π«ß Ÿ ºŸâªÉ«Ë â««õ ÕÕ π ß πõ À à«πµâπ πª»

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1 Ë â««õ ÕÕ π ß πõ À à«πµâπ 𪻠ª ÿ 2004 Consensus for Clinical Practice Guideline for the management of Upper GI Bleeding ÿà «æ Õ À æ å ß πõ À Ààߪ»

2 Ë â««õ ÕÕ π ß πõ À à«πµâπ 𪻠ÿà «æ Õ À æ å ß πõ À Ààߪ» æ æå Èß π«2547 ISBN ºŸâ ˪ : πæ. Õ«Ã æ : æ.«à ª π : πæ.õÿ π πÿ : æ.» µ «πå : æ. ÿµ ª Ÿ π æ å : πæ.æ» â ß : æõ.πæ. ÿ æ Ëπ µπ ÿ : πæ. «πå Õπ πµæ π ÿåæß»å : πæ.õßõ æ ± ß Ÿ ÕÕ Ÿª à Ÿ π Ë π Õ Ëπ 240/37. π «ß»å Õ. ß Õ πâõ øì å

3 Upper GI bleeding π «Õ ÕÕ π ß πõ À à«πµâπ ªìπ «Ëæ àõ «π «ªØ µ π ËÕß ªìπ «Ë Õ µ µ ß âõ à«π À àºÿâªé««µ π à«ß Ë æ æ åà Õ ß ßæ ºŸâ ªÉ«Ë â««õ ÕÕ π ß πõ À à«πµâπ ß «ªìπ Ë µâõß â Ÿ Õ à ß «Á«Ÿ µâõß À æ π ª π «ÿπ ß resuscitation ºŸâªÉ«πªí ÿ π â æ π π â π Ÿ ºŸâªÉ«æ â π ÿà antisecretory ß endoscopy Ëß π â æ Ë ÈπÕ à ß ª Õ ß à Ë â««õ ÕÕ π ß πõ À à«πµâπ 𪻠àõπ ÿà «æ Õ À æ å ß πõ À Ààߪ» â Áß ÀÁπ ß «π ËÕßπ È ß â ª ÿ consensus ËÕß Ÿ ºŸâªÉ«Ë â««õ ÕÕ π ß πõ À à«πµâπ â âõ ÿª ªìπ π«ß π Ÿ ºŸâªÉ«Ë â««õ Õ π ß πõ À à«πµâπ æ åºÿâ â ૪ ÿ ª Õ â«õ ÿ æ å â π ß πõ À» æ å Õ ÿ æ å Ë«ª æ å «ªØ µ Ë«ª º ª ÿ â âõ ÿª π â π ß à «πâπ âõ Ÿ π πÿπ Ë ªìπ evidencebased Àâ æ å ËÕ Ÿà π ßæ ÿ π π«ß Ÿ ß à «ªªØ µ â ß µ µ ª πº À ß Ë æ å â â π«ß ºŸâªÉ«Ë â«õ ÕÕ π ß πõ À à«πµâππ È â«1-2 ªï À Õ ËÕ âõ Ÿ Ë ªìπÀ πõ π À à â π«ß Ÿ ß à «Àâ «À Ëß Èπ 3

4 æ å ß πõ À Ààߪ» Õ Õ ÿ æ å ÿ à π Ë Àâ «à«õõ à ß Ëß â «π «Ÿâ ª å æ ËÕ à«π Ë â««õ ÕÕ π ß πõ À à«πµâπ Õ Õ ÿ Õ Ëß-æ «, (ª» ), π«åµ (ª» ), Õ å π ø å Ÿµ Õ Õ π µ È, Ÿ ø å ( π å), ø å Ÿµ Õ, Õ (ª» ) å Áµµ Èß, Õä Õµ Õ µõ, Õ µ â π π â (ª» ) Ë à«π πÿπ ª ÿ à ß ËÕπ Ê Àâß π Á ÿ à«ß ª â â««ÿàßà».πæ. Õ«Ã æ π æ å ß πõ À Ààߪ» 4

