Transcript GASTRO-INTESTINAL BLEEDING

GASTROINTESTINAL
BLEEDING
GIB
• 1-2% of acute hospital admissions.
• 5% mortality.
• 90% cease spontaneously.
Classification
• Level of bleeding - Upper / Low.
(above and below the ligament of
Trietz).
• Time - Acute / Chronic
• Severity of blood loss
Clinical Presentation
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Hematemesis - bloody vomiting
• Coffee Ground vomiting
• Melena- dark/black stool.(degradation
of hemoglobin).
• Hematochezia-Rectal bleeding
Evaluation of the bleeding
patient
-Patient assessment: anamnesis and hemodynamic
status.
-resusitation.
-dignosis: bleeding source.
-treatment.
Medical history
• Characteristics of bleeding ( melena, coffee
ground, rectal bleeding).
• Symptoms reflect severity of bleeding. (syncope,
dizziness, onset and frequency).
• Symptoms associate possible etiologies.
Dyspepsia, abdominal pain, weight loss, early
satiety, liver disease, alcohol abuse. Antececedent
vomiting. Dysphagia and reflux.
Cont• Constipation, bowel movements.
• Medications: NSAIDS, coumadin.
• Coagulopathy.
• History of aortic surgery.
• Previous episodes.
• Comorbidities. (ability to respond to hemorrhage).
Physical Examination
• Determine degree of blood loss:
- pale, cold extremeties, sweating.
-pulse, BP, orthostatism.
- consciousness.
• Epigastric tenderness. Abdominal mass.
• Signs of liver disease. (jaundices, ascites….)
• Oropharynx (rare).
Cont• Rectal examination – quality of
stool.
• Nasogastric tube. ( blood, coffee
ground, bile, gastric fluids)
Management and monitoring
• Large bore IV lines
(Haggen/Pousseleur low)
• Fluids - Hartman’s solution
(restoration of intravascular volume).
• Oxygen (espicially in IHD pts).
• Blood typing and cross matching .
• Blood tests- CBC, PT PTT, LFT.
Cont• Unstable pt- start packed cells,
consider intubation(prevent aspiration
in obtunded pts) .
• Repair coagulation defects.
• Consider central line cath (uaually not
needed).
• Urine output.
Level of bleeding-Upper/Low
Upper GI bleeding
- the source is
above the Treitz
ligament
• Lower GI bleeding
– is below
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Upper GI Bleeding Diagnosis
Naso-gastric tube – blood or coffee
ground
• Melena in rectal exam
• After stabilisation and primary
treatment - upper GI endoscopy in
first 12-24 hours
• Specific treatment: medical,
antibiotics, endoscopy, angiography,
surgery.
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Low GI Bleeding-diagnosis
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Rectal bleeding – blood on rectal
exam.
Normal NGT contents.
Melena with normal upper GI
endoscopy
After stabilization – rectoscopy ,
colonoscopy
Proffuse bleeding – lateralisation of
bleeding site by angio or bleeding scan
Upper Gastrointestinal
Bleeding
Upper GI Bleeding
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Peptic disease – duodenal or gastric ulcer, 50%.
Erosive gastritis 15-30%.
Esophageal Varices 10-20%.
Gastrinoma – Zollinger-Ellison synd.
Mallory-Weiss tears 8-10%.
Malignancy- 3%.
Dieulafoy’s.
Esophagitis.
Osler weber rendu.
Hypertrophic gastritis – Menetrier disease or
Water-Melon Stomach
Peptic disease
• 5% - hemorrhage is presenting symptom.
• 20%- develop bleeding at least once.
• Hemorrhage is the most lethal form of
complicated ulcer dis.
Peptic disease- Pathogensis
• Acid peptic erosions into submucosal or
extraluminal vessels.
• Helicobacter pylori. Most common etiology for
duodenal ulcer.
• NSAIDS. Damage to GI mucosa.
- inhibition of prostaglandin synthysis-->
inhibition of mucos and bicarbonate production.
