Non-variceal upper gastrointestinal bleeding

Initial ResuscitationIntravascular volume, hemodynamic status– Skin turgor, oral mucosa, axilla– BP, HR, orthostatic hypotensionLab data– CBC, PT, aPTT, Platelet count, blood group– Liver function (Alb/T.P., Bilirubin, PT, GPT)– Renal functionNPO, , IV fluid supplement (G/W, G/S)– Insertion of NG tube in selective patients.

Initial ResuscitationReplacement of intravascular volume– At least 2 IV lines (CVP?)Crystalloid , colloid, PRBC if Hb < 7 g/dLHct to 30% in p’t p t with cardio-pulmonary diseasedCorrection of coagulopathy– FFP, Vit K, fresh platelet (Plt

Gastrointestinal BleedingAcute UGI bleeding– Common: hematemesis or melena– Rare: hematocheziaAcute LGI bleeding– Common: hematochezia– Rare: melenaObscure bleeding– Unknown origin after endoscopic evaluation– Overt bleeding– Occult bleeding

Cause of Acute Upper GI Bleeding

Blatchford scoring systemGoHome≧1 Needintervention ?GASTROINTESTINAL ENDOSCOPY Volume 71, No. 7 : 2010

Rockall Scoring Systemfor UGI BleedingVARIABLEPoints0 1 2 3Age (yr) 80 —Pulse rate(beats/min)SBP(mm Hg)ComorbidityDiagnosisEndoscopicstigmata ofrecenthemorrhage100 — —Normal >100

community work together. Becominga GEAR UP school in 2007 was onecritical factor in our story; we wereable to teach college readiness skillsin classrooms, increase our secondaryrigor, and take students to post-highschool campuses all over the state.As of June 2013, 100% of the seniorsin the Class of 2013 met the new statemath requirement for graduation, 68%of the 10th graders in 2013 passedthe Biology EOC, and 93% of thissame class passed the writing HSPE.By all accounts, we certainly provideevidence of significant change. nMore from Ann RenkerRenker, Ann (2012) Growing aGrowth Mindset to Boost StudentAchievement. Mindset Works,February 2012. http://community.mindsetworks.com/growing-agrowth-mindset-to-boost-studentsachievementHow will you lead?Do you want to be a catalystfor transformative change?A leader who guides the talentsof employees and managers?Someone who builds strongcommunity through ethical service?Seattle University willprepare you for thiskind of leadership.No matter where you sit.Seattle University’s Doctorate in Educational Leadershipwww.seattleu.edu/coe/leaderschangelives206-296-5908SU AdWashingtonPrincipal2013-2.indd 11/25/13 1:52 PMAWSP/WASA Summer ConferenceJune 29-July 1, 2014 | Spokane Convention CenterIf there was a recipe for student, teacher and administratorsuccess, what would it be?At this year’s AWSP/WASA Summer Conference, let ushelp you with the ingredients needed to make your schoolsuccessful: Smarter Balanced, TPEP, Common Core andeverything in between.Spice up your leadership skills with this year’s concurrentsession offerings, keynote speakers and special events. You’llleave well-stocked for the 2014-15 school year.Learn more at wcm.awsp.org/summerconferenceSave the DateJune 29-July 1, 2014Speaker HighlightsDr. Shane Lopez, Clifton Strengths Institute, SeniorScientist, GallupDonalyn Miller, author of The Book WhispererRegistrationRegistration is coming in March. Watch for details!WASHINGTON PRINCIPAL | WINTER 201415

Approach of UGI Bleeding輕 微 出 血– Elective UGI endoscopy– Empiric therapy (PPI)嚴 重 出 血– Hypovolemic shock?– Hematemesis? Fresh blood from NG tube?– Massive bloody-tarry stool?– Arrange urgent (

Pharmacologic ManagementInitial evaluation & resuscitationH2RA, Somatostatin, and Octreotide– Not recommended for acute ulcer bleedingPPIPromotility agentsNPO ?

