Gastrointestinal Bleeding Dr.Mirzaei

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GastrointestinalBleedingDr.Mirzaei
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• Bleeding oropharynx gt Anus
• Acute rapid loss of blood even shock
• Chronic anemia, fatigue
• Maybe the first symptom of GI disease
• Self limited or need for intervention

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• Hematemesis , coffee-ground
• Melena (50 60 cc)
• Hemato chezia
• Occult blood in stool (10 cc)

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• Upper G I Bleeding
• Lower G I Bleeding
• Obscure G I Bleeding

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• UPPER GI BLEEDING

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Causes of Upper GI Bleeding

• PUD 40
• Oesophagitis 10
• Varices 5
• Mallory Weiss Syndrome (longitudinal tear in
  the mucosa of the GE junction) 5
• Erosive Disease 6
• Neoplasm 4
• Other 6
• No Obvious Cause 24

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Massive Upper GI Bleeding

• Acute Bleeding Proximal to the ligament of treitz
• Requires blood transfusion

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Massive Upper GI Bleeding

• PUD
• Gastritis
• Mallory weiss Syndrome
• Esophagogastric Varices

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Massive Upper GI Bleeding ( Less Common Causes)

• Neoplasm (malignant benign)
• Angiodysplasia
• Dieulafoys Lesion (Congenital arteriovenous
  malformation)
• Arterioenteric Fistula (Aortic Graft-Repair of
  visceral artery aneurysm)

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History

• P. U. D-Heart burn reflux
• Drugs (NSAID- stroid- anticoagulant)
• Alcohol
• Cirrhosis

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Peptic ulcer disease

• Bleeding may be the first symptom
• DU GU 4 1

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Upper GI Bleeding

• Most common complication of PUD
• Most peptic ulcer related death
• Typically Present with melena and/or hematemesis

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Management

• Resuscitation
• Large-bore IV access (2 IV line)
• Foley catheterization
• NGT irrigation with normal saline (room
  temperature)
• Continuous IV PPI

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Managment

• Lab test
• CBC, Hb, HCT, Platelet
• BUN - Cr Na K
• PT, PTT
• L.F.T
• ABG
• E.C.G

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Upper GI Bleeding due to peptic ulcer

• Acid suppression NPO
• ¾ will stop
• ¼ will continue to bleed or will rebleed
• All mortalities operations occur in this group

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Risk Stratification

• Magnitude of the Hemorrhage
• - Shock
• - Hematemesis
• - Transfusion gt 4 units in 24 h
• - Hypotension
• - Tachycardia
• - Oliguria
• - Low Hct
• - Pallor
• - Altered Mentation

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Risk Stratification

• Comorbidities
• - Lung
• - Liver
• - Kidney
• - Heart
• Age
• Anticoagulated or immunosuppressed

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Risk Stratification

• Endoscopic Findings
• Bleeding from varices
• Active bleeding or Visible vessel

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High Risk Patients (25)

• Type Crossmatch
• Admit to ICU
• Consult Surgeon
• Consult gastroenterologist
• Start continuous infusion of PPI

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High Risk Group (25)

• Endoscopy within 12 hours after correction of
  coagulopathy (Diagnosis the cause Assess the
  need for hemostatic therapy)
• Endoscpic hemostasis
• Arteriography (occasionally)
• Operation

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Endoscopic Therapy

• Injection with epinephrine
• Electrocautery
• Clip (exposed vessel)

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Indications of Operation

• Massive Bleeding unresponsive to Endoscopic
  Therapy
• Transfusion requirement of gt 4-6 Unit
• Persistent bleeding or rebleeding after one or
  more endoscopic therapy
• Lack of availability of a therapeutic endoscopist
• Lack of availability of blood for transfusion
• Repeat hospitalization for bleeding ulcer
• Concurrent indication Perforation Obstruction

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Indications of Early Elective Operation