- delay ulcer healing.
- epithlial acidification.
- platelet dysfunction.
• ZES. Gastrin secreting tumor.
Peptic dis- prognostic factors
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Severity of bleeding, hemodynamic status.
Persistent or recurrent.
Transfusion requirements.
Nasogastric aspirate, blood, coffee groud.
Older pts.
Comorbidities.
Gastric ulcer- Classification
• Type 1- distal lesser curvature.
• Type 2- combined gastric and duodenal.
High acid secretion.
• Type 3- prepyloric. High acid secretion.
• Type 4- proximal lesser curvature.
• Type 5- secondary to NSAIDS.
Gastric ulcer
• 10% of gastric ulcers are malignant.
• Most bleedind ulcers arise in incisura,
antrum and distal body of stomach.
Duodenal ulcer
• 95% - secondary to Helicobacter pylori
infection.
• 10% of pts with HP develop ulcer. 20% of
pts with ulcer and HP bleed.
• Bleeding DU, usually located on the
posterior duodenal wall.
Peptic dis- Treatment
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NPO.
Fluids.
Stop NSAIDS.
Antisecretory agent. H2-rec blockers or proton
pump inhibitors.
PPI may reduce rebleeding.
Endoscopy- diagnostic and therapeutic. within
12-24 hours.
Anti H pylori treatment. Not immediatly.
Massive bleeding- consider emergent endoscopoy.
The Role of Adjunctive
Pharmacological Therapy
• Clot stabilization: at a pH of above 6.0
pepsin is inactivated and cannot lyse clots
• Effective clotting may not occur at pH<6.
• Antacids, iced saline gastric lavage and H2blockers and other interventions are
ineffective in reducing rebleeding.
• PPI decreases the incidence of rebleeding.
Peptic dis- Endoscopy
• Rebleeding 10-20%. Consider re-endoscopy
• Prognostic endoscopic findings for rebleed:
1) appearence -small clean ulcer base. 0%
- flat, pigmented 10%
- adherent clot. 20%
- visible vessel. 40%
- active bleeding.
2) size > 2cm.
Peptic Ulcer
• Endoscopic manipulation
- Coagulation
- Injection of sclerosant or
vasoconstricting agent.
- Clip.
Peptic Ulcer Endoscopy
Endocliping of Bleeding
Ulcer
Angiography- embolization
• To consider in:
- high risk pts.
- rec bleeding.
Duodenum: gastroduodenal art.
Angioembolization of
bleeding duodenal ulcer
Surgical therapy
• Indications:
-active bleeding not responsive to endoscopic
treatment.
- significant rec bleeding after endoscopic
treatment.
-ongoing transfusion requirment. 6 pc/d.
• The goal of surgery: to control hemorrhage.
• Acid reducing procedure is secondary, but
important.
Surgery for bleeding ulcer
• DU: Suturing of
bleeding ulcer +/vagotomy with or
without drainage.
Rebleeding<10%.
• GU: Partial
gastrectomy or wedge
resection.
• Antrectomy+truncal
vagotomy
Vagotomy
Drainage Procedure
Gastrectomy
Bleeding ulcer in pts with HP
• Eradication of HP decrease the incidence of
rebleeding.
• Only 0.2 % of ulcer pts with HP infection
need surgery for bleeding peptic ulcer.
Erosive Gastritis
• common source of
bleeding in critically ill
pts, elderly and NSAIDS
treated pts.
• Lesions distributed
throught the gastric
mucosa.
• Pathogenesis- acid peptic
injury and mucosal
ischemia d/t
hypoperfusion
Erosive gastritis
• in critically ill pts- prophylaxis H2 rec antagonist
is recommended.
• Treatment- conservative+ treat the underlying dis.
• PPI
• In profuse bleeding :
- angiography- embolization.
- surgery- rarely indicated,
if single bleeding site gastrotomy,
suturing of and vagotomy.
if multiple sitesnear/total gastrectomy
Esophageal varices
• Dilated submucosal
veins that communicate
portocollateral
circulation and the
systemic venous system
secondary to Liver
cirrhosis or portal
hypertension.
