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Samah Chiry, R1. Objectifs 1. Chez un patient qui a du sang dans ses selles et dont létat hémodynamique est instable, tenez compte des antécédents pour.

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Présentation au sujet: "Samah Chiry, R1. Objectifs 1. Chez un patient qui a du sang dans ses selles et dont létat hémodynamique est instable, tenez compte des antécédents pour."— Transcription de la présentation:

1 Samah Chiry, R1

2 Objectifs 1. Chez un patient qui a du sang dans ses selles et dont létat hémodynamique est instable, tenez compte des antécédents pour distinguer entre un saignement gastro-intestinal supérieur et un saignement inférieur, car lexamen sera alors différent. 2. Chez un patient chez qui vous soupçonnez la présence de sang dans les selles, explorez dautres causes possibles (p. ex. ingestion de betteraves, de fer, de Pepto-Bismol) avant de procéder à un examen général. 3. Recherchez les patients à risque plus élevé de saignement GI (p. ex. saignement GI antérieur, séjour aux soins intensifs, anti-inflammatoires non stéroïdiens, alcool) afin de modifier le traitement pour diminuer le risque de saignement GI (p. ex. cytoprotection) 4. Chez les patients souffrant dun saignement GI évident, identifiez ceux qui pourraient nécessiter un traitement en temps opportun même sils ne sont pas encore en état de choc. 5. Chez un patient stable atteint dun saignement GI inférieur, recherchez des causes sérieuses (p. ex. tumeur, maladie intestinale inflammatoire, ulcère, varices) même quand le saignement semble avoir une cause évidente (p. ex. nattribuez pas un saignement rectal aux hémorroïdes ou à un anticoagulant oral). 6. Chez un patient souffrant dun saignement GI supérieur : a) incluez le saignement de varices dans votre diagnostic différentiel; b) utilisez les antécédents et lexamen physique pour évaluer la probabilité dun saignement variqueux, car sa prise en charge est différente.

3 Anatomie saignement GI superieur vs inferieur determine par le ligament de treitz (LT). Superieur: proximal au LT: Oesophage, estomac, 2 eme / 3 eme portion du duodenum inferieur : distal au LT: petit intestin et colon

4 Saignement GI superieurSaignement GI inferieur Incidence : cas/ adultes / annee Mortalite : 10 a 14% La moyenne pour le sejour a lhopital (nincluant pas les varices) avec ou sans complications est de 2.7 a 4.4 jours. Mortalite a diminue de 23% aux EU (1998 a 2006), de 40% en Bretagne (1993 a 2007), inchange au Canada (1993 a 2003) 20-33% des episodes de saignement GI Mortalite: 10 a 20% surtout avec les patients ages et ceux avec comorbidites Plus frequent chez les personnes agees a cause de la haute incidence de la diverticulose et la maladie vasculaire chez ce groupe. >

5 Saignement aigu: - moins de trois jours - Instabilite hemodynamique et/ou besoin de transfusion sanguine

6 Evaluation initiale Le premier point dans la prise en charge dun saignement digestif est de definir le site et la cause du saignement: Est ce que le saignement GI est superieur ou inferieur?

7 Lhistoire La nature du saignement : 1. Hematemese (vx du sang): origine superieure - Coffee ground emesis - Rouge frais - Caillots de sang - Apres des vomissements excessifs 2. Melena - Selles noires (verifier avec le TR) - A besoin dau moins 50cc de sang dans le tractus GI - Typiquement survient dune origine superieure, mais 5% peuvent etre dorigine inferieure - Occasionnellement la source est le petit intestin ou le colon proximal 3. Hematoschezia (sang rouge per rectum) - dhabitude suggere un saignement distal au LT - A considerer un saignement superieur si instabilite hemodynamique

8 Les points importants dans lhistoire La duree du saignement, la frequence Les sx associes: douleur abd, un nouveau chgt dans les habitudes de selles, fievre, urgence/tenesme, perte de poids, anorexie, N/V, satiete precoce, dysphagie/odynophagie, epistaxis/hemoptysie Antcds: - Saignement anterieur - Trauma - Hx de radiation a labd et au pelvis - Ulcere peptique anterieur - Hx de maladie inflammatoire de lintestin - Comorbidites : MCAS, ins cardiaque, maladie hepatique - Chx anterieure: AAA - Endoscopies anterieures : les rapports Medication: - NSAIDs - ASA - Anticoagulants

9 Laboratoire FSC Base : E, Cr, Uree (uree peut augmenter sans augmentation de la Cr du a labsorption des proteines du sang et a la dehydratation) PT/PTT Type et crossmatch ECG chez les patients > 50 ans, ou ayant une hx de MCAS ou arrythmie, ou ayant une DRS/palpitations associees avec le saignement

10 Diagnostic differentiel : saignement GI superieur Les causes rares: ulcere de stress,ulcere de Dieulafoy, malformation AV, Fistule aorto-enterique, anastomose chirurgicale..

