Transcript bleeding - yeditepetip4

Gastrointestinal Bleeding
Prof. Dr. Orhan Tarçın
Yeditepe Üniversitesi, Gastroenteroloji Bölümü
Gastrointestinal Bleeding
• The annual rate of hospitalization for any type of
gastrointestinal (GI) hemorrhage in the United
States is estimated to be 350 hospital
admissions/100,000 population, with more than
1,000,000 hospitalizations annually.
• Approximately 50% of admissions for GI bleeding
are for upper GI (UGI) bleeding (from the
esophagus, stomach, duodenum), 40% are for
lower GI (LGI) bleeding (from the colon and
anorectum), and 10% are for obscure bleeding
(from the small intestine).
Gastrointestinal Bleeding
• The source of most GI bleedings can be
suspected by the clinical symptoms and
physical examination and confirmed by upper
or lower endoscopy.
• Initial management focuses on medical
resuscitation, followed by endoscopic
diagnosis and interventions to stop acute
bleeding and prevent recurrent bleeding.
Gastrointestinal Bleeding
• Pharmacologic therapy is playing an
increasingly important role in the
management of UGI bleeding from peptic
ulcers and varices.
• Optimal patient outcomes depend on
successful medical resuscitation, precise
endoscopic diagnosis, and appropriate use of
therapeutic endoscopy
Defining of GI Bleeding
• Severe gastrointestinal bleeding is defined as
documented gastrointestinal bleeding (i.e.,
hematemesis, melena, hematochezia, or
positive nasogastric lavage) ;accompanied by
shock or orthostatic hypotension, a decrease
in the hematocrit value by at least 6% (or a
decrease in the hemoglobin level of at least 2
g/dL), or transfusion of at least two units of
packed red blood cells.
Hematemesis
• Hematemesis is defined as vomiting of blood,
which is indicative of bleeding from the
esophagus, stomach, or duodenum.
Hematemesis includes vomiting of bright red
blood, which suggests recent or ongoing
bleeding, and dark material (coffee-ground
emesis), which suggests bleeding that stopped
some time ago.
Melena
• Melena is defined as black tarry stool and results
from degradation of blood to hematin or other
hemochromes by intestinal bacteria.
• Melena can signify bleeding that originates from
UGI, small bowel, or proximal colonic source.
• Melena generally occurs when 50 to 100 mL or
more of blood is delivered into the GI tract
(usually the upper tract), with passage of
characteristic stool occurring several hours after
the bleeding event.
Hematochezia
• Hematochezia refers to bright red blood per
rectum, and suggests active UGI or small
bowel bleeding, or distal colonic or anorectal
bleeding.
Obscure gastrointestinal bleeding
• Obscure gastrointestinal bleeding is bleeding
from a site that is not apparent after routine
endoscopic evaluation with
esophagogastroduodenoscopy (upper
endoscopy) and colonoscopy, and possibly
small bowel radiography.
• Occult gastrointestinal bleeding refers to
subacute bleeding that is not clinically visible.
Causes Of Upper GI Bleeding
CAUSE
FREQUENCY (%)
Peptic ulcer
38
Gastric or esophageal varix
16
Esophagitis
13
No cause found
8
Upper gastrointestinal tract tumor
7
Angioma*
6
Mallory-Weiss tear
4
Erosions
4
Dieulafoy's lesion
2
Other
2
Causes of Severe Hematochezia (%)
LESION
Study
REFERENCE 218
REFERENCE 219
UCLA CURE
Diverticulosis
30
33
30
Colon cancer or polyps
18
21
6
Colitis
17
17
21
NP( not provided)
7
12
IBD
NP
4
9
Noninfectious colitis
NP
5
0
Infectious colitis
NP
1
0
6
3
Ischemic colitis
Angioectasia
7
Postpolypectomy
6
NP
8
Rectal ulcer
NP
1
6
Hemorrhoids
NP
20
14
Anorectal source (unspecified)
4
3
0
Radiation colitis
0
0.5
3
Other
8
3
6
Unknown
16
0
0
History Taking
• Initial assessment of the patient with acute GI
bleeding includes medical history taking,
obtaining vital signs, performing a physical
examination, including a rectal examination,
and nasogastric lavage.
• During history taking, patients should be
questioned about risk factors and historical
features that help identify diagnostic
possibilities for the bleeding source.
PHYSICAL EXAMINATION
• On initial evaluation, physical examination should
focus on the patient's vital signs, with attention
to signs of hypovolemia such as hypotension,
tachycardia, and orthostasis.
• The abdomen should be examined for surgical
scars, tenderness, and masses.
• Signs of chronic liver disease include spider
angiomata, palmar erythema, gynecomastia,
ascites, splenomegaly, caput medusae, and
Dupuytren's contracture.
