 Our next speaker for today's evening session is Dr. Dheerich Karthar, Senior Consultant of the Department of Medical Gastroenterology. He's going to educate all of us on the GAE emergencies and how to handle them. What is it? Thank you. I see a packed hall in the middle of the week, that's very good. People are inclined to learn about emergencies, that's very interesting. But most of these emergencies I would say are very difficult to manage in clinical care setting. The identification of the signs where they should be immediately shifted to a higher care center is what is very important. So I will be talking on gastroenterological emergencies under these few headings. I will try to wind up within the next 20 minutes. So we will discuss about GI bleed, foreign body in the gastroenterological tract, acute abdomen which is more of a surgical purview but I will tell you what an acute abdomen should be looked for in an acute presentation of an abdominal pain, acute dysphagia, cholangitis, hepatic encephalopathy and of course acute constipation. Most bothersome symptoms to any human being gets relieved very easily by a simple clinical manual. So we will go through all of these. So gastroenterstinal bleed can be either an upper GI bleed from the upper tract above the ligament of treats or from anywhere below it which could be a small intestine or the large intestine. The commonest cause for a small amount of gastroenterstinal bleed which is which may be massive sometimes is hemorrhoids. The commonest cause for a upper GI bleed is either a esophageal varicis where you can see or an ulcer within the stomach which can present as a peptic ulcer related bleed which is a very common medical emergency that we see. How do patients present? It is either hematocystia, hematomesis or is it a melin? So this usually patients nowadays with all the mobiles available they come with these photographs. But the most important history is whether there was dark tarry stools, whether there was fresh blood in the stools or whether there was coffee ground vomitors followed by fresh blood in the stools. So these things help us differentiate whether it is a purely upper GI bleed or a lower GI bleed. About 10 to 30 percent of the massive upper GI bleeds wherein they are torrentially blood they will present with fresh blood in the stools because the rapid transit of the blood through the intestinal tract makes them present as a hematocystia rather than as melin. So in about 30 percent of the cases this is so and we should be very careful in history taking and clinical examination. A patient's hemodynamic status tells us whether it is upper GI bleed or lower GI bleed and the history of course the subtleties of the history. So these are the common causes for an upper GI bleed of the world over 50 percent of the cases of upper GI bleed are due to Peptic ulcer disease which is commonly a diurnal ulcer. The next comes isophageal varices which is secondary to a liver disease either due to viral disease as commonly seen in India or due to ethanol or nowadays the next new epidemic that is naturally related liver disease. The rest of all are very rare. You can see Malarivi, Stumors and all those things they are all very rare causes. If you know that the bleed is either variceal or non-variceal that is the most important differentiation that a gastroenterologist has to make. So this is how the images look when you do an endoscopy I will show you more images. So in a lower GI bleed what are the common causes? The angiotysplasia, ischemia, carcinoma, colon, polyps, either inflammatory bowel disease, the McCall's diverticulum which is just close or within two feet of the iliocecal junction, carcinoma, solitary rectal ulcers and haemorrhoids. These are the common causes for lower GI bleeds but the by far most difficult bleeds as far as I am concerned are diverticula bleeds which are seen in elderly people. They are benign causes of bleed but the problem is identifying the cause of bleed. The trick in identifying a diverticula bleed I will talk to you as we go through these slides. If you see this slide what are the things that commonly a patient with a massive GI bleed present is vomiting of blood either coffee ground or fresh blood or black tharistools. The rest of the things are mostly clinical examination and assessment of the modynamic status. So if you look at the entire GI tract these are the various causes of bleed above the ligament of traits is an upper GI bleed, below the ligament of traits is a lower GI bleed. The color is not always an indicator as I told about one third of the cases of GI bleed can be upper GI bleed but present as hemotopygia. So what do you do in a GI bleed? As usual the airway of breathing and the circulation transfusion of blood to be arranged as early as possible to keep the blood ready depending on the hemodynamic status indication and octriotide was the previous drug that we used to use. The problem with octriotide was we had to give an infusion. Today we have wonderful drug called Tarliprasin which can be given as bolus shots especially for variceal bleeds either