11 Saignement variqueux Sx de la maladie hepatique Antecedants Faiblesse, anorexie et malaise Nausee et vomissement Perte de poids Discomfort ou douleur abdominal (QSD, epigastre et QSG) Jaunisse et urine foncee Oedeme et ascite Prurit Ecchymoses (easy bruising) Impotence et dysfonction sexuel Crampes musculaires Hx de jaunisse suggerant une hepatite anterieure infectieuse ou medicamenteuse Hx de transfusion Hx de drogues IV Prise dalcool ou AINS Hx de cirrhose

12 Saignement variqueux Paleur Hypertrophie des parotides (reliee a lalcolisme et/ou malnutrition) Jaunisse Telangiectasis ( peau, levres, doigts). Gynecomastie chez les hommes Fetor hepaticus erytheme palmaire Ascites Circulation collaterale autour de lombilic, venous hums (bruit audible du flot turbulent dans les veines collaterales) Slenomegalie Atrophie testiculaire Angiome stellare Caput medusa hemorrhoides

13 Diagnostic differentiel : saignement GI inferieur

14 Recommendations de la prise en charge des patients avec saignement GI superieur non variqueux A. Resuscitation, risk assessment, and preendoscopy management A1. Immediately evaluate and initiate appropriate resuscitation. A2. Prognostic scales are recommended for early stratification of patients into low- and high-risk categories for rebleeding and mortality. A3. Consider placement of a nasogastric tube in selected patients because the findings may have prognostic value.* A4. Blood transfusions should be administered to a patient with a hemoglobin level 70 g/L. A5. In patients receiving anticoagulants, correction of coagulopathy is recommended but should not delay endoscopy. A6. Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield. A7. Selected patients with acute ulcer bleeding who are at low risk for rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy. A8. Preendoscopic PPI therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay

15 Determiner lurgence de la situation clinique: 1. Est ce que le patient est en choc? - Tachypnee, tachycardie, agitation, diminution de letat de conscience, palleur indiquent une perte de sang > 1500 mL ( 30% du volume circulatoire) - Att aux beta-bloqueurs 2. Est ce que le patient est orthostatique? - SV avec TA couche et debout - Une de > 10 mmhg ou une de > 10 batt/min indiquent une perte de sang > 800 mL (15% du volume circulatoire)

16 Recommendations de la prise en charge des patients avec saignement GI superieur non variqueux A. Resuscitation, risk assessment, and preendoscopy management A1. Immediately evaluate and initiate appropriate resuscitation. A2. Prognostic scales are recommended for early stratification of patients into low- and high-risk categories for rebleeding and mortality. A3. Consider placement of a nasogastric tube in selected patients because the findings may have prognostic value.* A4. Blood transfusions should be administered to a patient with a hemoglobin level 70 g/L. A5. In patients receiving anticoagulants, correction of coagulopathy is recommended but should not delay endoscopy. A6. Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield. A7. Selected patients with acute ulcer bleeding who are at low risk for rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy. A8. Preendoscopic PPI therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay

17 Les predicteurs cliniques pour resaignement ou mortalite Age > 65 ans Choc Comorbidites Hb initialement bas Melena Besoin de transfusion Sang rouge frais au TR, dans le Vx, ou le TNG Sepsis uree, creat, AST, ALT

18 Glasgow- Blatchford Bleeding score Uree (mmol/L) 6·5-7·9 = 2 points 8·0-9·9 = 3 points 10·0-25·0 = 4 points >25·0 = 6 points Haemoglobin pour les hommes (g/L) =1 points = 3 points <100 = 6 points Haemoglobin pour les femmes (g/L) =1 point <100 = 6 point Pression systolique(mm Hg) =1point =2 point <90 =3 point Dautres marqueurs: Pouls 100/min =1 point presentation avec melena = 1 point presentation avec syncope = 2 point Maladie hepatique= 2 point Insuffisance cardique=2 point

