Acute upper gastrointestinal bleeding in adults nice. In preparing this document, a search of the medical literature was. A case of variceal bleeding from the jejunum in liver cirrhosis article pdf available in clinical and molecular hepatology 191. Variceal hemorrhage is a major cause of death in patients with cirrhosis. Nonvariceal upper gi bleed acute management inhospital key highlights from the recommended guideline consider inserting a nasogastric tube and empiric highdose proton pump inhibitors while waiting for endoscopy. The diagnosis is established by emergency endoscopy when one of the following is observed. Recent advances in the management of variceal bleeding. Patients who require endoscopic therapy for ulcer bleeding should receive high dose proton pump inhibitors after endoscopy, whereas those. Management of variceal bleeding ucd emergency medicine. Colorectal variceal bleeding managed by endoscopic therapy. Variceal bleeding occurs when the tension exerted by the thin wall of a varix is beyond a critical value, determined by the elastic limit of the vessel. The standards of practice committee of the american society for gastrointestinal endoscopy prepared this text. Stop treatment after definitive haemostasis has been achieved, or after 5 days, unless there is another indication for its use 1. Recommendations on the management of patients with non.
Pdf on jan 25, 2016, nazish butt and others published clinical practice guidelines. Acute variceal bleeding avb is a severe complication of portal hypertension pht and causes 70% of all upper gastrointestinal gi bleeding episodes in patients with liver cirrhosis. Pdf a case of variceal bleeding from the jejunum in. Acute variceal haemorrhage can be diagnosed endoscopically with confidence if there is an actively bleeding varix or a varix that shows signs of recent bleeding, e. At this point, the variceal wall cannot resist further dilation, and variceal figure 11.
Gastric varices 25% of patients with portal hypertension have gastric varices, preferred endoscopic therapy for fundal gastric variceal bleeding is injection of polymers of cyanoacrylate nbutyl2. Causes of variceal bleeds prehepatic portal vein thrombosis obstruction increased portal blood flow. Management of variceal bleeding rachael harry, ma, mrcp, and julia wendon, frcp variceal hemorrhage complicates cirrhosis in as many as 50% of patients and results in considerable morbidity and mortality. Influence of portal hypertension and its early decompression by tips placement on the outcome of variceal bleeding. Algorithm for the prevention of recurrent variceal bleeding secondary prophylaxis.
The clinical presentation varies according to the intensity of bleeding from occult bleeding to melena or haematemesis and haemorrhagic shock. Us multisociety task force on colorectal cancer guideline. The most important predictor of hemorrhage is the size of varices. They are most often a consequence of portal hypertension, commonly due to cirrhosis. Management of upper gastrointestinal bleeding annals of internal. A metaanalysis of these 2 studies 78, 79 was performed for this guideline supplement appendix 2. Colonoscopy quality indicators competencies in endoscopy. Variceal bleeding stops spontaneously in over 50 percent of patients, but the mortality rate approaches 70 to 80 percent in those with continued bleeding. Clinically and endoscopically stratify patients as low or highrisk for rebleeding andor mortality to guide management.
Variceal bleeding definition of variceal bleeding by. Primary prophylaxis for variceal hemorrhage, the treatment of variceal hemorrhage, and the prevention of recurrent variceal hemorrhage. Pdf management of nonvariceal upper gastrointestinal bleeding. Nonvariceal upper gastrointestinal bleeding is a medical emergency in which bleeding develops in the oesophagus, stomach or proximal duodenum and is often caused by peptic ulcers as a result of. Nonvariceal upper gastrointestinal bleeding ugib is defined as bleeding proximal to the ligament of treitz in the absence of oesophageal, gastric or duodenal varices. The majority of the nonvariceal upper gastrointestinal bleeding nvugib in the uk is caused by pud. Haemochezia is the passage of red blood per rectum. Nonvariceal upper gi bleed acute management inhospital.
Management of acute variceal bleeding linkedin slideshare. The incidence of nonvariceal acute upper gi bleeding is approximately 85 per 100,000 per year 1. Uk guidelines on the management of variceal haemorrhage in. This clinical practice guideline is meant to be a guide for clinical practice, based on the. Complications include portal hypertension ph with gastroesophageal varices, ascites, hepatorenal syndrome, hepatic encephalopathy, bacteremia, and hypersplenism.
There are two distinct phases in the course of variceal hemorrhage. Improved survival with the patients with variceal bleed. Over the past two decades new treatment modalities have been introduced in the management of acute variceal bleeding avb and several recent studies have suggested that the outcome of patients with cirrhosis and avb has improved. Nonvariceal upper gastrointestinal bleeding remains a common clinical.