Preendoscopic PPIDownstage the endoscopic lesionDecrease the need for endoscopic interventionNo reduction in recurrent bleeding, surgery andmortality rates.– Should not delay endoscopy.– IV blous, followed by continous infusion PPI80 mg bolus, plus 8 mg/h continous infusion for 3 days– High-dose iv i and oral PPIs (in Asia)are are recommended– Low-doseiv PPIs: : insufficient dataCochrane Database Syst Rev 2006;(1):CD002094.

Endoscopic Therapy最 有 效 的 止 血 方 法– Early endoscopyWithin 24 hr of presentation with acute GI bleeding– Delay in selected high risk patients (active ACS, criticalcardiopulmonary condition, or perforation)Endoscopic irrigation for adherent clots– Controversial, But beneficial in patients at high risk forrebleeding rate (Serious concurrent illness, Asian)Second look– Within 16- 24 hr for active bleeding or NBVV– Not routine, recommend if rebleeding

I IIa IIb IIcIII

Rebleeding Rates withoutEndoscopic Therapy or PPIHemostatic therapyConservative therapyClot dislodgment ?IA IIA IIB IB IIC IIIUniversity of California, Los Angeles, Center for Ulcer Research Education database

Endoscopic TherapyHeater probe 熱 探 針Injection therapy 局 部 注 射– Epinephrine (1:10,000, 需 併 用 其 他 治 療 ), absoluteethanol, normal saline, water, 50% dextrose, andsclerosing agents.Metal clips, , rubber band ligation, endoloops,argon plasma coagulation, , and sewing devicesCombination therapy– Superior to injection alone, not to clips or thermaltherapy alone

Protocol of GI BleedingIA & IIA IIB IIC IIILow risk patient, feedwithin 24 hours

Nonendoscopic and Nonpharmacologic In-hospital ManagementLow risk after endoscopy– Feed within 24 hours.High-risk stigmata, s/p initial hemostasis– Hospitalized for at least 72 hours thereafter.Admission to a monitored setting for at least the first24 hours if– Risk of hemodynamic instability, increasing age, severecomorbidity, active bleeding at endoscopy, or large ulcersize ( ex > 2 cm) or clinical condition.H.P eradication if positive finding.– Recheck if negative H. pylori diagnostic tests inacute bleeding.

Failed Endoscopic TherapyRecurrent bleeding despite 2 sessions ofendoscopic hemostasis– Spurting hemorrhage could not be stopped byendoscopic means– The bleeding point not be seen because ofheavy active bleeding– Recurrent bleeding appeared after initialendoscopic controlSurgical therapy or percutaneousembolization: about 5% to 10% patientsSleisenger and Fordtran's Gastrointestinal and Liver Disease Ninth Edition

Angiographic TherapySevere, persistent bleeding– Endoscopic therapy is unsuccessful or unavailable– Surgery is too risky– Both embolization etherapy & an expertise are availableSuccess rate 52-98%, recurrent bleeding 10-20%– Gelatin sponges, polyvinyl alcohol, cyanoacrylic glues, or coils.Compared to surgery– No difference in rebleeding, surgery or mortality rateComplication: Bowel ischemia; secondary duodenal stenosis;and gastric, hepatic, and splenic infarctionHigh periprocedural mortality rate– 25% to 30%, selected patients due to high surgical riskAnnals of Internal Medicine Volume 152 • Number 2, 19 January 2010

Risks of RebleedingActive bleeding after endoscopic therapyNon-bleeding visible vesselAdherent clot

Risks of RebleedingRISK FACTORClinical FactorsHealth status (ASA class 1 vs. 2-5) 21.94-7.63Comorbid illness 1.6-7.63Shock (systolic blood pressure < 100 mm Hg) 1.2-3.65Erratic mental status 3.21Ongoing bleeding 3.14Age ≥ 70 yr 2.23Age > 65 yr 1.3Transfusion requirementPresentation of BleedingRANGE OF ODDSRATIOS FOR INCREASEDRISKNAHematemesis 1.2-5.7Red blood on rectal examination 3.76Melena 1.6