19 Rockall scoring system the most widely used, gives estimates of the risks of recurrent bleeding and death. It is based on the three clinical factors mentioned above and on two endoscopic ones, awarding points for: Age0 points if less than 60; 1 point if 60 to 79; or 2 points if 80 years or older Shock1 point if the pulse is more than 100; 2 points if the systolic blood pressure is less than 100 mm Hg Comorbid illness2 points for ischemic heart disease, congestive heart failure, or other major comorbidity; 3 points for renal failure, hepatic failure, or metastatic disease Endoscopic diagnosis0 points if no lesion found or a Mallory- Weiss tear; 1 point for peptic ulcer, esophagitis, or erosive disease; 2 points for GI malignancy Endoscopic stigmata or recent hemorrhage0 points for a clean- based ulcer or flat pigmented spot; 2 points for blood in the upper GI tract, active bleeding, a nonbleeding visible vessel, or adherent clot. The Rockall score can thus range from 0 to 11 points, with an overall score of 0, 1, or 2 associated with an excellent prognosis.

20 Recommendations de la prise en charge des patients avec saignement GI superieur non variqueux A. Resuscitation, risk assessment, and preendoscopy management A1. Immediately evaluate and initiate appropriate resuscitation. A2. Prognostic scales are recommended for early stratification of patients into low- and high-risk categories for rebleeding and mortality. A3. Consider placement of a nasogastric tube in selected patients because the findings may have prognostic value. A4. Blood transfusions should be administered to a patient with a hemoglobin level 70 g/L. A5. In patients receiving anticoagulants, correction of coagulopathy is recommended but should not delay endoscopy. A6. Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield. A7. Selected patients with acute ulcer bleeding who are at low risk for rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy. A8. Preendoscopic PPI therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay

21 Tube NasoGastrique Indication : - Devant tout saignement superieur ou saignement indetermine Benefices therapeutiques et diagnostiques Positive evidence que le saignement est superieur sang rouge frais endoscopie en urgence coffee ground endoscopie ds prochains 24h Negative nexclut pas un saignement superieur (saignement intermittent, spasme pylorique, oedeme empechant le reflux du sang duodenal) Contraindications: - Varices oesophagiennes ne sont pas une contraindication - Trauma facial/ fracture de los nasal

22 Recommendations de la prise en charge des patients avec saignement GI superieur non variqueux A. Resuscitation, risk assessment, and preendoscopy management A1. Immediately evaluate and initiate appropriate resuscitation. A2. Prognostic scales are recommended for early stratification of patients into low- and high-risk categories for rebleeding and mortality. A3. Consider placement of a nasogastric tube in selected patients because the findings may have prognostic value. A4. Blood transfusions should be administered to a patient with a hemoglobin level 70 g/L. A5. In patients receiving anticoagulants, correction of coagulopathy is recommended but should not delay endoscopy. A6. Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield. A7. Selected patients with acute ulcer bleeding who are at low risk for rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy. A8. Preendoscopic PPI therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay

23 Recommendations de la prise en charge des patients avec saignement GI superieur non variqueux A. Resuscitation, risk assessment, and preendoscopy management A1. Immediately evaluate and initiate appropriate resuscitation. A2. Prognostic scales are recommended for early stratification of patients into low- and high-risk categories for rebleeding and mortality. A3. Consider placement of a nasogastric tube in selected patients because the findings may have prognostic value. A4. Blood transfusions should be administered to a patient with a hemoglobin level 70 g/L. A5. In patients receiving anticoagulants, correction of coagulopathy is recommended but should not delay endoscopy. A6. Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield. A7. Selected patients with acute ulcer bleeding who are at low risk for rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy. A8. Preendoscopic PPI therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay

24 Warfarin peut precipite un saignement Le risque de saignement GI chez les patients ayant du coumadin est de 2.3 a 4.9 fois plus grand que ceux qui nont pas. Malgre que le nbre de plaquettes nest pas un predicteur de la mortalite, un INR > 1.5 a la presentation est un predicteur significatif de la mortalite chez les patients avec saignement superieur. Endoscopie peut se faire avec un INR entre 2-3 Si INR supratherapeutique, il faut le corriger avant.

25 Recommendations de la prise en charge des patients avec saignement GI superieur non variqueux A. Resuscitation, risk assessment, and preendoscopy management A1. Immediately evaluate and initiate appropriate resuscitation. A2. Prognostic scales are recommended for early stratification of patients into low- and high-risk categories for rebleeding and mortality. A3. Consider placement of a nasogastric tube in selected patients because the findings may have prognostic value. A4. Blood transfusions should be administered to a patient with a hemoglobin level 70 g/L. A5. In patients receiving anticoagulants, correction of coagulopathy is recommended but should not delay endoscopy. A6. Promotility agents should not be used routinely before endoscopy to increase the diagnostic yield. A7. Selected patients with acute ulcer bleeding who are at low risk for rebleeding on the basis of clinical and endoscopic criteria may be discharged promptly after endoscopy. A8. Preendoscopic PPI therapy may be considered to downstage the endoscopic lesion and decrease the need for endoscopic intervention but should not delay endoscopy.

