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. Nonvariceal upper gastrointestinal bleeding remains a common clinical. 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. Variceal haemorrhage is associated with clinical stigmata of chronic liver disease. What the quality statement means for service providers, healthcare practitioners, and commissioners. European society of gastrointestinal endoscopy esge guideline. Patients who require endoscopic therapy for ulcer bleeding should receive high dose proton pump inhibitors after endoscopy, whereas those.
The role of endoscopy in the management of acute non. Colorectal variceal bleeding managed by endoscopic therapy. Improved survival with the patients with variceal bleed. Upper gastrointestinal bleeding ugib is a critical condition that demands a quick and effective medical management. Esophageal varices are typically diagnosed through an esophagogastroduodenoscopy. Us multisociety task force on colorectal cancer guideline. The most important predictor of hemorrhage is the size of varices. Causes of variceal bleeds prehepatic portal vein thrombosis obstruction increased portal blood flow. Advances in the management of avb have resulted in decreased mortality. A case of variceal bleeding from the jejunum in liver cirrhosis article pdf available in clinical and molecular hepatology 191.
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. This clinical practice guideline is meant to be a guide for clinical practice, based on the. The incidence of nonvariceal acute upper gi bleeding is approximately 85 per 100,000 per year 1. Oesophageal variceal bleed oxford medical education. Although the rate of bleeding was equivalent between the treatment groups, the authors concluded that evl should. Acute variceal bleeding avb is the most common cause of upper gastrointestinal hemorrhage in patients with cirrhosis. Nonvariceal upper gastrointestinal bleeding is a medical emergency in which bleeding develops in the oesophagus, stomach or proximal duodenum and.
At this point, the variceal wall cannot resist further dilation, and variceal figure 11. Management of variceal bleeding icm case summaries. Endoscopic therapy is a way of preventing and treating variceal bleeding without the requirement for surgery. The majority of the upper gi bleeding is 8090 % are non variceal. Management of upper gastrointestinal bleeding annals of.
Algorithm for the prevention of recurrent variceal bleeding secondary prophylaxis. Stop treatment after definitive haemostasis has been achieved, or after 5 days, unless there is another indication for its use 1. Portal hypertension results from increases in portal flow and portal vascular resistance. This guideline will not address obscure gi bleeding or the role of endoscopy in the managementofvaricealbleeding,bothofwhichareaddressed in existing asge practice guidelines. 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. Oesophageal variceal bleed definition of a variceal bleed oesophageal varices are dilated oesophageal veins secondary toportal hypertension. Recommendations on the management of patients with non. 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. Clinically and endoscopically stratify patients as low or highrisk for rebleeding andor mortality to guide management.
Recent advances in the management of variceal bleeding. Nonvariceal upper gastrointestinal bleeding ugib is a critical clinical condition that requires an urgent management. Responsible for 5% of episodes of gi bleeding in the uk. Improved supportive measures, combination therapy which include early use of portal. Colonoscopy optimizing adequacy of bowel cleansing. Management of nonvariceal upper gastrointestinal bleeding.
Management of upper gastrointestinal bleeding annals of internal. In highrisk small esophageal varices, nonselective. Nonvariceal upper gi bleed acute management inhospital. Nonendoscopic management of acute esophageal variceal bleeding gilberto silvajunior, anna baiges, fanny turon, virginia hernandezgea, juan carlos garciapagan pages 7983. 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. 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. Influence of portal hypertension and its early decompression by tips placement on the outcome of variceal bleeding. Sarin s, lamda gs, kumar m, et al comparison of endoscopic ligation and propranolol for the primary prevention of variceal bleeding. Management of variceal bleeding ucd emergency medicine. 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.
Nonvariceal upper gastrointestinal bleeding ugib is defined as bleeding proximal to the ligament of treitz in the absence of oesophageal, gastric or duodenal varices. Pdf management of nonvariceal upper gastrointestinal bleeding. Complications include portal hypertension ph with gastroesophageal varices, ascites, hepatorenal syndrome, hepatic encephalopathy, bacteremia, and hypersplenism. The standards of practice committee of the american society for gastrointestinal endoscopy prepared this text. Upper gastrointestinal bleeding is defined as bleeding proximal to the ligament of treitz without evidence of esophageal, gastric, and duodenal varices. 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. Variceal hemorrhage is a major cause of death in patients with cirrhosis.
Endoscopic advances in the management of nonvariceal upper. Non variceal ugib, especially peptic ulcer bleeding is the most significant cause. Variceal bleeding stops spontaneously in over 50 percent of patients, but the mortality rate approaches 70 to 80 percent in those with continued bleeding. 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. 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. Inpatient bed stay, endoscopy provision and blood product transfusions are the main contributors to the overall cost of ugib. Management of acute upper gastrointestinal bleeding.
The diagnosis is established by emergency endoscopy when one of the following is observed. Pdf a case of variceal bleeding from the jejunum in. 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. Colonoscopy quality indicators competencies in endoscopy.
Nonvariceal upper gastrointestinal bleeding nature. They are most often a consequence of portal hypertension, commonly due to cirrhosis. Ann intern med 2003 rebleeding 16% 31% gov2 varices. 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. 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. Management of acute variceal bleeding linkedin slideshare. The clinical presentation varies according to the intensity of bleeding from occult bleeding to melena or haematemesis and haemorrhagic shock.
Haemochezia is the passage of red blood per rectum. Nonselective betablockers or endoscopic variceal ligation. 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. 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. Uk guidelines on the management of variceal haemorrhage in.
At diagnosis of liver disease 40% of those with compensated cirrhosis. Acute upper gastrointestinal bleeding in adults nice. 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. Clinical practice guidelines on the management of variceal bleeding. The most recent guidelines for managing ugib were published primarily. Portal hypertension is a complication of cirrhosis and is the causative factor behind gastroesophageal varices and subsequent bleeding. Variceal bleeding definition of variceal bleeding by. There are two distinct phases in the course of variceal hemorrhage. 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. In preparing this document, a search of the medical literature was. A metaanalysis of these 2 studies 78, 79 was performed for this guideline supplement appendix 2. Pdf on jan 25, 2016, nazish butt and others published clinical practice guidelines. The role of endoscopy in the management of variceal.
737 1359 63 642 1243 1514 809 698 1115 882 516 858 1146 1016 1319 709 925 714 1311 47 1468 343 1300 646 744 33 141 977 70 1270 911 920 1462