Inpatient bed stay, endoscopy provision and blood product transfusions are the main contributors to the overall cost of ugib. This guideline will not address obscure gi bleeding or the role of endoscopy in the managementofvaricealbleeding,bothofwhichareaddressed in existing asge practice guidelines. The aetiology of cirrhosis in malaysia ismainly due to hepatitis b or alcohol in alcoholic liver disease, continuedabstinence from alcohol may result in adecreasing in size or even disappearance ofvarices. Management of variceal bleeding icm case summaries.
In the most common procedure called endoscopic variceal banding or ligation, rubber bands are placed around varices in the esophagus through a flexible endoscope which is used to visualize the vessels. Upper gastrointestinal bleeding ugib is a critical condition that demands a quick and effective medical management. The most recent guidelines for managing ugib were published primarily. Advances in the management of avb have resulted in decreased mortality. A large randomized study demonstrating that for patients with large varices grade 3 or 4, endoscopic banding was associated with lower rebleeding rates compared with propranolol. Management of upper gastrointestinal bleeding annals of. Responsible for 5% of episodes of gi bleeding in the uk.
Portal hypertension is a complication of cirrhosis and is the causative factor behind gastroesophageal varices and subsequent bleeding. Variceal haemorrhage is associated with clinical stigmata of chronic liver disease. Upper gastrointestinal bleeding is defined as bleeding proximal to the ligament of treitz without evidence of esophageal, gastric, and duodenal varices. Specific to variceal haemorrhage resuscitation is the need to avoid overtransfusion in the initial management of these patients as well as ensuring rapid consideration and correction of any. Nonvariceal upper gastrointestinal bleeding ugib is a critical clinical condition that requires an urgent management. Although the rate of bleeding was equivalent between the treatment groups, the authors concluded that evl should. In highrisk small esophageal varices, nonselective. Esophageal varices are typically diagnosed through an esophagogastroduodenoscopy. The role of endoscopy in the management of variceal hemorrhage this is one of a series of statements discussing the use of gi endoscopy in common clinical situations. Management of nonvariceal upper gastrointestinal bleeding.
Cause of bleeding varices portal hypertension is an increase in the pressure within the portal vein the vein that carries blood from the digestive organs to the liver. The majority of the upper gi bleeding is 8090 % are non variceal. Esophageal varices are extremely dilated submucosal veins in the lower third of the esophagus. Portal hypertension results from increases in portal flow and portal vascular resistance. Nonvariceal upper gastrointestinal bleeding is a medical emergency in which bleeding develops in the oesophagus, stomach or proximal duodenum and.
Oesophageal variceal bleed definition of a variceal bleed oesophageal varices are dilated oesophageal veins secondary toportal hypertension. Service providers ensure that systems are in place for people with nonvariceal acute upper gastrointestinal bleeding and stigmata of recent haemorrhage to be offered endoscopic treatments combination or a mechanical method healthcare practitioners offer endoscopic treatments. Clinical practice guidelines on the management of variceal bleeding. Non variceal ugib, especially peptic ulcer bleeding is the most significant cause.
The role of endoscopy in the management of variceal. The role of endoscopy in the management of acute non. In a 2017 study by jensen and colleagues, most of the 148 patients with severe nonvariceal ugib 85% had peptic ulcer bleeding active bleeding, visible vessel, adherent clot, or flat spot. Nonendoscopic management of acute esophageal variceal bleeding gilberto silvajunior, anna baiges, fanny turon, virginia hernandezgea, juan carlos garciapagan pages 7983. Ann intern med 2003 rebleeding 16% 31% gov2 varices. What the quality statement means for service providers, healthcare practitioners, and commissioners.
Acute variceal bleeding avb is the most common cause of upper gastrointestinal hemorrhage in patients with cirrhosis. Oesophageal variceal bleed oxford medical education. Nonvariceal upper gastrointestinal bleeding nature. Liver cirrhosis is the end stage of chronic liver disease, independent of etiology, and is characterized by accumulation of fibrotic tissue and conversion of the normal liver parenchyma into abnormal regenerative nodules. Management of acute upper gastrointestinal bleeding. Colonoscopy optimizing adequacy of bowel cleansing. Nonselective betablockers or endoscopic variceal ligation. Although there was a significant reduction in the incidence of bleeding peptic ulcers with the introduction of proton pump inhibitor ppi and eradication of helicobacter pylori,1,2 ugib still remains a clinically important issue due to the increase in the. Sarin s, lamda gs, kumar m, et al comparison of endoscopic ligation and propranolol for the primary prevention of variceal bleeding. European society of gastrointestinal endoscopy esge guideline. Improved supportive measures, combination therapy which include early use of portal. Endoscopic therapy is a way of preventing and treating variceal bleeding without the requirement for surgery.
733 470 784 316 1124 946 1628 813 227 258 446 560 98 369 1192 707 1434 798 1444 1489 1250 1277 1045 1081 881 329 749 1491 1348 1363 700 1283