GI Bleeding

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GI Bleeding
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G.I. Bleeding Case

• 50 yrs, Pakistani, male
• C/O Bleeding/rectum Abdominal pain
• Painless rectal bleeding, 1 yr excess bleeding,
  1 month
• Black, 4-5 times/day, little quant.
• Abdominal pain
• Vomiting, 1 week

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G.I. Bleeding Case

• M.H
• no peptic ulcer disease
• no medications (NSAIDs)
• no urinary symptoms
• not known DM, HPTN, IHD
• ve weight loss

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G.I. Bleeding Case

• O/E
• Afebrile
• no pallor
• not dyspneaic
• no lymphoadenopathies
• no S.C.L.N

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G.I. Bleeding Case

• Vital Signs
• Pulse 78 bts/min
• BP 130/80
• RR 18 br/min
• Heart NAD
• Lung NAD

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G.I. Bleeding Case

• Abdomen exam
• not distended
• no epigastic tenderness
• tender, firm, partly mobile mass at Rt
  lumbar region.
• spleen not palpable
• Lt lobe liver palpable, mildly tender
• bowel sounds present

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G.I. Bleeding Case

• PR
• no enlarged piles
• no active bleeding
• no palpable mass
• no blood on finger
• ECG, CBC, Sr Amylase, Bleeding profile, Abd
  X-ray, fecal loading ascending colon

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G.I. Bleeding Case

• Lab Results
• Hb 14.1 g/dl Plt 252 103
• Hypochromic, microcytic
• PT 17.3 sec aPTT 35.4 sec
• Sr Amy 129 U/l ? 106 U/l
• Na 140 mmol/l K 4.1 mmol/l
• BUN 17 mg/dl

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Epidemiology

• GI bleeding can occur in individuals of any age,
  but most commonly affects people in their 40s
  through 70s (mean age 59 years).
• Most deaths caused by GI bleeding occur in
  patients older than age 60 years.
• UGIB is more common in men than women (21),
  whereas LGIB is more common in women.
• Significant UGIB requiring admission is more
  common in adults, whereas LGIB requiring
  admission is more common in children.

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Epidemiology

• The overall mortality of GI bleeding is
  approximately 10
• GI bleeding is often easy to identify when there
  is clear evidence of vomiting blood or passing
  blood in the stool, but it may present subtly
  with signs and symptoms of hypovolemia, such as
  dizziness, weakness, or syncope.

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Epidemiology

• The approach to GI bleeding depends on whether
  the hemorrhage is located in the proximal or
  distal segments of the GI tract (i.e., upper or
  lower GI bleeding).
• These segments are defined by the ligament of
  Treitz in the fourth section of the duodenum.
• Upper GI bleeding (UGIB) affects 50 to 150 people
  per 100,000 population each year and results in
  250,000 admissions.
• Lower GI bleeding (LGIB) affects a smaller
  portion of patients and results in proportionally
  fewer hospital admissions than UGIB.

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G.I. Bleeding

• Acute Vs Chronic
• Acute Upper G.I.Bleeding
• Acute Lower G.I.Bleeding

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Acute Upper G.I. Bleeding

• Haematemesis
• Melaena

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Etiology of Significant GI Bleeding in Adults

• Upper
• Peptic ulcer disease   
• Gastric erosions   
• Varices   
• Mallory-Weiss tear   
• Esophagitis  
• Duodenitis

• Lower
• Upper GI bleeding   
• Diverticulosis   
• Angiodysplasia   
• Cancer/polyps   
• Rectal disease   
• Inflammatory bowel disease

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Etiology of Significant GI Bleeding in Childrens

• Upper
• Esophagitis   
• Gastritis   
• Ulcer   
• Esophageal varices  
•  Mallory-Weiss

• Lower
• Anal fissure   
• Infectious colitis   
• Inflammatory bowel   
• Polyps   
• Intussusception

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Acute U.G.I. Bleeding

• Aetiology
• 1. Drugs (Aspirin NSAIDs)
• 2. Alcohol
• 3.Chronic peptic ulceration (50 of GI
  hemorrhage)
• 4.Others reflux esophagitis, varices, gastric
  carcinoma, acute gastric ulcers erosions.