a fundal variceal bleed or anisophageal variceal bleed. It can be repeated every 6th hour in a dose of 0.5 milligram. The only caveat is that you should look at the ECG before you do this. Any underlying cardiac arrhythmias can get worse. So Tarliprasin is the new drug. Antibiotics are a must not in cases of non-variceal GI bleed or ulcer related bleed but it is must in cases of variceal bleed where there is a liver disease because the commonest cause of death after a GI bleed is secondary infection due to bacterial translocation. Antibiotics have been found to be life saving in this group of patients. Whether there is a role of tranhexamic acid the answer is no. We do not have a role for tranhexamic acid in these bleeds. Do we need to place a NG tube the answer is again no it does not make any difference. What are the goals of resuscitation is to keep the blood pressure at about 100 systolic if it is a variceal bleed. If it is a non-variceal bleed about 120 is the target blood pressure systolic. These are various schools which scores which are used for diurnal ulcer related bleeds clinically have no role. Basically what you have to look at is the hemodynamic status of the patient heart rate the blood pressure how much of a shock is in or the periphery is cold. In a simple clinical history is there a history of past liver disease wherein there is a clear cut suspicion of a variceal bleed if there is no history of liver disease then it is most likely a non-variceal bleed. The commonest cause as of today for a non-variceal bleed is the use of over the counter NSAIDs either they would have been taking a dichlofenac or ibuprofen for a low backache for a migraine. You just have to probe the history it will come out it just takes two good minutes and you will find the answer. If there is still a confusion a clinical examination for presence of minimal pediladema a clinical examination of the abdomen to palpate the spleen will tell you if there is pediladema and spleenomegaly you are looking at a variceal bleed because terlipresin will be life-saving if there is still a doubt infuse both pantoprosol infusion and terlipresin but if you are clear and you know this patient has got liver disease and he has come with variceal bleed you start with terlipresin antibiotic arranged for blood depending on the amount of blood loss. So these are how things look like these are isophageal varices the large blue veins this is how a rubber band is applied for the isophageal varices this is how a diurnal ulcer looks like especially when it is pigmented and not actively oozing this is a nightmare for any gastroenterologist sparting vessel previously we used to use this chlorotherapy injections go in and inject all around and elevated and cause tamponade to irritate the bleed thank God to the thanks to the Lord for us making availability of these clips we have plenty of clips now different companies manufacture them at reasonably priced rates and if you can apply a clip over a vessel you can erase the bleed very easily now as I was mentioning the lower GI bleed nightmare is a diverticular bleed always look at the number of divertically in this small segment that I'm seeing sometimes a patient especially elderly people come with diverticular bleed we do a horrid endoscopy we go in we see blood everywhere we see diverticulum everywhere now which diverticulum is causing a bleed we don't okay we'll take another scenario patient has come hemodynamically stabilized we have given him blood but next day morning we've prepped him with the colonoscopy preparation he's passed a lot of tools the colon is clear go in look at multiple divertically we don't know which is to do it emergency to do it later still you are in a catch 22 situation in a diverticulum that's the biggest problem with the diverticulum bleed because when you go in in my last 12 years believe me I have seen only four cases where there was a sparting diverticular and I could clip it the rest of the cases it's always a catch you know cat and mouse game you have to go in when it is bleeding but by the time with the diverticula has stopped bleeding there is blood everywhere there are divertically everywhere you don't know which diverticulum has caused a very difficult the other thing that you can do in diverticula bleed is when they come if the bleeding rate is too high and if the creatinine is good you ask your interventional radiology colleague whether he can intervene he goes in does an angiogram CT angiogram initially localizes the bleed if not a regular angiogram you know conventional angiogram if he can embolize that particular vessel then it's it's a great relief you can you can always get away without doing much so diverticula bleeds are always a nightmare the other things the other massive bleeds that we see is polypectomy bleeds we do a polypectomy we send the patient home after 24 hours they come back with a massive bleeds because the base of the polyp would have had artery which would have you know given way and cause bleed at least in those situations we know where the bleed is and it's easy to identify and clip them