5 Upper GI bleeding ºπ Ÿ Ÿ ºŸâªÉ«Ë â««õ ÕÕ π ß πõ À à«πµâπ æ π æ å ß πõ À Ààߪ» 1 Hematemesis / Melena 2 Initial Assessment and Resuscitation 3 Risk Stratification A Low Risk 3 B High Risk PPI for Suspected Samotostain for Supportive Treatment 6 Non-variceal Suspected Variceal 7 and Monitoring Bleeding Bleeding Endoscopy Available Elective Endoscopy Yes No 8 Ulcer bleeding Variceal Bleeding Others Refer 9 High risk 10 Low risk 16 Pharmacologic Therapy (Somatostatin or analogue) Endoscopic Hemostasis for Major Stigmata Hemorrhage 11 Therapeutic Endoscopy Feasible 15 Antisecretory therapy 11 Therapeutic Endoscopy Feasible 18 Yes No Yes No Continue Pharmacologic Therapy Endoscopic Consult Surgeon 17 EVL/EIS 19 SB hrs Fail Success Hemostasis or Refer Bleeding Stop Ongoing Bleed Success Fail Success Fail OR 14 Pharmacologic Therapy and Monitoring Re-endoscopy and Hemostasis Rebleed OR Rebleed SB hrs TIPS or Surgery or Refer 23 OR Re-endoscopy Fail EVL/EIS Success Rebleed 5

6 1 Hematemesis / Melena 2 Initial Assessment and Resuscitation 3 Risk Stratification 3 A Low Risk 3 B High Risk Supportive Treatment and Monitoring Elective Endoscopy PPI for Suspected Non-variceal Bleeding Endoscopy Available Samotostain for Suspected Variceal Bleeding 6 7 Yes No

7 Upper GI bleeding Yes No 8 Ulcer bleeding Variceal Bleeding Others Refer Endoscopic Hemostasis for Major Stigmata Hemorrhage 9 High risk 10 Low risk 16 Pharmacologic Therapy (Somatostatin or analogue) Therapeutic Endoscopy Feasible Antisecretory therapy Therapeutic Endoscopy Feasible 18 Yes No Yes No Continue Pharmacologic Therapy EVL/EIS 19 SB hrs Fail Success Consult Surgeon or Refer Endoscopic Hemostasis 12 7

8 EVL/EIS 19 SB hrs Fail Success Consult Surgeon or Refer Endoscopic Hemostasis Bleeding Stop Ongoing Bleed Success Fail Success Fail OR 23 Rebleed SB hrs TIPS or Surgery or Refer OR Re-endoscopy and Hemostasis 14 Fail Re-endoscopy EVL/EIS OR Rebleed Pharmacologic Therapy and Monitoring Success Rebleed

9 Upper GI bleeding Õ æ Ë µ µ ºπ Ÿ 1. ºπ Ÿ π È â æ À ºŸâªÉ«Ë â««õ ÕÕ π ß πõ À à«πµâπ æ π Ë Èπ π 48 Ë«ß à π Èπ ºŸâªÉ«Õ â«õ Õ π ªìπ Õ À Õ à melena 2. Initial Assessment and Resuscitation ë Supportive Treatment a. Maintain airway b. History and physical examination for assessment of severity and causes c. NG irrigation d. Fluid resuscitation e. Blood for CBC, cross-match blood group for blood transfusion À Àµÿ : Õ Ÿ À⪠µ «À ÕߺŸâªÉ«µà µ æ «æ âõ Õß πæ 3. Risk Stratification 3A Low clinical risk factors 3B High clinical risk factors include ë Host factors - Age > 60 years - Co-morbid conditions e.g. renal failure, cirrhosis, cardiovascular disease, COPD - Hemodynamic instability e.g. orthostatic hypotension, pulse >100 /min, systolic BP < 100 mmhg - Coagulopathy including drug-related ë Bleeding character - Continuous red blood from NG after irrigation 9