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Acute U.G.I. Bleeding

•     Clinical approach
• High risk pts.
• age (60 )
• amount of blood lost
• continuing visible blood loss.
• signs of chronic liver disease
• classical clinical features of shock
• Liver disease? severe (varices)
• splenomegaly ? portal hypertension

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Rapid Assessment and Stabilization

• Patients may complaining of vomiting blood or
  passing black or bloody stool.
• If hemodynamically unstable should undergo rapid
  evaluation and resuscitation.
• cardiac and oxygen saturation monitors.
• At least 2 large-bore IV lines (minimum
  18-gauge)
• blood should be drawn for
• hemoglobin or hematocrit,
• platelet count,
• prothrombin time (PT), and
• type and screen or type and
• Crossmatch.

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Rapid Assessment and Stabilization

• ABCs
• Is pt. in shock or not??
• IV crystalloid fluid should be given as a 2-L
  bolus in adults or 20 mL/kg in children.
• Then consider type O, type-specific, or
  crossmatched blood.

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History

• Hematemesis (vomiting blood)
• occurs with bleeding of the esophagus, stomach,
  or proximal small bowel.
• Approximately 50 of patients with UGIB present
  with this complaint.
• Hematemesis may be bright red or darker (i.e.,
  coffee groundlike) as a result of conversion of
  hemoglobin to hematin or other pigments by
  hydrochloric acid in the stomach.
• The color of vomited or aspirated blood from the
  stomach cannot be used to determine if the
  bleeding is arterial or venous in nature.

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History

• Melena, or black tarry stool,
• occurs from approximately 150 to 200 mL of blood
  in the GI tract for a prolonged period.
• Melena is present in approximately 70 of
  patients with UGIB and a 1/3 of patients with
  LGIB.
• Black stool that is not tarlike may result from
  60 mL of blood from the upper GI tract.
• Blood from the duodenum or jejunum must remain in
  the GI tract for approximately 8 hours before
  turning black.
• Stool may remain black and tarry for several
  days, even though bleeding has stopped.

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• Rectal bleeding may be manifested by bright red
  blood, blood mixed with stool, or black, tarry
  stools.
• Bright red blood per rectum (BRBPR), also known
  as HEMATOCHEZIA, can occur from colonic tumors,
  diverticular disease, or ulcerative colitis.
• Blood mixed with stool can be the result of
  ulcerative colitis, diverticular disease, tumors,
  or hemor- rhoids.
• Ask the patient who describes rectal bleeding the
  following questions
• "How long have you noticed bright red blood in
  your stools?"
• "Is the blood mixed with the stool?"
• "Are there streaks of blood on the surface of the
  stool?"
• "Have you noticed a change in your bowel habits?"
  
• "Have you noticed a sensation in your rectum that
  you have to move your bowels but cannot?

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• TENESMUS is the painful, continued, and
  ineffective straining at stool.
• It is caused by inflammation or tumor at the
  distal rectum or anus.
• Hemorrhoidal bleeding is a common cause of
  hematochezia and streaking of stool with blood.
• MELENA is a black, tarry stool that results from
  bleeding above the first section of the duodenum,
  with partial digestion of the hemoglobin.
• A useful way of questioning is to show the
  patient the black tubing on the stethoscope and
  ask, "Have your bowel movements ever been this
  color?" If asked directly whether the bowel
  movements have ever been black, the patient may
  answer in the affirmative, equating dark (normal)
  stools with black stools.

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• Ask these questions of a patient who describes
  melena
• "Have you passed more than one black, tarry
  stool?" If so, "When?"
• "How long have you been having black, tarry
  stools?"
• "Have you noticed feeling lightheaded?"
• "Have you had any nausea associated with these
  stools? any vomiting? diarrhea? abdominal pain?
  sweating?"
• The answers to these questions can provide some
  information regarding the acuteness and the
  amount of the hemorrhage.
• Lightheadedness. nausea, and diaphoresis are seen
  with rapid gastrointestinal bleeding and
  hypotension.

