Transcript hemoragii digestive superioare

Upper GI bleeding
UGI bleding
ONE syndrome: a group of
diseases
Definitions
Intraluminal, exteriorised bleeding
 Hematemesis – above the angle of
Treitz
 Melena – above the ileo-cecal valve
 Hematochezia – bellow the spelnic
flexure

A major health problem
100-150/100.000 admission/year in US
 Mortality is high ~10% even if:
 fiberoptic endoscopy - general
 better understanding of pathology
 high performance medication

POPULATION IS GROWING OLDER

Great variety of pathologies
risk of
rebleeding very difficult to evaluate
Major cause
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Duodenal ulcer
Gastritis
Gastric ulcer
Esophageal varices
Esofagitis
Sdr. M-W
7%
Duodenitis
Tumors
24%
23%
21%
10%
8%
6%
3%
Large
variations
according to
region
DIAGNOSTIC VS TRATAMENT
Major emergency
 Urgent treatment before ethiological
diagnostic
 Sequence:
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» Diagnostic of UGI bleeding
» Resuscitation
» Empiric treatment
» Ethiologic treatment
» Specific treatment
Emergency
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URGENT EVALUATION

URGENT TREATMENT OF
HYPOVOLEMIA
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INSSURING A SECURE
TRANSPORTATION TO A HOSPITAL
Anamnesis
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Describe bleeding
» Quantification of blood loss is ridiculous
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Other symptoms on onset: ex cough
Past medical history – associated with
bleeding: hepatitis, chirrhosis…
Family problems
Alchool intake
Previous bleedings
Medication intake in the last week
FIRST AID
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Decubitus
One or two large vein access
Insure vital function
Safe transportation
A sample for blood typing
No macromolecules before sample
Nill per mouth
+/- nasogastric tube + drainage
Haemodynamic evaluation
Hypovolemic shock if: Systolic blood
pressure <90 mmHg = 50% circulating
volume
 NO shock – check for changes in blood
pressure and puls in orthostatism
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» BP<90 - 25-50% loss
» BP-10 or puls rate >120/min - 20-25%
EVALUATION BEFORE
ETHIOLOGY IS ESTABLISHED
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1. Hemoglobine
2. Platelets
3. Hematocrit
4. Screening test for coagulation
5. BUN
6. Screening for live function tests
7. Abdominal and/or thorax X-Ray for
associated pathology that could change
protocol
EVALUATION BEFORE
ETHIOLOGY IS ESTABLISHED
Patient in ICU under gastroenterology care
 Supress HCl secretion (i.v. H2 bloxkers,
PPI)
 Treat coagulation disfunctions
 Blood products
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» Balance for risks – viral infections
» Risks vs benefits in continuous bleeding
SURVEILANCE
-MODELES FOR REBLEEDING 
CONTINUOUS BLEEDING
– No response
– 42% do not present a major episode of rebleeding
– Aggressive monitoring = ESSENTIAL
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MAJOR EPISODE OF REBLEEDING
– 15,2% rebleeding in ICU
» 61% sudden onset
– ONLY shock is very unusual but possible
REBLEEDING
MAJOR RISK FACTOR
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Definition: new bleeding episode after an
initial stop and haemodynamic stability
High mortality: 20% (3x more then average
for UGU bleeding)
3 major risk factors for in hospital morbidity
and mortality:
Major rebleeding during hospital stay
Old age
Total quantity of transfused blood
ETHIOLOGICAL
EVALUATION
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Clinical
Rx + US
 endoscopy
“GOLD DIAGNOSTIC”
ANAMNESIS
PATIENT + FAMILY
Clinical Evaluation
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Haemodyanmic evaluation and stabilisation
Confirm the dg of UGI bleeding
– HEMATEMESIS, MELENA + rectal exam
– Ex oral cavity + ENT for swallowed blood
– Medicaton
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Clinical signs suggestive for liver chirrhosis
Palpable tumors
Other medical problems that can cause UGI
bleeding
IMAGISTICS
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Can point to a possibel diagnostic
Rx thorax
– Pleural efusions
– TBC
– Primary or secondarty tumors
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Abdominal US
– Liver chirrhosis + portal hypertension
– Abdominal tumors
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Rx g-d
– Unusual alternative to explore UGI after the remission of
signs or when endoscopic examination is incomplete.