• 25-30% develop
hemorrhage.
• 70% rebleeding.
Esophageal varices
• Pathogenesis: elevated portal venous
pressure. Hepatic pressure gradient>12
mmHg  varices.
• Risk for hemorrhage:
size.
red color signs on endoscopy.
poor liver function.
active alcohol use.
Primary treatment
• B-blockers.
• Nitrate. Less common.
• Endoscopy. Band ligation , sclerotherapy.
Treatment of acute hemorrhage
• Vasoactive drugs:Vasopressin IV, empiric
Somatostatin IV.
effective 80-90%.
• Emergent Endoscopy-ligation or
sclerotherapy.
- Rule out other etiologies.
- decrease rebleeding and mortality.
Esophageal Varices
Endoscopy
Endoscopic Ligation of
Varices
Varices – acute hemorrhage
• Blackmore tube insertion- massive bleeding
Varices-Treatment of rec bleeding
• B-blocker. Decrease rebleed- 30%.
• Repeated endoscopy.
• TIPS: - nonselective shunt. decrease hepatic flow may
induce encephlopathy.
- rebleeding-20%.
- thrombosis- 30-40%.
- useful in acute hemorrhage.
-definitive or temporary treatment.
• Surgical shunt.
• Liver Tx.
Surgical porto-systemic shunt
• High mortality rate as emergency procedures.
• Nonselective- more effective in reduce hemorrhage.
- greater risk for encephalopathy.
- effective for ascites.
• Selective- selective decompressing of left side portal
system and esophageal varices.
-allow hepatic perfusionlower rate of
encephlopathy.
• Procedure of choice- distal splenorenal shunt.
• Devascularization procedure- if shunt procedure not
possible.
Mallory-Weiss Tears
• Tear in the gastric
mucosa near GEJ.
• Characterized by
antecedent history of
vomiting,retching or
coughing.
• Common- associated
alcoholism, nsaids, hiatal
hernia, age>60.
Mallory-Wiess treatment
• 90% stop spontaneously.
• Endoscopy for diagnosis and treatment.
• Rebleeding:pts with active bleeding in
initial endoscopy, or pts with coagulation
disorders.
• Surgery rarely needed.(gastrotomy and
oversewing of the mucosal tear).
Esophageal sources
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Esophagitis
GERD.
Barrett’s
Malignancy.
Medications.
Radiation.
IBD.
Rare Source - Dieulafoy
Aberrant submucosal
vessel m/p in the
lesser curv.
• Treatmentendoscopy / surgery.
• Endoscopic diagnosis
is difficult, no
ulcerated lesion.
• Rebleeding is
common.
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Hypertrophic Gastritis
• Water-melon stomach
or Menetrier syndrome
Zollinger-Ellison
Syndrome
• Bleeding from ulcers
– duodenal and
postbulbar origin
• CT and EUS are
diagnostic tools
• Operation with
complete resection or
at least debulking is
treatment of choice
Lower GI Tract
Bleeding
LGIB
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Bleeding below ligament of Trietz.
97% colon
3% small bowel.
Incidence increases with age.
Slow bleeding may present as melena.
Shock is less common than in UGIB.
Usually intermittent.
LGIB- Etiology
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Diverticulosis of the colon
AV malformation or angiodysplasia
Colon Cancer
IBD-Ulcerative colitis/Crohn’s
Hemorrhoides and anorectal diseases.
Ischemic colitis.
Radiation injury.(proctitis)
Meckle’s diverticulum, or other small bowel
diverticula.
Etiology by age group, in order of
frequency
Adults over
55 y.o.
- Diverticulosis
- AVMs
- Polyps
- Malignancy
Adults to 55 y.o.