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History

• Hematochezia, or bloody stool (bright red or
  maroon),
• most often signifies LGIB, but may be due to
  brisk UGIB with rapid transit time through the
  bowel.
• Because UGIB is much more common than LGIB, a
  more proximal source of significant bleeding must
  be excluded before assuming the bleeding is from
  the lower GI tract.
• Approximately two thirds of patients with LGIB
  present with red blood per rectum.
• Small amounts of red blood (e.g., 5 mL) from
  rectal bleeding, such as bleeding due to
  hemorrhoids, may cause the water in the toilet
  bowl to appear bright red.
• Bright red stools also can be seen after
  ingestion of a large quantity of beets, but
  Hemoccult testing would be negative.

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History

• When taking the history, specific questions
  should address
• the duration and quantity of bleeding,
• associated symptoms,
• previous history of bleeding,
• current medications,
• alcohol, NSAIDs and long-term aspirin ingestion,
• allergies,
• associated medical illnesses,
• previous surgery,

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History

• Patients with GI bleeding may complain of
  symptoms of hypovolemia, such as dizziness,
  weakness, or LOC, most often after standing up
  (POSTURAL).
• Other nonspecific complaints include dyspnea,
  confusion, and abdominal pain.
• Rarely an elderly patient may present with
  ischemic chest pain from significant anemia.
• One in five patients with GI bleeding may have
  only nonspecific complaints.

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History

• History is of limited help in predicting the site
  or quantity of bleeding.
• Patients with a previously documented GI lesion
  bleed from the same site in only 60 of cases.
• Gross estimates of blood loss based on the volume
  and color of the vomitus or stool (e.g., brown or
  black, pink or red) or the number of episodes of
  hemorrhage are notoriously inaccurate.

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Physical Examination

• Vital Signs
• Vital signs and postural changes in heart rate
  can be used to assess the amount of blood loss.
• All patients with a history suggesting GI
  bleeding who are hypotensive, are tachycardic, or
  have sustained postural changes of greater than
  20 beats/min in heart rate should be assumed to
  have significant hemorrhage.
• Normal vital signs do not exclude significant
  hemorrhage.

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Physical Examination

• General Examination
• vital signs, mental status (including
  restlessness),
• skin signs
• (e.g., color, warmth, and moisture to assess for
  shock and lesions such as telangiectasia,
  bruises, or petechiae to assess for vascular
  diseases or hypocoagulable states),
• pulmonary and cardiac findings,
• abdominal examination, and
• rectal and stool examination.
• Frequent reassessment is important because a
  patient's status may change quickly.

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Physical Examination

• Rectal Examination
• Rectal and stool examination are often key to
  making or confirming the diagnosis of GI
  bleeding.
• The finding of red, black, or melenic stool early
  in the assessment is helpful in prompting early
  recognition and management of patients with GI
  bleeding.
• The absence of black or bloody stool does not
  exclude the diagnosis of GI bleeding.
• Regardless of the apparent character and color of
  the stool, occult blood testing is indicated.

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Ancillary Testing

• Tests for Occult Blood
• Stool tests for occult blood may have positive
  results 14 days after a single, major episode of
  UGIB.
• False-positive with
• ingestion of red fruits and meats, methylene
  blue, chlorophyll, iodide, cupric sulfate, and
  bromide preparations.
• False-negative
• bile or ingestion of magnesium-containing
  antacids or ascorbic acid.
• In newborns, maternal blood that is swallowed may
  cause bloody stools.

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• A stool guaiac test detects the presence of fecal
  occult blood.

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Ancillary Testing

• Clinical Laboratory Tests
• hematocrit or hemoglobin, coagulation studies (PT
  and platelet count), and type and crossmatch (or
  type and screen if the patient is stable).
• The optimal hematocrit with respect to
  oxygen-carrying capacity and viscosity in
  critically ill patients has been reported to be
  33.
• In general, patients with hemoglobin of 8 g/dL or
  less (hematocrit lt25) from acute blood loss
  usually require blood therapy.
• After transfusion and in the absence of ongoing
  blood loss, the hematocrit can be expected to
  increase approximately 3 for each unit of blood
  administered (hemoglobin increases by 1 mg/dL).