PHYSICAL EXAMINATION
• The skin, lips, and buccal mucosa should be examined for
telangiectasias, which are suggestive of hereditary
hemorrhagic telangiectasia (HHT), or Osler-Weber-Rendu
disease.
• Pigmented lip lesions may suggest Peutz-Jeghers syndrome.
• Purpuric skin lesions may suggest Henoch-Schönlein
purpura.
• Acanthosis nigricans may suggest underlying malignancy,
especially gastric cancer.
• The patient's feces should be observed to identify melena
or maroon (kesteane rengi) and red stool; however, the
subjective description of stool color varies greatly among
patients and physicians.[4]
PHYSICAL EXAMINATION-2
• Nasogastric or orogastric tube placement to
aspirate and visually characterize gastric
contents can be useful to determine the
presence or absence of large amounts of red
blood, coffee-ground material, or nonbloody
fluid.
LABORATORY STUDIES
• Blood from the patient with acute GI bleeding
should be sent for standard hematology,
chemistry, liver biochemical, and coagulation
studies and for typing and crossmatching for
packed red blood cells.
• The hematocrit value immediately after the onset
of bleeding may not reflect blood loss accurately
because over 24 to 72 hours there is equilibration
of red blood cells in the vascular space with
extravascular fluid and hemodilution resulting
from intravenous administration of saline.
MCV –WBC-Platelet
• The mean corpuscular volume (MCV) is an important
indicator of the chronicity of blood loss; an MCV lower than
80 fL suggests chronic GI blood loss and iron deficiency,
which can be confirmed by the finding of low blood iron,
total iron-binding capacity (TIBC), and ferritin levels.
• A low MCV and negative fecal occult blood test result raise
the possibility of celiac disease. A high MCV (>100 fL)
suggests chronic liver disease or folate or vitamin B12
deficiency.
• An elevated white blood cell count may occur in more than
half of patients with UGI bleeding and has been associated
with greater severity of bleeding.[
• A low platelet count can contribute to the severity of
bleeding and suggests chronic liver disease or a
hematologic disorder.
LABORATORY STUDIES
• The blood urea nitrogen (BUN) and serum
creatinine levels can help assess the patient for
hemoconcentration (elevated levels) or chronic
kidney disease, which may lead to chronic anemia
because of decreased erythropoietin production.
• In patients with UGI bleeding, the BUN level
typically increases to a greater extent than the
serum creatinine level because of increased
intestinal absorption of urea after the breakdown
of blood proteins by intestinal bacteria.
PT-INR and Others
• The prothrombin time (PT) and international
normalized ratio (INR) assess whether a patient
has impairment of the extrinsic coagulation
pathway.
• Values can be elevated in chronic liver disease or
with the use of warfarin.
• Liver biochemical test levels may indicate the
presence of acute or chronic liver disease; a low
serum albumin level suggests possible chronic
liver disease, malnutrition, or protein loss via the
intestine or kidney.
CLINICAL DETERMINATION OF THE
BLEEDING SITE
• Presentation with hematemesis, coffee-ground emesis, or
nasogastric lavage with return of a large amount of blood
or coffee-ground emesis indicates an UGI source of
bleeding.
• A small amount of coffee-ground material or pink-tinged
fluid that clears easily may represent mucosal trauma from
the nasogastric tube rather than active bleeding from an
UGI source.
• A clear (nonbloody) nasogastric aspirate does not
necessarily indicate a more distal GI source bleeding,
because 16% of patients with actively bleeding UGI lesions
have a clear nasogastric aspirate.
• The presence of bile in the nasogastric aspirate makes UGI
bleeding unlikely but can be seen with an intermittently
bleeding UGI source.
CLINICAL DETERMINATION OF THE
BLEEDING SITE-2
• Melena generally indicates an UGI source but can
be seen with small intestinal or proximal colonic
bleeding.
• Hematochezia generally implies a colonic or
anorectal source of bleeding unless the patient is
hypotensive, which could indicate a severe, brisk
UGI bleed with rapid transit of blood through the
GI tract.
• Maroon-colored stool can be seen with an
actively bleeding UGI source or a small intestinal
or proximal colonic source
HOSPITALIZATION
• Patients with severe GI bleeding require
hospitalization,
• Whereas those who present with only mild acute
bleeding (self-limited hematochezia or infrequent
melena) and who are hemodynamically stable
(not suspected to be volume depleted), have
normal blood test results, and can be relied on to
return to the hospital if symptoms recur may be
candidates for semiurgent outpatient endoscopy
rather than direct admission to the hospital.
• %80 of GI bleeding stop spontaneously.
HOSPITALIZATION-2
• On the other hand, patients should be
hospitalized in an intensive care unit if they have
large amounts of red blood in the nasogastric
tube or per rectum, have unstable vital signs, or
have had severe acute blood loss that may
exacerbate other underlying medical conditions.