26 Recommendations de la prise en charge des patients avec saignement GI superieur non variqueux B. Endoscopic management B1. Develop institution-specific protocols for multidisciplinary management. Include access to an endoscopist trained in endoscopic hemostasis. B2. Have available on an urgent basis support staff trained to assist in endoscopy. B3. Early endoscopy (within 24 hours of presentation) is recommended for most patients with acute upper gastrointestinal bleeding. B4. Endoscopic hemostatic therapy is not indicated for patients with low-risk stigmata (a clean-based ulcer or a nonprotuberant pigmented dot in an ulcer bed). B5. A finding of a clot in an ulcer bed warrants targeted irrigation in an attempt at dislodgement, with appropriate treatment of the underlying lesion. B6. The role of endoscopic therapy for ulcers with adherent clots is controversial. Endoscopic therapy may be considered, although intensive PPI therapy alone may be sufficient. B7. Endoscopic hemostatic therapy is indicated for patients with high-risk stigmata (active bleeding or a visible vessel in an ulcer bed). B8. Epinephrine injection alone provides suboptimal efficacy and should be used in combination with another method. B9. No single method of endoscopic thermal coaptive therapy is superior to another. B10. Clips, thermocoagulation, or sclerosant injection should be used in patients with high-risk lesions, alone or in combination with epinephrine injection. B11. Routine second-look endoscopy is not recommended. B12. A second attempt at endoscopic therapy is generally recommended in cases of rebleeding.

27 Recommendations de la prise en charge des patients avec saignement GI superieur non variqueux Pharmacologic management C1. Histamine-2 receptor antagonists are not recommended for patients with acute ulcer bleeding. C2. Somatostatin and octreotide are not routinely recommended for patients with acute ulcer bleeding. C3. An intravenous bolus followed by continuous-infusion PPI therapy should be used to decrease rebleeding and mortality in patients with high-risk stigmata who have undergone successful endoscopic therapy. C4. Patients should be discharged with a prescription for a single daily-dose oral PPI for a duration as dictated by the underlying etiology.

28 IPP La dose recommendee domeprazole: 80 mg bolus suivi dune perfusion de 8 mg/h pour 72 h diminue le resaignement, lindication pour la chirurgie et la mortalite. Apres le traitement de levenement aigu, un IPP est recommende pour 6 a 8 semaines, plus long si test positif pour H.pylori ou sil prend lASA ou un AINS.

29 Algorithm for patients with acute upper gastrointestinal bleeding. ALBELDAWI M et al. Cleveland Clinic Journal of Medicine 2010;77: ©2010 by Cleveland Clinic

30 Endoscopic stigmata of bleeding peptic ulcer (arrows) and risk of recurrent bleeding and death. Upper endoscopy is 90% to 95% diagnostic for acute upper GI bleeding. ALBELDAWI M et al. Cleveland Clinic Journal of Medicine 2010;77: ©2010 by Cleveland Clinic

31 Recommendations de la prise en charge des patients avec saignement GI superieur non variqueux D. Nonendoscopic and nonpharmacologic in-hospital management D1. Patients at low risk after endoscopy can be fed within 24 hours. D2. Most patients who have undergone endoscopic hemostasis for high-risk stigmata should be hospitalized for at least 72 hours thereafter. D3. Seek surgical consultation for patients for whom endoscopic therapy has failed. D4. Where available, percutaneous embolization can be considered as an alternative to surgery for patients for whom endoscopic therapy has failed. D5. Patients with bleeding peptic ulcers should be tested for H. pylori and receive eradication therapy if it is present, with confirmation of eradication. D6. Negative H. pylori diagnostic tests obtained in the acute setting should be repeated.

