GIB algorithm

 

Upper vs. Lower

 

Upper:

 

Medical management:  volume, prbcs, correct coagulopathy

arterial vs. variceal:  is there hx of Cirrhosis/ portal hypertension?

Endoscopy first- if cannot, why

CTA- get one, if neg get NM scan

 

If embo, decide loc

agents:  gelfoam and coils, possibly spheres

 

if fundal:  L GA embo, can be tricky to cath- consider Sos or upward facing catheter

If distal:  GDA embo

consider SMA- IPDA backdoor bleeding

 

if Variceal:

endoscopic management

coag correction

blood products

BLAKEMORE TUBE - is it in?

Child pugh score or Meld to predict mortality

 

Lower:

Again, endo usually first

usually they will say unprepped colon difficult to treat

 

again, medical mangament, blood and coag correction

CTA and / or NM scan

 

if failed endo management or do not want, do angiography

 

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for small bowel:

 

there are various endoscoipc methods of getting into small bowel

double balloon enteroscopy?

 

still anybody's guess

CTA

NM scan

Angiography poss embolization

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post Whipple GDA stump bleed

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can happen post whipple

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what to do

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usually will see excessive bleeding from drain sites

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can order CTA to eval GDA stump

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overall plan for managemnet is to stent across GDA and exclude with covered balloon exp stent eg the Atrium Icast

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stent has to pass through sheath

so have to go to 6F sheath to enter celiac

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case like this:
access RCFA

get celiac access

track wire (glide) out to R HA

then switch over 4F glidecath for amplatz

track 6F sheath up to celiac

if can track sheath past GDA stump, thats ideal- why cuz DK says stent can shear off delivery cath

do pre angio

figure out where to drop balloon exp stent

to size stent, measure off angio or prior CTA

advance stent over wire through sheath

try to unsheath the stent

then using insufflator, blow up stent to nominal

afterwards, likely to have type1 endoleak

can balloon stent up past nominal (like 7 to 8 mm or 9 if have to)

will have better seal

do post angio

close groin with Proglide (good for up to 8F access)

when able, place pt on Plav and asa

it is likely the stent will thrombose in 1 yr

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