10 - Red blood per rectum ë Patient course - Need blood transfusion - Rebleeding - Hemodynamic instability Note: In special circumstances, patientsû referral may be considered if - The patient has rare blood group (group AB, Rh negative) - Taking more than 1 hr to the nearest referral hospital - Blood transfusion is not available 4. Supportive Treatment and Monitoring ë Supportive treatment as 2 ë Oral PPI double dose until endoscopy 5. Elective Endoscopy ë Every patient should have endoscopy done if available ë If endoscopy is not available, consider patientûs referral 6. Suspected non-variceal bleeding ë Continuous IV infusion or bolus PPI or oral PPI double dose ë If endoscopy is available with in 8 hr, PPI may not be needed Note: - Continuous IV infusion PPI: Omeprazole or Pantoprazole 80 mg v bolus then infusion drip 8 mg/hr - Bolus PPI: Omeprazole or Pantoprazole 40 mg v twice daily 7. Suspected variceal bleeding ë Clinical signs include - Previous documented of esophageal varices or gastric varices or - Signs of portal HT e.g. splenomegaly, ascites, hepatic encephalopathy, dilated superficial vein 10

11 Upper GI bleeding or - Clinical cirrhosis with thrombocytopenia and/or splenomegaly ë Medication: Somatostatin 250 microgram bolus followed with somatostatin 250 microgram/hour IV or Octreotide 50 microgram bolus followed with octreotide 50 microgram/hour IV ë If endoscopy can be performed urgently, somatostatin or its analogue may not be needed 8. Patient should be referred if ë High risk of bleeding including recurrent bleeding and no endoscopic treatment or no surgical treatment available ë Rare blood group ë No blood transfusion available 9. High endoscopic risks ë Arterial bleeding; spurting, oozing ë Non-bleeding visible vessel ë Adherent clot 10. Low endoscopic risks ë Hematin spot ë Clean-based ulcer ë Gastritis 11. Therapeutic endoscopy feasible ë Defined as ability to do any of therapeutic modalities (even 1 modality) 12. Endoscopic hemostasis ë Spurting : injection with adrenaline and followed with thermal coagulation or hemoclips ë Clot adherent : injection with adrenaline then removal of clot, 11

12 followed with thermal coagulation or hemoclips ë Non bleeding visible vessel : thermal coagulation, fibrin sealant or hemoclips 13. Consult surgeon as soon as possible or refer if no surgeon available 14. Pharmacologic therapy ë Drugs : oral or IV infusion PPI is either used depending on patients severity and physicianûs judgement 15. Antisecretory therapy ë Drugs : oral or IV infusion PPI is either used depending on patients severity and physicianûs judgement ë In NSAID user including low dose ASA - PPI is recommended in ongoing NSAIDs use - H 2 RA is as effective as PPI if NSAIDs are stopped 16. Pharmacologic therapy in variceal bleeding ë Somatostatin 250 microgram bolus, followed with somatostatin 250 microgram/hour IV or Octreotide 50 microgram bolus, followed with octreotide 50 microgram/hour IV ë If the patient already received somatostatin or its analogue before endoscopy, bolus dose is not needed 17. Endoscopic variceal ligation (EVL) or Endoscopic injection sclerotherapy (EIS) depends on the experiences of the endoscopist 18. Continue pharmacologic therapy for 5 days 19. Sengstaken Blakemore tube (SB) insertion 20. Hemostatic success means bleeding stopped ë May consider discharge somatostatin or its analogue if the EVL or EIS is completely performed 12

13 Upper GI bleeding 21. If hemostasis fail ë Somatostatin or its analogue should be continued ë Consider options according to healthcare resources, experiences of the endoscopist and the patientûs conditions - Consult for surgery or Transcutaneous intrahepatic portosystemic shunt (TIPS) with or without temporary tamponade with Sengstaken Blakemore tube - Temporary tamponade with Sengstaken Blakemore tube and re-endoscopy after hr 22. If bleeding is still ongoing more than hour surgery or TIPS is needed 23. The surgeon should be capable for shunt surgery otherwise refer to the center that has more equipped facilities À Àµÿ: ÿà «æ Õ À æ å ß π Õ À Ààߪ» â Statement ËÕß π«ß Ÿ ºŸâªÉ«Ë â««õ ÕÕ π ß πõ À à«πµâπ Ëß Õ «Èß Õ Õâ ßÕ ß æ ËÕ âª Õ guideline πàπ ß Õ à π È â àßµàõ ª ß «Õ ÿ æ å Ààߪ», «ß ÿ πæ π Õß ÿ æ ßæ (æ æ) æ ËÕ º æ àµàõ ª à π À Õ â π ÿ æ å ß πõ À Ààߪ», «Õ ÿ æ å Ààß ª» 13

