Gastrointestinal Bleeding

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Gastrointestinal Bleeding

• Rajeev Jain, M.D.

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GI Bleeding

• Background
• Acute Upper GI Bleed
• Acute Lower GI Bleed

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Clinical PresentationDefinitions

• Hematemesis bloody vomitus (bright red or
  coffee-grounds)
• Melena black, tarry, foul-smelling stool
• Hematochezia bright red or maroon blood per
  rectum
• Occult positive guaiac test
• Symptoms of anemia angina, dyspnea, or
  lightheadedness

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Clinical Presentation

• Reflection of bleeding
• Site
• Etiology
• Rate

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Initial Patient Assessment Hemodynamic Status
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Resuscitation

• 2 large bore peripheral IVs
• Colloid (normal saline or lactated Ringers)
• Transfuse packed RBCs
• In elderly, goal Hct 30
• In young, goal Hct 20-25
• In cirrhotics, goal Hct 25-28
• Correct coagulopathy
• Reassess hemodynamics

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History

• Prior history of bleeding
• Previous gastrointestinal illnesses
• Previous surgery
• Other medical conditions (ie, cirrhosis)
• Medications
• Aspirin, NSAIDs, anti-platelet agents
• Anticoagulants
• ? SSRIs
• Abdominal pain, weight loss

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Physical Exam Labs

• Focused but thorough
• Look for markers of liver disease
• Laboratory studies
• CBC
• INR
• Electrolytes
• Type and crossmatch RBCs

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Acute BleedingChanges Before and After 2 Liter
Bleed
45
45
27
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Location of Bleeding

• Upper
• Proximal to Ligament of Treitz
• Melena (100-200 cc of blood)
• Azotemia
• Nasogastric aspirate
• Lower
• Distal to Ligament of Treitz
• Hematochezia

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Acute UGIBDemographics

• Annual incidence of hospitalization 100/100,000
  persons
• 80 self-limited
• Mortality stable at 10
• Continued or recurrent bleeding - mortality 30-40

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Acute UGIBPrognostic Indicators

• Cause of bleeding
• Severity of initial bleed
• Age of the patient
• Comorbid conditions
• Onset of bleeding during hospitalization

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Acute UGIBPrognostic Indicators
Tedesco et al. ASGE Bleeding Survey. Gastro Endo.
1981.
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Acute UGIBDifferential Diagnosis
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Acute UGIBDifferential Diagnosis

• Peptic ulcer disease
• Gastric ulcer
• Duodenal ulcer
• Mallory-Weiss tear
• Portal hypertension
• Esophagogastric varices
• Gastropathy
• Esophagitis

• Dieulafoys lesion
• Vascular anomalies
• Hemobilia
• Hemorrhagic gastropathy
• Aortoenteric fistula
• Neoplasms
• Gastric cancer
• Kaposis sarcoma

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Acute UGIBFinal Diagnoses of the Cause in 2225
Patients
Tedesco et al. ASGE Bleeding Survey. Gastro Endo.
1981.
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Acute UGIBCauses in CURE Hemostasis Studies
(n948)
Savides et al. Endoscopy 199628244-8.
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Acute UGIBCORI Database 7822 EGDs b/n 1999-2001
Boonpongmanee S. et al. Gastrointest Endosc
200459788-94.
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Peptic UlcersStigmata of Recent Hemorrhage (SRH)
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Acute Peptic Ulcer BleedingPrognosis by SRH
Laine and Peterson. New Eng J Med
1994331717-27.
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Endoscopic Therapy of PUD

• Thermal
• Bipolar probe
• Monopolar probe
• Argon plasma coagulator
• Heater probe
• Mechanical
• Hemoclips
• Band ligation

• Injection
• Epinephrine
• Alcohol
• Ethanolamine
• Polidocal

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Endoscopic Therapy of PUD
Laine and Peterson New Eng J Med 1994331717-27.
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Peptic Ulcer BleedingAdjuvant Medical Therapy

• Erythromycin
• 250 mg IV 30 minutes before endoscopy decreases
  blood in stomach
• Proton pump inhibitor therapy
• 80 mg IV bolus followed by 8 mg/hr continuous
  infusion for 72 hrs
• Reduced risk
• Rebleeding (NNT 12)
• Surgery (NNT 20)

Leontiadis, G. et al. BMJ 2005330568
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Mallory-Weiss Tear
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Esophageal Varices
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Variceal Band Ligation
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Variceal Band Ligation
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Variceal Band Ligation
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MEDICAL THERAPYAcute Variceal Bleeding

• Octreotide
• Cyclic octapeptide analog of somatostatin
• Longer acting than somatostatin
• Equivalent to sclerotherapy and improves
  endoscopic results

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Transjugular Intrahepatic Portosystemic Shunt
(TIPS)
Coronary Vein
IVC
Splenic Vein
Portal Vein
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Aortoduodenal Fistula
Aorta
Duodenum
Fistula
Graft
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Acute UGIB Surgery

• Recurrent bleeding despite endoscopic therapy
• gt 6-8 units pRBCs

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Acute LGIBDifferential Diagnosis
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Acute LGIBDifferential Diagnosis

• Diverticulosis
• Colitis
• IBD (UCgtgtCD)
• Ischemia
• Infection
• Vascular anomalies
• Neoplasia
• Anorectal
• Hemorrhoids
• Fissure

• Dieulafoys lesion
• Varices
• Small bowel
• Rectal
• Aortoenteric fistula
• Kaposis sarcoma
• UPPER GI BLEED

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Acute LGIBDiagnoses in pts with hemodynamic
compromise.
Zuccaro. ASGE Clinical Update. 1999.
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Etiology of Acute LGIB
Strate LL. Gastroenterol Clin North Am. 2005
Dec34(4)643-64.
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Outcomes of Acute LGIB
Strate LL. Gastroenterol Clin North Am. 2005
Dec34(4)643-64.
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Diverticulosis
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Diverticular Bleeding
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Urgent Colonoscopy for the Diagnosis and
Treatment of Severe Diverticular Hemorrhage

• 121 pts with severe bleeding (gt4 hrs after
  hospitalization)
• 1st 73 pts no colonoscopic tx
• Last 48 pts eligible for colonoscopic tx
• Colonoscopy w/in 6-12 hrs

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Urgent Colonoscopy for the Diagnosis and
Treatment of Severe Diverticular Hemorrhage
Jensen DM, et al. New Eng J Med 200034278-82.
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Ischemic Colitis

• Most common form of intestinal ischemia
• Transient and reversible
• Abdominal pain
• Watershed areas
• Splenic flexure
• Rectosigmoid junction

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Hemorrhoids
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Bleeding AVM
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Radiation Proctitis
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Acute LGIBMeckels Diverticulum

• Incidence 0.3 - 3.0
• Etiology Incomplete obliteration of the
  vitelline duct.
• Pathology 50 ileal, 50 gastric, pancreatic,
  colonic mucosa
• Complications
• Painless bleeding (children, currant jelly)
• Intussusception

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Acute LGIBEvaluation
Zuccaro. ASGE Clinical Update. 1999.
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Acute LGIBKey Points

• Annual incidence of hospitalization
• 20-30/100,000 persons
• Resuscitation
• Exclude an UGI source
• Most bleeding ceases
• Colonoscopy
• No role for barium studies