upper gi bleeding & portal hypertension in children
TRANSCRIPT
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UPPER GASTROINTESTINAL
BLEEDING & PORTAL HYPERTENSION IN
CHILDREN
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MANIFESTATIONS OF GI BLEED
Melaena – the passage of black, tarry stools indicates likely UGI bleed (proximal to the
ligament of Treitz)
Haematemesis – vomitus containing frank blood or brown-black “coffee grounds”
Haematochezia – passage of bright or dark red blood per rectum
In general, the redder the blood, the more distal the site of bleeding
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SPURIOUS GI BLEED
Red: beets, laxatives, phenytoin, rifampin
Black: bismuth, activated charcoal, iron, spinach, blueberry, licorice
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GUAIAC TEST
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ETIOLOGY
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ETIOLOGY
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ETIOLOGY
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“plucked chicken appearance”
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HISTORY Drugs Retching or vomiting Jaundice Procedures Recurrent abdominal pain Bleeding disorders in family Odynophagia
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EXAMINATION Stigmata of chronic liver disease
General condition
External vascular malformation
Hyperpigmented lips
Dilated abdominal wall veins, Splenomegaly
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NASO GASTRIC LAVAGE Removes blood from stomach –
facilitates easier endoscopy
Confirmation of bleed/ongoing blood loss
Prevents development of encephalopathy in cirrhotic patients
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ASSESSMENT OF BLOOD LOSS Disproportionate tachycardia
“Tilt” test
Capillary refill time
Signs of shock
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THERAPY
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PORTAL HYPERTENSION
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CIRRHOSIS - PATHOLOGY
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EXTRAHEPATIC PORTAL HYPERTENSION Portal vein agenesis, atresia, stenosis
Portal vein thrombosis or cavernous
transformation
Splenic vein thrombosis
Arteriovenous fistula
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VASOPRESSIN Acts by increasing splanchnic vascular tone
0.3 units per kg per hour after a bolus of 0.3 U/kg over 20 min
The addition of nitroglycerin (skin patch) decreases the systemic .effects of vasopressin
Terlipressin-longer duration of action and lesser cardiac side effects
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SOMATOSTATIN & ANALOGUES much better side-effect profile and
similar efficacy
3 to 5 μg per kg per hour
Octreotide has a longer half-life- bolus (2 μg/kg) followed by continuous infusion (1 to 5 μg per kg per hour)
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OTHER DRUGS antibiotic prophylaxis directed at
intestinal flora (third-generation cephalosporin) should be started from admission
H2 receptor blocker or proton pump inhibitor intravenously
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ENDOSCOPIC SCLEROTHERAPY (EST) Acts by producing intimitis
Injected either intra- or paravariceal
Intravariceal cyanoacrylate or histacryl glue and thrombin for gastric varices
Complications of EST include ulceration, pain, perforation, and bacteremia.
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ENDOSCOPIC VARICEAL LIGATION (EVL) Draws a visible varix into the lumen of
the ligator and a band is placed around the varix
EVL is just as effective as EST but was associated with fewer complications and faster obliteration of varices.
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BALLOON TAMPONADE
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TRANSJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT (TIPSS)
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TIPSS Indications: Recurrent variceal hemorrhage Refractory ascites Hepatorenal syndrome
Contraindications Polycystic liver disease Right heart failure Systemic infection Portal vein thrombosis Severe hepatic encephalopathy
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PROPHYLAXIS Primary prophylaxis - propranolol
Secondary prophylaxis – EVL/EST
Surgical treatment: Patients with EHPVO bleeding gastric or other nonesophageal
varices severe hypersplenism
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SURGICAL TREATMENT OPTIONS Decompressive shunts Devascularization Liver transplantation
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THANK YOU!!!