Adolescents and young
adults
-Anorectal dis
- Inflammatory
bowel disease
- Diverticulosis
- Polyps
- Malignancy
- AVMs
- Meckel’s
diverticulum
- Inflammatory
bowel disease
- Polyps
Diagnostic procedures
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Rigid proctoscopy- in the ER, for all pts.
Colonoscopy.
Nuclear scintigraphy.
Angiography.
Operative intervention.
proctoscopy
• Rule out anorectal disease.
Colonoscopy
• Useful in evaluating patients with:
- occult chronic GI bleeding
-Acute self limited hemorrhage that has stopped
bleeding.(test of choice).
• Use in patients with massive ongoing bleeding
remains controversial.
• PROS :Diagnostic and therapeutic tool.(laser,
coagulation, Injection).
• CONS:-Technical difficulty in not prepared pts.
-Complications, Perforation.
Nuclear scintigraphy
• Bleeding scan- detect intraluminal extravasation of
blood, utilize technetium sulfur colloid or
technetium 99m-labeled red blood cells.
• PROS:-Noninvasive.
-Detects bleeding as slow as 0.1 mL/min.
- repeated scans are possible up to 24h,
it can detect intermittent bleeding.
• CONS:-not therapeutic.
- delay in diagnosis.
-lateralization lt or rt , but not localization
of bleeding.
Red blood cells bleeding
scan
Angiography
• Selective catheterization of mesenteric vessels and
injection of contrast
– Looking for extravasation and pooling of media within
intestinal lumen
– In absence of preangiographic localization catheterize
SMA  IMA  Celiac.
– Once site of hemorrhage found intra-arterial infusion
of vasopressin arterial, venous, and bowel
contraction  promotes thrombosis at bleeding site
--If patient an operative risk, transcatheter embolization
with gel foam, wire coils, or autologous blot clots.(may
be complicated with bowel infarction).
Angiography
• PROS:- localization of bleeding.
- visualize nonbleeding vascular malformations, neoplasms and
other lesions.
- Detects bleeding as slow as 0.5 mL/min.
- therapeutic
- recently superselective embolization is optional .
- 85% effectiveness – identify and control hemorrhage.
• CONS: - achieves temporary control before definitive surgical
resection.
- Invasive.
- Complications: cardiac, visceral, and peripheral ishchemia
(relative contraindication)
- Chance of rebleeding.
Angiography
Diverticulosis
• Diverticular bleeding is
the most common source
of LGIB, 40-50%.
• Diverticulosis Present in >
50% of population > 60 y.o.
• Risk of bleeding 5% of pts.
• Hemorrhage is not
associated with
diverticulitis.
Diverticulosis
• Hemorrhage d/t weakening and erosion/rupture of
vasa recta/branches of the marginal arteries,at the
dome or the neck of the diverticulum, with
decompression into bowel lumen.
• Luminal traumatic factors lead to hemorrhage .
• Hemorrhage tends to be massive d/t arterial source
• The most common source of massive LGIB, from
the lt colon.
Diverticulosis
• Most cases stop spontaneously.
– Risk of rebleeding 25% at 4 years.
– 50% risk if patient has suffered two prior
episodes of diverticular bleeding
• 10-20% bleeding continues in absence of
intervention.
• Colonoscopy- diagnostic and therapeutic.
• Consider surgery for recurrent episodes.
Endoscopy of
Diverticulosis
Angiodysplasia=AVM
• Small ectatic vessels in the
submucosa, arteriovenous
malformation.
• common in old cardiac
pts, CRF, AS.
• 5-20% of LGIB.
• The most common cause
of hemorrhage from SB.
• The most common cause
of massive LGIB from rt
colon.
Endoscopy of
angiodyspasia
AVM- diagnosis
• Occur primarily in cecum and ascending colon of
elderly patients> 50%.
• Recurrent intermittent bleeding.
• Colonoscopy-most sensitive tool.
- diagnostic and therapeutic.
• Angiographic criteria for identification of AVM
– 1) early and prolonged filling of draining vein
– 2) clusters of small arteries
– 3) visualization of vascular tufts
Colon Cancer
• Most common after
AVM and
diverticulosis.