32 Preferred therapies for Helicobacter pylori infection 1. Triple therapy : - Proton pump inhibitor twice a day + Clarithromycin (Biaxin) 500 mg twice a day + Amoxicillin 1,000 mg twice a day - 10–14 days - 70%–85% - Proton pump inhibitor twice a day + Clarithromycin 500 mg twice a day + Metronidazole (Flagyl) 500 mg twice a day - 10–14 days - 75%–85% - Consider in penicillin-allergic patients who have not previously received a macrolide or who cannot tolerate bismuth quadruple therapy 2. Quadruple therapy - Proton pump inhibitor twice a day + Bismuth subsalicylate 525 mg twice a day + Metronidazole 250 mg four times a day + Tetracycline 500 mg four times a day - 10–14 days - 75%–90% - Consider in penicillin-allergic patients

33 Recommendations de la prise en charge des patients avec saignement GI superieur non variqueux E. Postdischarge, ASA, and NSAIDs E1. In patients with previous ulcer bleeding who require an NSAID, it should be recognized that treatment with a traditional NSAID plus PPI or a COX-2 inhibitor alone is still associated with a clinically important risk for recurrent ulcer bleeding. E2. In patients with previous ulcer bleeding who require an NSAID, the combination of a PPI and a COX-2 inhibitor is recommended to reduce the risk for recurrent bleeding from that of COX-2 inhibitors alone. E3. In patients who receive low-dose ASA and develop acute ulcer bleeding, ASA therapy should be restarted as soon as the risk for cardiovascular complication is thought to outweigh the risk for bleeding. E4. In patients with previous ulcer bleeding who require cardiovascular prophylaxis, it should be recognized that clopidogrel alone has a higher risk for rebleeding than ASA combined with a PPI.

34 ASA The higher the aspirin dose, the higher the risk. Aspirin doubles the risk of upper GI bleeding at daily doses of 75 mg, and quadruples it at doses of 300 mg. The most important risk factor for upper GI bleeding in patients taking aspirin is a history of peptic ulcer bleeding. Approximately 15% of aspirin users who have bleeding from ulcers have recurrent bleeding within 1 year. When considering whether to discontinue antiplatelet therapy, a cardiologist should be consulted along with a gastroenterologist to weigh the risks of GI bleeding vs thrombosis.

35 Clopidogrel (Plavix) Clopidogrel (Plavix) is recommended for hospitalized patients with acute coronary syndrome who cannot tolerate the GI side effects of aspirin. This recommendation was largely based on the safety data from the CAPRIE (Clopidogrel Versus Aspirin in Patients at Risk of Ischemic Events) trial, in which the incidence of major GI bleeding was lower in the clopidogrel group (0.52%) than in the aspirin group (0.72%; P <.05).

36 In a recent double-blind randomized controlled trial in patients with a history of aspirin-induced bleeding, the combination of low-dose aspirin plus esomeprazole (Nexium) twice a day was superior to clopidogrel by itself in terms of the rate of recurrent bleeding (0.7% vs 8.6%; P <.05). A similar trial showed nearly identical results: 0% upper GI bleeding in the group receiving aspirin plus esomeprazole 20 mg daily, vs 13.6% in the clopidogrel group (P =.0019). These studies suggest that a once-daily proton pump inhibitor combined with aspirin is a safer alternative than clopidogrel alone

37 Clopidogrel plus a proton pump inhibitor Interestingly, recent studies have shown that omeprazole (Losec) decreases the antiplatelet effect of clopidogrel, possibly by inhibiting the CYP2C19 enzyme. However, concomitant use of, lansoprazole (Prevacid), and esomeprazole (Nexium) did not have this effect, suggesting that although all proton pump inhibitors are metabolized to a varying degree by CYP2C19, the interaction between proton pump inhibitors and clopidogrel is not a class effect. Therefore, pantoprazole, lansoprazole, and esomeprazole may be the appropriate proton pump inhibitors to use with clopidogrel in patients who have a clear indication for the medication, consistent with current guideline recommendations.

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39 Indications pour la chirurgie Emergency surgery is required in about 10-25% of patients with lower gastrointestinal bleeding (LGIB). The indications for surgery :indications for surgery 1. Persistent hemodynamic instability with active bleeding 2. Persistent, recurrent bleeding 3. Transfusion of more than 4 units packed red bloods cells in a 24-hour period, with active or recurrent bleeding

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41 Take Home message The first priority is to ensure that the patient is hemodynamically stable, which often requires admission to the intensive care unit for monitoring and fluid resuscitation. Peptic ulcers account for most cases of upper GI bleeding, but bleeding from varices has a much higher case-fatality rate and always demands aggressive treatment. Patients with ulcer disease should be tested and treated for Helicobacter pylori infection. Patients with a history of bleeding ulcers who need long- term treatment with aspirin or a nonsteroidal anti- inflammatory drug should also be prescribed a proton pump inhibitor.

42 Bibliographie International Consensus Recommendations on the Management of Patients With Nonvariceal Upper Gastrointestinal Bleeding, Annals of Internal Medicine, 2010; 152: Management of the Adult Patient With Acute Lower Gastrointestinal Bleeding, American Journal of Gastroenterology (1998) 93, 1202–1208


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