ENDOSCOPY
Establishes SOURCE OR SOURCES
of bleeding
 Evaluation of risk of rebleeding
 THERAPEUTIC acces directly to the
lesion
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ENDOSCOPY - in emergency - not after 24 hourse
SHORT LIVED LESIONS
PREPARE FOR ENDOSCOPY
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Patient should be stable / in OR
Empty stomach if possible
+/- sedation – risk of aspiration
Patient in left lateral position – prevent
aspiration
ENDOSCOPIC
DIAGNOSTIC
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Portal hypertension: varices YES/NO
– Significant in massive bleeding
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Diagnostic for all lesions with potential of
bleeding
Evaluation of RISK of rebleeding
Type of ACTIVE bleeding
Complete vs incomplete examination: which
areas not evaluated
MIRAGE – the first lesion
? the most significant lesion?
TREATMENT
Stabilise and monitor patient
 STOP THE BLEEDING
 Prevent recurrent bleeding
 Treat the disease CAUSE
 Treat complications and associated
diseases
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TRATAMENT
according to cause
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ENDOSCOPY: Oclude the vessel
the least aggressive for patient
immediate after diagnosis
very efficient
required in all cases with major risk of
rebleeding
Medication
Surgical
Interventional radiology
ESOPHAGIAN CAUSES - 4%
a. Congenital
 Weber-Rendu-Osler
 Blue rubber bleb
nevus
 Bullous epidermolisis
 Esophageal
duplication
b. Inflamatory
 GERD
 Barrett disease
 Infectious esophagitis
 Caustic lesions
 RT induced lesions
 CHT induced lesions
 Crohn disease
 Behcet disease
 pemfigoid
b. Traumatic or
mechanic
 Hiatus hernia
 Mallory-Weiss
syndrome
 Boerhaave syndrome
 Foreign body
 Iatrogenic
c. Neoplasia
 malignant
 benign
d. Vascular
 Varices
 Aortic aneurism
 After cardiac surgery
e. Hematological
 anticoagulants
 coagulation disorders
ESOPHAGIAN CAUSES
Esophagus varices
 Mallory-Weiss
sundrome
 Hiatus hernia and
GERD
 Tumors
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Varices
10% of cases
Associated with alcohol abuse and
hepatitis: clinical signs of chirrhosis
ESSENTIAL to exclude variceal
haemorrhage
Endoscopy may be difficult but very
important
VARICELE ESOFAGIENE
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Endoscopic difficulties
– Important bleeding
– Stomach full of cloths
– Gastric varices
– Encephalopathy
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BUT ONLY 60% of patients with
chirrhosis bleed from varices
DIAGNOSTIC
TRATAMENT
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MEDICATION - OCTREOCTIDE: decreases
portal flux and pressure in varices
TAMPONDE – Segstaken Blackmore tube
– Not a first choice
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SURGICAL SHUNT
– ~70% mortality in emergency cases
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TIPS
– ~50% mortality on emergency
M-W SYNDROM
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Diagnostic only with endoscopy in
emergency
– Short lived lesions
» Usually with small quantity of blood but may
produce shock
» Short monitoring
» ~0% risk of rebleeding
» Conservative treatment ~ 100%
Mallory Weiss
HIATUS HERNIA AND GERD
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dg+ EDS – stigmata
of recent bleeding
HH very frequent
encounter
Treatment: H2
blockers, PPI
TUMORS of ESOPHAGUS
Very unusual cause of
clinical manifest
bleeding: occult
 Endoscopic hemostasis
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» Laser YAG
» Argon plasma
GASTRIC ORIGINE
Hemorrhagic gastritis
 Gastric ulcer
 Benign tumors
 Malignant tumors
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HEMORRHAGIC GASTRITIS
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Morfologic criteria
EDS aspect may vary
Radiology useless and
pointless
EDS: if late may not show
anything
HEMORRHAGIC GASTRITIS
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H2 blockers and PPI – routine but doubtful
benefit
Rebleeding extremely rare
Endoscopic treatment: not recommended
(numerous lesions with small risk of
rebleeding)
SURGICAL(unusual: doubtfull diagnostic +
hemodynamic instability)
» In situ hemostasissutura in situ
» Vagotomy + gastrectomy
GASTRIC ULCER
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Some localisations
are difficult to see
EDS needs to
evaluate
» Stigmata of bleeding
» Risk of rebleeding
Treatment
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H2, IPP +/i.v route
Endoscopic direct
treatment
•Sclerosis
•Thermocoagulation
•Clips
Surgical treatment
If so, resection of lesion is better
 Frozen section pathology: malignnancy
always in doubt
 Limited resections for bening disease
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Benign gastric tumors
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Bleding is RARE
 Polipoid lesions can be
resected endoscopically
 Surgical excision
Malignant gastric tumors
 6%
 Special
characteristics
 High mortality 9%
 Frequently nonresectable
 Large costs little
benefit in survival
ENDOSCOPY
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Examination:
advanced lesion
Hemostasis (laser or
argon plasma) Ex.