Risks of RebleedingRISK FACTORLaboratory FactorsCoagulopathy 1.96Initial hemoglobin ≤ 10 g/dL 0.8-2.99Endoscopic FactorsUlcer location on superior wall of duodenum 13.9Ulcer location on posterior wall of duodenum 9.2Active bleeding 2.5-6.48High-risk stigmata 1.91-4.81Ulcer size ≥ 2 cm 2.29-3.54Ulcer location high on lesser curve 2.79Diagnosis of gastric or duodenal ulcer 2.7Clot over ulcer 1.72-1.91.9RANGE OF ODDSRATIOS FOR INCREASEDRISKAnn Intern Med 2003; 139:843-57

Prevention of Recurrent Ulcer BleedingFollow-up endoscopy– To document healing and exclude malignancyin certain gastric ulcers– Not routineDiscontinue NSAIDs or reduce dose– PPI , misoprostolHP eradication therapy

Early DischargeA clean ulcer base or flat pigmented spotHemodynamic stabilityNo serious concurrent medical illness– Heart failure, recent cardiovascular orcerebrovascular event, chronic alcoholism, oractive cancerEasy accessibility to hospitalAdequate sociofamily support at home.Gastrointest Endosc. 2002;55:1-5.

Aspirin Discontinuation relatedAdverse OutcomesEuropean Heart Journal (2006) 27, 2667–2674

Disadvantage in GI Procedurev.s Vascular EventsJournal of Internal Medicine 257: 399–414

Prepare before EndoscopicProcedures

Risk of Haemorrhagein Endoscopic ProceduresGut 2008;57:1322–1329

Management of patients on warfarin or clopidogrelundergoing endoscopic proceduresGut 2008;57:1322–1329

一 位 31 歲 男 性 , 無 明 顯 藥 物 史 及 過 去 病 史 , 因口 吐 鮮 血 由 朋 友 送 急 診 室 醫 治 , 病 人 朋 友 告 知 病人 與 同 事 喝 醉 酒 , 先 嘔 吐 兩 次 吐 出 食 物 , 第 三 次嘔 吐 發 現 多 量 鮮 血 參 雜 少 量 食 物 。 下 列 上 消 化 道出 血 疾 病 中 , 首 要 考 慮 之 鑑 別 診 斷 為 :(1) 食 道 靜 脈 瘤 破 裂(2 ) 胃 潰 瘍(3) 十 二 指 腸 潰 瘍(4)Mallory-Weiss裂 傷

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上 消 化 道 出 血 內 視 鏡 下 所 見 , 何 者 可 不 考慮 立 即 進 行 內 視 鏡 止 血 ?A. 噴 水 狀 出 血 (Forrest Ia) (spurting)B. 滲 出 性 出 血 (Forrest Ib) (oozing)C. 露 出 血 管 (Forrest IIa) (non-bleeding visiblevessel) (NBVV)D. 凝 血 塊 附 著 (Forrest IIb) (adherent blood clot)E. 黑 色 潰 瘍 底 部 (Forrest IIc) (hemorrhagicbase)

關 於 腸 胃 道 出 血 , 下 列 何 者 是 錯 誤 的 ?A. 潰 瘍 出 血 時 , 出 血 量 每 分 鐘 0.5-1 西 西 以 上 ,血 管 攝 影 才 可 診 斷 出 來B. 注 射 腎 上 腺 素 ( 單 一 或 合 併 其 他 溶 液 ) 是 最 常用 於 治 療 潰 瘍 出 血 的 止 血 方 法C. 上 消 化 道 大 量 出 血 的 病 患 必 需 注 意 其 呼 吸 道 保護 的 必 要 性D. 注 射 腎 上 腺 素 於 上 消 化 道 , 常 會 引 起 病 患 的 心跳 加 速 或 心 律 不 整 情 形

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