تصفح
دخول
تسجيل
نسيتها؟

Algorithm for the management of upper gastrointestinal bleeding


Algorithm for the management of upper gastrointestinal bleeding

Algorithm for the management of upper gastrointestinal bleeding

Algorithm for the management of upper gastrointestinal bleeding. NSAID, nonsteroidal anti-inflammatory drug; PPI, proton-pump inhibitor; LGIB, lower gastrointestinal bleeding
Ranim's picture
by
السنة السادسة


I have many reservations on this algorithm
Do have the source?
Here are some of the points
1- PPI (and not H2 receptor blockers) are shown to reduce rebleeding risk and possibly need for transfusion
2- Although NG tube placement can be helpful and sometimes necessary (with persistant vomiting) but it is not needed in all patients , same goes for foley's cath
3- I am not sure about direct role for OR. I mean what do you expect the surgeon to do where to operate if he does not know where to open and work. Another alternative is vascular angiography . Surgery can be still needed in about 10 % of Upper GI bleed
4- Even when the first endoscopic treatment fails we tend to repeat it and not send patient to surgery unless thereis failure on the second attempt of endoscopic hemostasis
5- When se do endoscopy we can't do injection therapy alone (we either combine it with electrocautery / clipping or do the latter alone but just injection with saline or epinephrine is not enough to have long term control of the bleed.
6- Most cases (90%) of Mallory Weiss tear do not require any endoscopic interferrance and the bleed stops spontaneuosly

ABIM's picture
ABIM

Quote:
Do have the source?

Sabiston Textbook of Surgery 17th EDITION
و كتابنا معتمد بقسم النزوف على هالمرجع..

Ranim's picture
Ranim
السنة السادسة

I am not sure what to say about this, but I think (don't know if it's correct or not) that:
Quote:
PPI (and not H2 receptor blockers) are shown to reduce rebleeding risk and possibly need for transfusion

I've read that H2 receptor blockers are also used in this case (general surgery 4th year)

Quote:
same goes for foley's cath

I think it is necessary in order to monitor the patient's stability in case rebleeding occurs

Quote:
I am not sure about direct role for OR. I mean what do you expect the surgeon to do where to operate if he does not know where to open and work

If we couldn't manage the bleeding through endoscopy (endoscopy fails) we will have to go for surgery cuz' naturally when endoscopic measures fail to manage a bleeding so we know where the bleeding is but we could't terat it (cuz' we saw it and couldn't treat it) but we use angiography when endoscopy fails to determine the source of the bleeding

Ranim's picture
Ranim
السنة السادسة


Here is the problem

Quote:
Sabiston Textbook of Surgery 17th EDITION

First this is a textbook and that simply means it is outdated: The American College of Physcians (ACP) published International Consensus Guidelines in Jan of this year(2010) about the manegement of Upper GI bleed and that talks about the points I mentioned. Unfortunately you can't access it for free .
International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding
Alan N. Barkun, Marc Bardou, Ernst J. Kuipers, Joseph Sung, Richard H. Hunt, Myriam Martel, Paul Sinclair, and for the International Consensus Upper Gastrointestinal Bleeding Conference Group
Ann Intern Med January 19, 2010 152:101-113;

The other problem is that: with all due respect surgeons are good in going surgeries but not as good in other aspects.
In All the hospitals that I worked in or been to GI bleed is first handled by gastroenterology and only 10-15% will require surgical intervention. So for the most part GI bleed is a medical problem and NOT a surgical one. (unlike what used to be 20-30 years ago)
The third problem is that the 18 edition of this text book came in 2008 . (meaning the literature reviewed goes back to no later than mid 2007) . I would imagine that the 17 th ediction is 4 years before that. So it is good to study history of medicince rather than current medicine.

I Do appreciate efforts in looking up the algorithm and posting it but just to let you know where and how you can improve and update your knowledge
Embarrased Eye-wink

ABIM's picture
ABIM


سؤال...
كاتبين من أسباب النزف الهضمي العلوي اعتلال كلوي مزمن و ارتفاع البولة الدموية
ما هي الآلية التي تسبب النزف؟؟
Rolling Eyes

Ranim's picture
Ranim
السنة السادسة

Quote:
كاتبين من أسباب النزف الهضمي العلوي اعتلال كلوي مزمن و ارتفاع البولة الدموية

مين اللي كاتبين؟
renal failure is NOT a direct cause for GI bleed BUT there is platelet dysfuction and higher incidence of angiodyplastic lesions that make such patients more prone for bleeding.

ABIM's picture
ABIM


معناها كتابنا من العصر الحجري !! لأنه معلوماته من الاصدار الأقدم من المرجع! confused

Ranim's picture
Ranim
السنة السادسة

Quote:
مين اللي كاتبين؟

بكتابنا الجراحة confused

Ranim's picture
Ranim
السنة السادسة


و شكرا كتير دكتور على معلوماتك القيمة Surprised

Ranim's picture
Ranim
السنة السادسة


By the way I had the chance of discussing many issues about these guidelines with the primary auther himself( Alan Barkun).There are still some controversies and you may still see some differences in practice among different hospitals.
On the other hand the over all picture is still holds true: Assess patient-- Support hemodynamics---- Suppress Acid--- Perform endoscopy---- Surgery is the final solution

ABIM's picture
ABIM
ابق على تواصل مع حكيم!
Google+