• 5-10%.
• Colonoscopy and
biopsy is essential
• massive bleeding
uncommon.
Endoscopy of Colon
Cancer
COLON CANCER
• Proximal colonic tumors have high
propensity for occult bleeding
• Rectosigmoid tumors easily confused with
hemorrhoidal bleeding
– Treatment of hemorrhoids should be preceded
by flexible sigmoidoscopy in patients > 40-50
y.o.
Inflammatory Bowel
Disease
• bleeding more
common in ulcerative
colitis
IBD- UC
• Minor and hemodynamically insignificant
bleeding  conservative treatment directed
at inflammatory disease
• Hemodynamically significant bleeding 
surgery
– total abdominal colectomy
– End ileostomy + Hartmann’s pouch
Anorectal disease
• Small amounts of bright red blood on surface of
stool and toilet tissue, hemodynamically
insignificant
– Precipitated by strained passage of hard stool
• Hemorrhoids
– Engorgement of venous plexi of rectum/anus with
protrusion of mucosa
• Anal Fissure
– Tear in anal epithelium
Internal hemorrhoids
Colitis
Infectious •
Ischemic •
Obscure GI bleeding
• Intermittent GI bleeding for which no
source has been determined, despite
rigorous endoscopic
(gastroscopy+colonoscopy) and radiologic
investigation.
• Almost all are from small bowel.
Bleeding from obscure source
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Angiodysplasia of small bowel, most common.
40%. Acquired lesions, may recur .
Polyps and neoplasms.
Meckel’s Diverticulum. Most common in young.
Submucosal lesion – lymphoma, stromal cell
tumor etc.
Others.
Obscure GIB- Diagnostic modalities
-Enteroclysis or CT enterography:
Able to detect SB tumors (80%), but poor modality for
superficial mucosal lesions as AVM.
– Enteroscopy : can visualize through to the jejunum.
– Arteriography: special attention to evidence of
angiodysplasia. 60% sen
– Meckel’s scan. Initial evaluation in young pts.
– GI capsule- camera.
– Laparotomy and intraopertive enteroscopy. (70%sen)
– Provocative testing: arteriography + heparin or
thrombolytics to precipitate acute bleeding
Obscure GI bleeding (cont.)
• Operative exploration
– Exploratory laparotomy with examination from GE
junction to intraperitoneal rectum followed by:
• Transillumination of bowel wall with fiberoptic light source
• Intraoperative endoscopy
• Vigorous hydrationaccentuates thin walled veins that
constitute most AVMs
– Treatment = resection of segment of SB or LB
containing the offending lesion
Meckel’s Diverticulum
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Rare, true diverticulum.
• Gastric, pancreatic
mucosa.
• The origin of bleeding is
ulceration of small bowel
mucosa distally to the
diverticulum.
• Treatment: excision of
diverticulum and segment of
ileum to assure inclusion of
adjacent ulceration.
Submucosal lesions
Lymphoma of
small bowel – rare
disease
• Stromal cell tumor
- GIST may be a
reason of mucosal
erosions and
bleeding.
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Operative intervention in massive
unidentified bleeding source
• Exploratory laparotomy :
– Thorough examination of entire GI tract
• Initial step: determine visually location of
blood within GI tract
• Next: careful inspection and gentle
palpation of entire GI tract
• Intraoperative upper endoscopy in absence
of obvious bleeding source.
Operative intervention (cont.)
• If bleeding site localized preoperatively:
– Segmental bowel resection that includes
offending lesion
– Usually safe to perform primary anastomosis
– End stoma + mucous fistula if patient
hemodynamically unstable, malnourished
Operative intervention (cont.)
• If bleeding site not localized preoperatively:
– intraoperative colonoscopy followed by segmental
colectomy.
– if bleeding site still not identified: “blind” total
colectomy is indicated.
• repeat proctoscopy to definitely rule out rectal source of
bleeding.
• 5% mortality rate.
Thank You !