14 14 π ºŸâ â ª ÿ π Consensus for Clinical Practice Guideline for the management of Upper GI Bleeding ßÀ 2546 ÀâÕߪ ÿ ß Õß Õ å. Õß πæ. ß Õ «ß»å æ. µ «ÿß æœ æ.» µ «πå ÿß æœ π.πæ. π«µ ÿ «π æ. Ÿ æ œ ÿß æœ æ. ÿµ ª Ÿ π æ å æ. ÿß æœ πæ. Ÿ µ Ÿ» «πå æ.õÿµ µ å Õÿµ µ å πæ. µ πÿ«µ æ.» ÿß æœ πæ. µ π Ÿ æ. À π ß À à ß À à πæ. «µπ Ÿ Õ æ. «ÿß æœ πæ. Õß æ π æ. µ «ÿß æœ πæ. πæ À æß æ. ß π π å ß πæ. π» «π ÿ æ. Á æ ÿ πæ. π» µ æπ å æ. À π ß À à ß À à πæ. «Õ «æÿ æ.» ÿß æœ πæ. Õ«Ã æ æ. ß π π å ß πæ. π ß «å«π πÿ ÿ æ.æπ π ÿ πæ.ª «ß» ªá æ. à π ÿå à π ÿå πæ.æ π â æ. ÿ π πæ.æ π ÿ «å æ. ÿã ß å ÿß æœ πæ.æ» â ß æ.» π π å Õπ àπ πæ.æ» æ» æß æ. À π ß À à ß À à πæ. ÿ ÕÕª Ÿ æ.æ ª â π ÿ πæ. æ æ π æ. - à æ ÿß æœ

15 Ï Upper GI bleeding å πæ. «π å æ.» µ å ª ÿ π æ. µπ ÿ» π å æ.«æ ÿß æœ πæ. «π π Ë æ.»ÿπ å ª ß ª ß πæ.«æ πå π ÿ æ. Á æ π ß â µµ ÿ æµõ.πæ.«æ π ÿ «æ.µ «ÿß æœ æ.«à æ. ÿã ß å ÿß æœ πæ.«π ÿ æ π æ. à ÿ Àå π ÿ πæ.«ÿ µ ÿ æ.π æ ß å ß À à πæ.» å «π æ. æ Ϫ ß å Õÿ π æ.»» ª ÿ æ Ø å æ.» ÿß æœ πæ.»ÿ»» ÿàß æ.æ» ÿ πæ. æ π µ å æ.» ÿß æœ πæ. µ µ ª ÿ æ. µ å µ âõπ ÿß æœ πæ. Õ µ Èß æ. à π ÿå à π ÿå πæ. «µ µ «πå æ. ÿß æœ πæ. «πå Õπ πµæ π ÿåæß»å æ. «ÿß æœ πæ. ÿ µπå» Õπ «π æ.àπõß ÀπÕß πæ. ÿπ µ πÿ«π æ. Áπ Ë π πæ. ÿπ πª» Ï æ.π π πæ. ÿæ πå æß»åª æ.» ÿß æœ πæ. ÿæ π«æ. æ ÿ æ ÿ æõ.πæ. ÿ æ Ëπ µπ ÿ æ.æ ß ÿæ â ÿß æœ æõ.πæ. ÿ æ ÿ ß å» æ.æ ß ÿæ â ÿß æœ πæ.õßõ æ ± ß Ÿ æ. À π ß À à ß À à πæ.õ π µ «π π å æ. ÿߪ å ÿß æœ πæ.õÿ π æ.» ÿß æœ πæ. Õà ««π à ß æ.õÿ π Õÿ π πæ. π π«ÿ æß å æ.» ÿß æœ πæ. ÿ» «ß»å æ.» ÿß æœ 15

16 π πß π ÿà «æ Õ À æ å ß πõ À Ààߪ» «æ.» ª π : æ.«à πÿ : πæ. «πå Õπ πµæ π ÿåæß»å À : æõ.πæ. ÿ æ Ëπ µπ ÿ : æ.» µ «πå : æ. ÿµ ª Ÿ π æ å : πæ. Õ«Ã æ : πæ.æ» â ß : πæ.õßõ æ ± ß Ÿ : πæ.õÿ π 16