• Patients who have had an acute GI bleed but are
hemodynamically stable can be admitted to a
monitored bed (step-down unit) or standard
hospital bed, depending on their clinical
condition.
RESUSCITATION
• Resuscitation efforts should be initiated at the
same time as initial assessment in the emergency
department and continue during the patient's
hospitalization.
• At least one large-bore (14- or 16-gauge) catheter
should be placed intravenously, and two should
be placed when the patient has ongoing bleeding.
• Normal saline is infused as fast as needed to
keep the patient's systolic blood pressure higher
than 100 mm ‘Hg and pulse lower than 100/min.
RESUSCITATION-2
• Patients are transfused with packed red blood
cells, platelets, and fresh-frozen plasma as
necessary to keep the hematocrit value higher
than 24%, platelet count higher than
50,000/mm3, and prothrombin time less than 15
seconds, respectively.
• A GI endoscopist should be consulted as soon as
possible to expedite the patient's assessment and
determine the optimal timing of endoscopy.
RESUSCITATION-3
• The patient's vital signs should be monitored
frequently, as appropriate to the level of
hospitalization.
• Laboratory-determined hematocrit values (not
fingerstick hematocrit values, which are less
reliable) should be obtained every four to eight
hours until the hematocrit value is stable.
• In patients with active bleeding, an indwelling
urinary catheter should be placed to monitor the
patient's urine output.
RESUSCITATION-4
• Endotracheal intubation should be considered in
patients with active ongoing hematemesis or
with altered mental status to prevent aspiration
pneumonia.
• Patients who are older than 60 years, have chest
pain, or have a history of cardiac disease should
be evaluated for myocardial infarction with
electrocardiography and serial troponin
measurements.
• A chest x-ray should also be considered.
INITIAL MEDICAL THERAPY
• Administration of a proton pump inhibitor (PPI) is
useful for reducing rebleeding rates in patients with
peptic ulcer disease .
• Starting a PPI in the emergency department or
intensive care unit (ICU) before endoscopy is
performed in patients with severe UGI bleeding has
become a common practice but is still controversial.
• It reduces the need for endoscopic therapy but does
not result in improved clinical outcomes in the
transfusion requirement, rebleeding rate, need for
surgery, or death rate.
Suspicion of Variceal Bleeding
• Patients with a strong suspicion of portal
hypertension and variceal bleeding should be
started empirically on intravenous octreotide
(which can reduce the risk of rebleeding to a
rate similar to that associated with endoscopic
therapy.
Medical Management of Acute
Variceal Bleeding
• Somatostatin and its long-acting analog
octreotide cause selective splanchnic
vasoconstriction and lower portal pressure,
without causing the cardiac complications seen
with vasopressin (even in combination with
nitroglycerin).
• A meta-analysis has shown that vasoactive
drugs (e.g., octreotide, somatostatin,
terlipressin [a long-acting vasopressin analog])
are as effective as sclerotherapy for controlling
variceal bleeding and cause fewer adverse
events
Figure 19-1. Algorithm for the initial management of severe upper gastrointestinal
(UGI) bleeding. The steps in the algorithm may take place simultaneously or in varying
orders and in the emergency department depending on the clinical situation.
Algorithm for the endoscopic and medical management of severe ulcer
hemorrhage following hemodynamic stabilization.
(IV, intravenous; NBVV, nonbleeding visible vessel; PPI, proton pump inhibitor; UGIB, upper
gastrointestinal bleed.)
Endoscopy
• Ideally, the patient should be hemodynamically stable, with
a heart rate of less than 100 beats/min and a systolic blood
pressure higher than 100 mm Hg.
• Respiratory insufficiency, altered mental status, or ongoing
hematemesis indicates the need for endotracheal
intubation before emergency upper endoscopy to stabilize
the patient and protect the airway.
• Coagulopathy and thrombocytopenia should be corrected
with transfusions prior to endoscopy.
• Proper medical resuscitation will not only allow safer
endoscopy, but also ensure a better diagnostic examination
for lesions, such as varices, that are volume dependent and
will allow more effective hemostasis because of the
correction of coagulopathy.
Endoscopic Stigmata of Recent Ulcer
Hemorrhage
RISK OF REBLEEDING
RISK OF REBLEEDING
AFTER ENDOSCOPIC
(%)
HEMOSTASIS (%)*
ENDOSCOPIC
APPEARANCE
FREQUENCY (%)
Active arterial
bleeding
12
90
15-30
Visible vessel
22
50
15-30
Adherent clot
10
33
0-5
Oozing without
stigmata
14
10
0-5
Flat spot
10
7
NA
Clean ulcer base
32
3
NA
Figure 19-7. Endoscopic stigmata of recent peptic ulcer bleeding. A, Active bleeding with
spurting. B, Visible vessel (arrow) with an adjacent clot. C, An adherent clot. D, Slight oozing
of blood after washing in the center of an ulcer without a clot or visible vessel.