• After initially successful endoscopic treatment
• Elderly Patients
• Multiple comorbidity
• (dont tolerate another episode of Hemorrhage)
• Deep ulcer overlying a large vessel posterior
  duodenal bulb(Gastroduodenal Artery) or lesser
  gastric curve (left gastric artery)

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• LOWER GI BLEEDING

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Symptoms

• Unexplained Iron Deficiency Anemia (Occult
  Blood)
• Hematochezia
• Dark or Clot Rectal Bleeding
• Massive
• Shock

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Causes

• Hemorrhoids
• Fissure
• SRU
• IBD
• Malignancy
• Polyps

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Causes - Angiodysplasia

• Usually in cecum R.T Side colon
• Non congenital or Neoplastic but Degenerative
• No relation with other skin visceral vascular
  lesions
• with age
• Usually small lt 5 mm

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Causes - Angiodysplasia

• Colonoscopy or Angiography for diagnosis
• 80 self limited
• 50 Recurrence during 3 years
• Treatment options laser, electrocoagulation
  ,surgery

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Causes - Diverticulosis

• Left sided colon
• Cause of gt 50 massive lower GI Bleeding

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Causes

• Meckels Diverticulum
• Infectious Colitis
• A-V malformation
• Ischemic colitis
• Mesenteric Thrombosis

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History

• Weight loss
• Abdominal Pain / Cramp
• Recent Bowel Habit Change
• Ve Family hx of colorectal CA
• Drug History

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Management

• Resuscitation (2 IV Line)
• Correction of coagulopathy, thrombocytopenia
• Lab test
• CBC, Hb, HCT, Platelet
• BUN - Cr Na K
• PT, PTT
• L.F.T
• ABG
• E.C.G

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Identify the Source

• NGT
• - Return of Bile gt Source of Bleeding is
  distal to the ligament of treitz
• - Blood gt Upper GI Bleeding

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Proctoscopy DRE

• Rectal Tumors
• Hemorrhoids
• SRU
• Proctitis
• Rectal Polyps
• Varices

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Colonoscopy

• Stable Patients
• Rapid Bowel Prep 4-6 h
• Therapeutic
• - Cautery
• - Injection of Epinephrine

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99 mTC RBC Scintigraphy

• Massive Bleeding Responsive to conservative
  treatment (Stable Patients)
• Extremely Sensitive
• Detection of 0.1 ml/min bleeding
• Localization is imprecise
• Intermittent bleeding (can repeat till 30 h)

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Positive TC gt Angiogaphy

• To localize bleeding (the most definite for
  localization)
• Detection of 0.5 cc/min
• Infusion of vasopressin or angioembolization
  (Therapeutic)
• Catheter can left for laparotomy

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Barium Enema

• Double contrast
• Difficult, poor prep, unsuccessful colonoscopy

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• Obscure GI Bleeding

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• 90 lesions for GI Bleeding are within the reach
  EGD and colon
• lt10 GI Bleeding, No source by endoscopic
  studies
• Overt 80 Hematemesis, Melena, Hematochezia
• Occult 20 Iron-Deficiency Anemia, Positive
  Guaiac
• Most lesions in small intestine
• Angiodysplasia 75
• Neoplasms 10
• Meckels diverticulum most common in
  children

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• Crohns
• Infectious enteritis
• NSAID induced ulcers erosions
• Vasculitis
• Ischemia
• Varices
• Diverticula
• Intussusception

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Enteroscopy

• Push gt 60 cm Jejunum ( therapeutic)
• Sonde gt 50-75 of the small intestinal mucosa
  can be examined (No Biopsy or therapy)
• Wireless Capsule gt Success rate 90
  Radiotelemetry, portable, detectors attached to
  the patients body, stable patient but continues
  to bleed, success rate 90

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Enteroscopy

• Intraoperative Enteroscopy
• Oral
• Cecum
• Enterotomy
• Exam during insertion rather than withdrawal

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• Enteroclysis
• Small Bowel follow through
• MR Enterography
• Angiography (angiodysplasia, vascular tumors)
• 99 mTC labeled RBC Scan (Meckels Diverticulum)

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