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Ancillary Testing

• Clinical Laboratory Tests
• PT should be used to determine preexisting
  coagulopathy.
• An elevated PT may indicate
• Vitamin K deficiency, liver dysfunction, warfarin
  therapy, or consumptive coagulopathy.
• elevated PT and evidence of active bleeding
  should receive fresh frozen plasma to correct the
  PT.
• Serial platelet counts are used to determine the
  need for platelet transfusions (i.e., if
  lt50,000/mm3).

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Ancillary Testing

• Blood Bank
• Blood should be sent for type and hold or type
  and crossmatch early in the patient's care.
• Immediate transfusion needs in unstable patients
  can be met with O-positive PRBC
• Within 10 to 15 minutes, type-specific blood is
  usually available.
• Fully crossmatched blood may take 60 minutes to
  prepare.
• Stable patients can be managed more
  cost-effectively by ordering type and hold for
  several units of blood.

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Ancillary Testing

• Other Laboratory Tests
• Determination of electrolytes, blood urea
  nitrogen, and creatinine may be useful in a small
  percentage of patients with GI bleeding when
  indicated.
• Patients with repeated vomiting may develop
  hypokalemia, hyponatremia, and metabolic
  alkalosis, which usually correct with adequate
  hydration and resolution of vomiting.
• The blood urea nitrogen is elevated in many
  patients with UGIB as a result of the absorption
  of blood from the GI tract and hypovolemia
  causing prerenal azotemia.
• After 24 hours, hypovolemia is probably the sole
  determinant of azotemia unless there has been
  recurrent bleeding.

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Ancillary Testing

• Electrocardiogram
• An electrocardiogram should be obtained on all
  patients older than age 50 patients with
  preexisting ischemic cardiac disease patients
  with significant anemia and all patients with
  chest pain, shortness of breath, or severe
  hypotension.
• Asymptomatic myocardial ischemia (ST segment
  depression gt1 mm) or injury (ST segment elevation
  gt1 mm) may develop in the setting of GI bleeding.
  
• Patients with GI bleeding and clinical or
  electrocardiogram evidence of myocardial ischemia
  should receive packed red blood cells as soon as
  they are available and appropriate treatment for
  ischemia.

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Ancillary Testing

• Imaging
• GI hemorrhage is not an indication for plain
  abdominal radiography.
• An upright chest radiograph should be performed
  in patients with UGIB suspected of aspiration or
  with signs and symptoms of bowel perforation
  (shock with significant abdominal/peritoneal
  tenderness).
• Subdiaphragmatic air consistent with bowel
  perforation is a rare finding with UGIB, but it
  is an indication for immediate surgical
  consultation and operative repair.

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Management

• Nasogastric Tube and Gastric Lavage
• it is important to identify whether the
  hemorrhage UGIB or LGIB. .
• Aspiration of bloody contents diagnoses UGIB, but
  it does not differentiate if the bleeding is
  ongoing or has already stopped.
• 10 incidence of.
• The presence of bile in an otherwise clear
  aspirate excludes the possibility of active
  bleeding above the ligament of Treitz, but is
  rarely seen and should not be used to exclude
  UGIB in a patient with documented melena.

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Management

• Nasogastric Tube and Gastric Lavage
• False-positive results may occur from nasal
  bleeding.
• Because up to 11 of patients with hematochezia
  have UGIB, a nasogastric tube is indicated in
  most cases of LGIB.
• Gastric tubes are safe in most patients, but
• pharyngeal and esophageal perforation,
• cardiac arrest,
• ethmoid sinus fracture with brain trauma, and
• bronchial intubation have been reported.
• No evidence exists that gastric tube placement
  aggravates hemorrhage from varices or
  Mallory-Weiss tears.

