Gastrointestinal Bleeding

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Gastrointestinal Bleeding

• Taimur Khan

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GI Bleed

• Upper GI Bleed
• Above the ligament of Treitz
• Common presentation hematemesis or melena
• Melena develops after 50-100 ml of blood loss in
  the upper GI tract
• Lower GI Bleed
• Below the ligament of Treitz
• Hematochezia can be the presentation but can also
  be present in 10 of upper GI bleed cases

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Upper GI Bleed

• Etiology of Rare Causes
• Aortoenteric Fistulas 2 of Abdominal Aortic
  Grafts
• Hemobilia (from hepatic tumors, angioma
  penetrating trauma
• Pancreatic Malignancy
• Pseudoaneurysm (hemosuccus pancreatitis)
• Dieulafoys Lesion (aberrant gastric sub-mucosal
  artery)

• Etiology Common Causes
• Peptic Ulcer Disease
• Portal Hypertension leading to variceal bleeding
• Mallory-Weiss Tears
• Vascular Anomalies
• Gastric Neoplasms
• Erosive Gastritis
• Erosive Esophagitis

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Management of Upper GI Bleed

• ABC always first and assess airway and breathing
  first
• For circulation assess blood pressure and pulse
  rate
• SBP lt 100 mmHg and pulse gt100 beats/min
  identifies high risk patients
• Postural hypotension and tachycardia may be
  present but other reasons also need assessment

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Management of Upper GI Bleed

• Two large bore at least 18 gauge needles placed
  and Intravenous (IV) fluids should be started
• CVP monitoring may be important in some cases but
  should not hinder the fluid resuscitation with IV
  fluids

• Lab Tests To Send
• CBC
• Chemistry panel and Creatinine
• PT/INR
• Liver Enzymes and Serologies if status not known
• Type and cross match
• Lactic acid whole blood

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Management of Upper GI Bleed

• Transfusion parameters keep Hematocrit between
  25-30, in absence of continued bleeding,
  hematocrit should rise 3 with each transfusion.
• Platelet transfusion for count below 50000/ µL,
  or platelet dysfunction due to aspirin regardless
  of counts
• Uremic Patient with platelet dysfunction with
  active bleeding are given three doses of DDAPV
  0.3 µgrams/kg IV at 12 hour intervals
• FFP for INR gt 1.5
• In cases of Massive GI bleeding, 1 unit of FFP
  for every 5 units of PRBC transfused
• Gastroenterology Consultation should also be
  sought for endoscopic procedures

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Management of Upper GI Bleed

• Medications
• Pantoprozole 80 mg IV bolus and then 8 mg/hr
  infusion for 72 hours, proven maintenance of high
  pH and also helps in healing
• For Variceal Bleeding Octreotide 100 µg bolus and
  then followed by 50-100 µg/hour. Once stabilized
  consider secondary prevention of variceal
  bleeding with beta-blockers
• Consider antibiotics for patients with variceal
  bleeding given high rate of spontaneous bacterial
  peritonitis after bleeding episode (3rd gen
  cephalosporins or fluroquinolones)
• Other Treatments
• Intra-arterial Embolization considered after
  endoscopic treatment has failed or cannot be done
• Transvenous intrahepatic portosystemic shunts
  (TIPS) can be done for acute variceal bleeding
  where endoscopic treatments have failed

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Management of Lower GI Bleed

• Other Causes
• Radiation-induced proctitis
• Acute infectious colitis
• Vasculitic ischemia
• Solitary rectal ulcer
• NSAID-induced ulcers
• Small bowel diverticula
• Colonic Vacices
• Meckels Diverticulum

• Etiology
• Diverticular bleeding most common in gt 50 yr age
• Vascular ectasias
• Neoplasms
• Inflammatory Bowel Disease
• Anorectal Disease
• Ischemic Colitis

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Management of Lower GI Bleed

• Exclude and upper GI source
• Volume resuscitation and blood transfusion by
  same principles of upper GI bleed
• Modalities of Treatment
• Colonscopy
• Nuclear Bleeding Scans, Technetium-labeled Red
  Blood Cell Scan (can detect up to 0.1 mL/min
  bleeding
• Angiography can detect up to 0.5-1mL/min of blood
  loss
• Meckels scan if Meckels diverticulum suspected
  usually in younger population but can
  occasionally be seen in adults

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Management of Lower GI Bleed

• Consider Gastroenterology consultation for
  procedures and management
• Consider General Surgery consult for
  non-resolving diverticular bleeding or for
  ischemic colitis and cancers.
• Other surgical indications 4-6 units of blood
  within 24 hours or more than total of 10 units of
  blood given for resuscitation