Echografic
Ultrasound: MTS
and large LN:
inoperable
Surgical treatment
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Laparotomy or
laparoscopy: confirm
advanced disease
vs operability
Massive bleeding:
most often advanced
lesions
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Paliation ~25%
bypass
gastrostomy
jejunostomy
Vascular malformations
Dielafoy (exulceratio simplex)
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~5%
Congenital anomaly
Abnormal artery
protruding in
submucoasa
Echoendoscopy
Treatment
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Mechanic destruction of the vascular
anomaly
» Surgery: in situ hemostasis
» Endoscopy – GOLD STANDARD
– Correct diagnostic
– Banding
– Hemoclips
– Laser thermocoagulation
Bading
DUODENAL ORIGIN
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Very frequent
Justifies the empiric
treatment with PPI
EROSIVE DUODENITIS
BIG BAG with different pathologies:
erosions
Confusion in term with ulcer/superficial
ulcer
Frequent association with Helicobacter
Pylori
Treatment conservative: H2 blockers,
PPI and antiobiotics
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DUODENAL ULCER
Incidence is constant
 53% known ulcer in PMH
 HDS iterative: 17%
High gravity and high risk
25% in difficult localizations
Requires a new approach
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ASSOCIATED LESIONS
Multiple ulcers
 Association with varices!!!!!
 Duodenal stenosis: may be associated
with postbulbar ulcer
 Association of bleeding and perforation
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RISK QUANTIFICATION
ENDOSCOPIC TREATAMENT
Standard
 Very good results
 Little requirement of surgical procedures
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Heater probe
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Very good on
visible vessels
Clips
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Visible vessels
Difficult and
expensive
SURGICAL
Emergency operation
 Major indication:
 Massive bleeding
 More then 6 units of blood/24 hours =
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continuous bleeding
SURGICAL PROCEDURES
In situ hemostasis: the most used
technique
 Resections (limited in number and
extent)
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CONCLUSIONS
UGI bleeding is still a significant problem
 Endoscopy is mandatory for diagnostic
and treatment
 Surgery is limited in emergency
situations
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LOWER GI
BLEEDNG
ETIOLOGY
Differential Diagnosis of Lower Gastrointestinal Hemorrhage
COLONIC BLEEDING (95%) %
SMALL BOWEL BLEEDING (5%)
Diverticular disease
30-40 Angiodysplasias
Ischemia
5-10 Erosions or ulcers (potassium, NSAIDs)
Anorectal disease
5-15 Crohn's disease
Neoplasia
5-10 Radiation
Infectious colitis
3-8
Meckel's diverticulum
Postpolypectomy
3-7
Neoplasia
Inflammatory bowel disease
3-4
Aortoenteric fistula
Angiodysplasia
3
Radiation colitis/proctitis
1-3
Other
1-5
Unknown
10-25
CLINICAL PRESENTATION
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History taking-type of bleeding
» Careful interpretation of data
» Blood on paper
» Red blood vs feaces mixed with blood
» Quantity
» etc
Paraclinical
Wbc
 Hct
 Plt
 Coagulation profile
 LFT
 + numerous other
according to
associated pathology
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Risk stratification
Initial Emergency Department Risk Stratification for Patients with Gastrointestinal
Bleeding
Low Risk
Moderate Risk
High Risk
Age <60
Age >60
Initial SBP ≥100 mm
Hg
Initial SBP <100 mm
Hg
Persistent SBP <100 mm Hg
Normal vitals for 1 hr
Mild ongoing
tachycardia for 1 hr
Persistent moderate/severe
tachycardia
No transfusion
requirement
Transfusions required
≤4 U
Transfusion required >4 U
No active major
comorbid diseases
Stable major comorbid Unstable major comorbid diseases
diseases
No liver disease
Mild liver disease—PT Decompensated liver disease—i.e.,
normal or near-normal coagulopathy, ascites,
encephalopathy
No moderate-risk or
high-risk clinical
features
No high-risk clinical
features
Risk stratification
Seven independent predictors of severity
in acute LGIB
» hypotension
» tachycardia,
» syncope,
» nontender abdominal exam,
» bleeding within 4 hours of presentation,
» aspirin use, and
» more than two comorbid diseases
LOCALIZATION
The duration, frequency, and color of blood passed
per rectum.