After EUS –İİAB Oozing Bleeding in the
Stomach and Endoscopic Therapy
Algorithm for the management of severe hematochezia.
(RBC, red blood cell)
The frequencies of the sources of severe hematochezia in patients seen at the University of
California, Los Angeles, Center for Ulcer Research Education. Note that in most cases (75%),
severe hematochezia is from the colon, 17% is from an upper gastrointestinal (UGI) (esophagus,
stomach, or duodenum) source, and 5% is from a small intestinal source.
Endoscopic stigmata of recent colonic diverticular bleeding.
A, Active bleeding (arrow).
B, Adherent clot (arrow)
C, Nonbleeding visible vessel
Endoscopy
• In patients with severe UGI bleeding, gastric lavage with a
large (34-Fr) orogastric tube should be performed to
evacuate blood and clots from the stomach to prevent
aspiration and allow good endoscopic visualization.
• In patients with severe hematochezia and suspected active
colonic bleeding, urgent colonoscopy can be undertaken
after a rapid purge.
• Patients should receive 4 to 8 L of polyethylene glycol purge
orally or via a nasogastric tube over four to six hours until
the rectal effluent is clear of stool, blood, and clots.
• Metoclopramide, 10 mg, may be given intravenously before
the purge and repeated every four to six hours to facilitate
gastric emptying and reduce nausea.
Maroon Stool
• Patients with maroon stool in whom there is
pretest uncertainty about the bleeding source
should be considered for an urgent
polyethylene bowel preparation as well.
• Colonoscopy immediately after push
enteroscopy
Algorithm for the management of severe overt obscure gastrointestinal
bleeding.*Deep enteroscopy includes double-balloon enteroscopy, singleballoon enteroscopy, and spiral enteroscopy
Endoscopic Therapy
• Injection Therapies
• Coagulation with contact methods (heater
prob, multipolar (bipolar) coagulation prob )
• Coagulation with non-contact methods (Argon
Plasma coagulation, laser)
• Clipping
RADIOLOGIC IMAGING
• Angiography may be used to diagnose and treat severe
bleeding, especially when the cause cannot be
determined by upper and lower endoscopy.
Angiography generally is diagnostic of extravasation
into the intestinal lumen only when the arterial
bleeding rate is at least 0.5 mL/min.
• An advantage of angiography is that it permits
therapeutic intra-arterial infusion of vasopressin or
transcatheter embolization for hemostasis if active
bleeding is detected, without the need for bowel
cleansing
• A disadvantage of angiography is that it usually does
not identify the specific cause of bleeding, only its
location.
Radionuclide imaging
• Radionuclide imaging is occasionally helpful for patients
with unexplained GI bleeding, although it is used less
frequently now.
• Radionuclide imaging can be performed relatively
quickly and may help localize the general area of
bleeding .
• The technique involves injecting a radiolabeled
substance intravenously into the patient's bloodstream
and then performing serial scintigraphy to detect focal
collections of radiolabeled material. Radionuclide
imaging has been reported to detect bleeding at a rate
of 0.04 mL/min.
• Up to 25% of bleeding scans suggest a site of bleeding
that proves to be incorrect
Surgery
• Most patients admitted for acute GI bleeding
have bleeding of mild to moderate severity
and do not need surgical consultation.
• In selected patients with severe, ongoing GI
bleeding in whom a diagnosis is not made by
urgent endoscopy or colonoscopy, surgical
consultation during the hospitalization is
recommended.
THE END
Independent Risk Factors for Persistent or
Recurrent Gastrointestinal Tract Bleeding
RISK FACTOR
RANGE OF ODDS RATIOS
FOR INCREASED RISK
Clinical Factors
Health status (ASA class 1 vs.
1.94-7.63
2-5)
Comorbid illness
1.6-7.63
Shock (systolic blood pressure
1.2-3.65
< 100 mm Hg)
Erratic mental status
3.21
Ongoing bleeding
3.14
Age ≥ 70 yr
2.23
Age > 65 yr
1.3
Transfusion requirement
NA
Presentation of Bleeding
Hematemesis
1.2-5.7
Red blood on rectal examination 3.76
Melena
1.6
Laboratory Factors
Coagulopathy
1.96
Initial hemoglobin ≤ 10 g/dL
0.8-2.99
Endoscopic Factors
Ulcer location on superior wall
13.9
of duodenum
Ulcer location on posterior wall
9.2
of duodenum
Active bleeding
2.5-6.48
High-risk stigmata
1.91-4.81
Ulcer size ≥ 2 cm
2.29-3.54
Ulcer location high on lesser
2.79
curve
Diagnosis of gastric or duodenal
2.7
ulcer
Clot over ulcer
1.72-1.9