to bloody field urgent angiography is indicated fordiagnosis & therapy.

Acute LGIB: Management algorythmAcute LGIB: Management algorythm

Moderate severe bleeding

On colonoscopy bleeding site not identified but bleeding had stopped

OGDOrRepeat colonoscopyOrSI evaluation/Or Others( RBC

scan,angiography) for rebleeding.

If on colonoscopy the bleeding had stopped & no lesion was identified, upper GI endoscopy is considered(if had already been done) or RBC scan/angigraphyIs done fordiagnosis/treatment specially if bleeding recurred.

Acute LGIB: Management algorythmAcute LGIB: Management algorythm

Hope it helps