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Characteristically, melena or black, tarry stool, indicates
bleeding from an upper gastrointestinal or small bowel
source
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Maroon color suggests rt. Sided lesion
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whereas bright red blood per rectum signifies bleeding from
the left colon or rectum. However, patient and physician
reports of stool color are often inaccurate and inconsistent
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In addition, even with objectively defined bright red
bleeding, significant proximal lesions can be found on
colonoscopy
LOCALIZATION
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past medical history.
antecedent constipation or diarrhea (hemorrhoids, colitis),
the presence of diverticulosis (diverticular bleeding),
receipt of radiation therapy (radiation enteritis),
recent polypectomy (postpolypectomy bleeding), and
vascular disease/hypotension (ischemic colitis).
A family history of colon cancer
Nonetheless, even after a detailed history, physicians
cannot reliably predict which patients with hematochezia
will have significant pathology and a history of bleeding
from one source does not eliminate the possibility of
bleeding from a different source.
LOCALIZATION
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Multiple factors make the identification of a
precise bleeding source in LGIB challenging.
The diversity of potential sources,
The length of bowel involved,
The need for colon cleansing, and
The intermittent nature of bleeding.
In up to 40% of patients with LGIB, more than one
potential bleeding source will be noted and
Stigmata of recent bleeding in LGIB are
infrequently identified
As a result, no definitive source will be found in a
large percentage of patients
Clinical scenarios
Pt. continued to bleed with
hypotension and tachycardia. Patient
requires 2 units of PRBCs
 Pt. stopped bleeding. Vitals
normalizes
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Options to diagnose and
control the bleeding
RBC scan, requires 0.5-1 ml/min
bleeding
 Mesenteric angiography, requires 11.5 ml/min bleeding
 Colonoscopy
 Surgery
 Meckels scan
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Scenario
onePt. continues to bleed
and is unstable.
Rbc scan vs colonoscopy
COLONOSCOPY
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Colonoscopy is undoubtedly the best test for
confirming the source of LGIB and for excluding
ominous diagnoses, such as malignancy.
The diagnostic yield of colonoscopy ranges from
45% to 95%
Identifies lesion in 75 % or more
Can provide endoscopic therapy
most patients undergoing radiographic
evaluation for LGIB regardless of findings and
interventions will subsequently require a
colonoscopy to establish the cause of bleeding.
CLINICAL SCENARIO
Patient continues to bleed
 RBC scan is positive on the left side?
How much true this information is??
 What to do next? surgery, ?angio
with embolization?
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RADIONUCLIDE SCAN
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radionuclide scanning has variable accuracy,
cannot confirm the source of bleeding, Correct
localization rate is 41-100%
Accuracy appears to be best when the scan
becomes positive within a short period of time
In one study, 42% of patients underwent an
incorrect surgical procedure based on scintigraphy
results.
CLINICAL SCENARIO
Patient underwent angiogram with
embolization
 Vitals improved
 What are the chances that pt. will
rebleed?
 Colonoscopy?
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MESENTERIC
ANGIOGRAM
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Selective embolization initially controls
hemorrhage in up to 100% of patients, but
rebleeding rates are 15% to 40%
Advantages:
» Precise localization
» Can provide therapy with intra-arterial
vasopressin or coil embolization
» Procedure of choice in briskly bleeding pts
» Minor complication rate of 9% and a 0%
major complication rate
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Disadvantages:
» Invasive
» Less sensitive in detecting venous
bleeding
» Can cause ischemia, contrast
reactions, arterial injury
DIAGNOSTIC DIFFICULTIES
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the diagnostic modalities for lower GI bleeding are not
as sensitive or specific in making an accurate
diagnosis (versus UGIB)
Diagnostic evaluation is complicated: more than one
potential source of hemorrhage is identified.
If more than one source is identified, it is critical to
confirm the responsible lesion before initiating
aggressive therapy.
This approach may occasionally require a period of
observation with several episodes of bleeding before
a definitive diagnosis can be made.
In fact, in up to 25% of patients with lower GI
hemorrhage, the bleeding source is never accurately
identified.
SURGERY
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Surgery usually is employed for hemorrhage in two settings:
massive or recurrent bleeding.
It is required in 15% to 25% of patients who have diverticular
Recurrent bleeding from diverticula occurs in 20% to 40% of
patients and generally is considered an indication for
surgery
In patients with serious comorbid medical conditions and
without exsanguinating hemorrhage, this decision should
be made carefully.
Great effort should be made to accurately localize the site of
bleeding preoperatively so that segmental rather than
subtotal colectomy can be performed Operative mortality is
10% even with accurate localization and up to 57% with
blind subtotal colectomy.