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Management

• Gastric lavage
• Gastric lavage does not reduce blood loss in
  patients with UGIB, and iced lavage is not
  recommended.
• Gastric lavage, in preparation for endoscopy, can
  be performed
• Gastric rupture has been reported as a rare
  complication of gastric lavage

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Management

• Endoscopy
• Endoscopy is the most accurate diagnostic tool
  available for the evaluation of UGIB.
• It identifies a lesion in 78 to 95 of patients
  with UGIB if it is performed within 12 to 24
  hours of the hemorrhage.
• allows for risk stratification with respect to
  predicting rebleeding and mortality.
• therapeutic value in select patients (e.g.,
  banding or sclerosing of varices).

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Management

• Angiography
• the use of angiography has decreased
  significantly, used in only 1 of patients with
  UGIB.
• more commonly in patients with LGIB
• Although angiography rarely diagnoses the cause
  of bleeding, it does identify the site of
  bleeding in approximately 40 of patients who
  have LGIB and 65 of patients who eventually
  require surgical intervention.

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Management

• Gastric Acid Secretion Inhibition
• All patients with documented peptic ulcer disease
  should be treated with a proton-pump inhibitor
  (e.g., omeprazole).
• Octreotide (Somatostatin Analogues)
• Patients with documented esophageal varices
  should be treated with an intravenous infusion of
  octreotide at 50 µg/hr .
• It is a useful addition to endoscopic
  sclerotherapy and decreases rebleeding
  occurrences.

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Management

• Vasopressin
• most commonly in patients with variceal
  hemorrhage.
• Controlled studies have not shown a positive
  effect of vasopressin on overall mortality.
• A trial of vasopressin may be warranted in an
  exsanguinating patient with suspected variceal
  bleeding, especially if endoscopy is unavailable.

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Management

• Sengstaken-Blakemore Tube
• The Sengstaken-Blakemore tube stops hemorrhage in
  approximately 80 of patients bleeding from
  esophageal varices.
• A trial of balloon tamponade should be
  considered, however, in an exsanguinating patient
  with probable variceal bleeding in whom endoscopy
  is not immediately available and vasopressin has
  not slowed the hemorrhage.

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• B to inflate the gastric balloon.
• Channel C (gastric aspiration) and
• D (esophageal aspiration) enable blood and
  secretion to be sucked out.

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Management

• Surgery
• Surgery is indicated for all hemodynamically
  unstable patients with active bleeding who do not
  respond to appropriate intravascular volume
  replacement, correction of any coagulopathy, and
  endoscopic intervention (if available).
• The mortality for patients undergoing emergency
  operations for GI bleeding is approximately 23.
• Emergency surgery should be considered when
  blood replacement exceeds 5 U within the first 4
  to 6 hours or when 2 U of blood is needed every 4
  hours after replacing initial losses to maintain
  normal cardiac output.

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Management

• Remmber
• ABCs

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Lower gastrointestinal haemorrhage

• Causes
• Diverticular disease
• Angiodysplasia
• Inflammatory bowel disease
• Ischaemic colitis
• Infective colitis
• Colorectal carcinom

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Investigation

• Most patients are stable and can be investigated
  once bleeding has stopped
• In the actively bleeding patient consider
  Colonoscopy - can be difficult
• Selective mesenteric angiography Requires
  continued bleeding of gt1 ml/minute
• May show angiodysplastic lesions even once
  bleeding has ceased

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Management

• Anoscopy/Proctosigmoidoscopy
• Patients with mild rectal bleeding who do not
  have obviously bleeding hemorrhoids should have
  anoscopy/proctosigmoidoscopy performed.
• The absence of blood above the rectum in a
  patient who is actively bleeding indicates that
  the source of bleeding is in the rectum.
• The presence of blood above the anoscope or
  sigmoidoscope does not invariably indicate a
  proximal source of bleeding because retrograde
  passage of blood into the more proximal colon
  commonly occurs.

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Management

• Acute bleeding tends to be self limiting
• Consider selective mesenteric embolisation if
  life threatening haemorrhage
• If bleeding persists perform endoscopy to exclude
  upper GI cause
• Proceed to laparotomy and consider on-table
  lavage an panendoscopy
• If right-sided angiodysplasia perform a right
  hemicolectomy
• If bleeding diverticular disease perform a
  sigmoid colectomy
• If source of colonic bleeding unclear perform a
  subtotal colectomy and end-ileostomy

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THE END