Transcript Document

GI Bleeding
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GI Bleeding
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Upper GI bleeding
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Lower GI bleeding
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Upper GI Bleeding
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Proximal to the ligament of Treitz
Causes:
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peptic ulcer disease (1/2 – 2/3 UGI bleeding)
esophageal varices (10 percent)
hemorrhagic gastritis
gastric varices
nose bleed
Mallory-Weiss tears
reflux esophagitis
gastric neoplasms
hematobilia
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Presentations of UGI Bleeding
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Severe bleeding
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Gradual bleeding
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hematemesis 25 %
 ‘red blood’ hematemesis
 ‘coffee ground’ emesis
hematochezia 15 %
hypotension
melena 25 % (50 – 100 cc of blood will render
stool melenic)
Occult bleeding
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positive tests for blood in the stool
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Initial Evaluation of UGI Bleeding 1
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Perceived rate of bleeding
Degree of hemodynamic stability
Outpatient basis
hemodynamically stable
 no evidence of active bleeding or
comorbidities
 endoscopic findings favorable
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Hospitalization
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evidence of serious bleeding
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Initial Evaluation of UGI Bleeding 2
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ABC
History of or current:
 hematemesis
 melena
 hematochezia
Lab Tests:
 CBC
 blood chemistries (liver and renal function
tests)
 prothrombin time (PT) and partial
thromboplastin time (PTT)
 blood typing and crossmatching
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Initial Evaluation of UGI Bleeding 3
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patient stable & no evidence of
recent or active hemorrhage –
proceed with the workup.
patient stable & shows evidence
of recent or active bleeding – largebore IV line before workup
patient unstable – immediate
resuscitation
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Resuscitation in UGI Bleeding
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secure airway for adequate ventilation (Oxygen as necessary)
large-bore I.V. line for lactated Ringer solution
urinary catheter for urine output monitoring
blood infusion as necessary
coagulopathy correcion
It is all too easy to forget these basic steps in a desire
to evaluate and manage massive GI hemorrhage!
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patient unstable & continues to bleed – intraoperative
diagnosis
laparotomy through an upper midline incision
anterior gastrotomy
pylorus-preserving duodenotomy
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Clinical Evaluation of UGI Bleeding
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History
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Physical Examination
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known causes of upper GI bleeding (e.g., ulcers, recent trauma or
stress, liver disease, varices, alcoholism, and vomiting)
use of medications that interfere with coagulation (e.g. NSAIDs,
dipyridamole) or alter hemodynamics (e.g., beta blockers and
antihypertensive agents)
cardiac history for assessing ability to withstand anemia
jaundice
ascites
tumor mass
bruit from an abdominal vascular lesion
Nasogastric Aspiration
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bloody aspirate – EGD
clear, nonbilious aspirate – bleeding site distal to the pylorus
clear and bile-stained aspirate – source of the bleeding is unlikely
to be the stomach, the duodenum, the liver, the biliary tree, or
the pancreas
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Upper GI Endoscopy 1
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almost always reveals the source of UGI
bleeding
requires considerable skill
hematemesis – emergency EGD (within
1 hour of presentation)
melena – urgent EGD
endoscopic control of bleeding sites
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injection
thermal coagulation
mechanical occlusion (clip application or
variceal banding)
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Upper GI Endoscopy 2
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Ulcer Appearance and Prognosis
Appearance
Prevalence %
Rebleed %
Mortality %
Clean base
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5
2
Flat spot
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10
3
Clot
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22
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Visible vessel
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43
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Active bleeding
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55
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Other Tests
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enteroclysis + RTG
Tc tagged red cell scan
arteriography
video capsule endoscopy
intraoperative endoscopy
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Enteroclysis
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Upper GI Tract Barium RTG
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Tc Red Cell Scan
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Celiac Arteriography
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Video Capsule Endoscopy
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Endoscopic Therapy in UGI
bleeding
Effectively reduces
 Rebleeding
 Need for Surgery
 Mortality (by meta-analysis)
 10 – 20 percent of patients have
rebleeding after (initially successful)
endoscopic therapy
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The Role of Adjunctive
Pharmacological Therapy
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Clot stabilization: at a pH of above
6.0 pepsin is inactivated and cannot
lyse clots
Effective clotting may not occur at a
pH of 5.9 or lower
Antacids, iced saline gastric lavage
and H2-blockers and other
interventions are ineffective in
reducing rebleeding rates
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Proton Pump Inhibitors
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NEJM 1997: high dose oral omeprazole effective
in reducing rebleeding rates. No endoscopic
therapy performed in this study from India
Two multicenter trials from Scandinavia showed
benefit of high dose I.V. omeprazole (1997)
Taiwanese study of 100 patients randomized
between IV omeprazole and cimetidine.
Intragastric pH was around 6.0 for first 24 hours
in omeprazole group but only between 4.5 to 5.5
for cimetidine group. 12 pts in the cimetidine
group and 2 pts in the omeprazole group rebled.
No change in LOS, number of procedures, or
mortality (1998)
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Management of UGI Bleeding 1
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Chronic duodenal ulcer
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Gastric ulcer
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endoscopic control
PPI
anti-HP antibiotherapy
surgery (anterior gastrotomy, duodenotomy)
endoscopic control
PPI
anti-HP antibiotherapy
surgery (ulcer excision, , hemigastrectomy,
duodenotomy, vagotomy+pyloroplasty?)
Esophageal or gastric varices
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endoscopy (rubber banding, intravariceal
sclerotherapy)
balloon tamponade (four-port Minnesota tube,
Sengstaken-Blakemore tube)
somatostatin, octreotide (synthetic analogue of
somatostatin)
vasopressin
surgery (transjugular intrahepatic portosystemic shunt
– TIPS, distal splenorenal shunt, central portacaval
shunt, Segura procedure)
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Management of UGI Bleeding 2
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Mallory-Weiss Tears
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Acute hemorrhagic gastritis
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H2 receptor blockers
PPIs
sucralfate
antacids
antibiotics
somatostatin
vasopressin
surgery (total or near-total gastrectomy)
Neoplasms
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endoscopic coagulation
surgery (anterior gastrotomy and direct suture ligation of the tear)
Benign tumors – wedge excision of the offending lesion
Malignant neoplasms
 endoscopy
 surgery (excision)
Esophageal Hiatal Hernia
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PPI
anti-H. pylori antibiotherapy
surgery (i.e., laparoscopic Nissen fundoplication)
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Management of UGI Bleeding 3
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Hemobilia
 Arteriographic embolization
 Surgery (hepatic artery ligation or hepatic resection)
Aortoenteric fistula
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Vascular ectases (vascular dysplasia, angiodysplasia, angiomata,
telangiectasia, and arteriovenous malformations)
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surgery (excision)
Duodenal and jejunal diverticula
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air around the aorta or the aortic graft – emergency exploration
(resection of the graft with extra-abdominal bypass, resection of the
graft with in situ graft replacement)
surgery (excision)
Jejunal ulcer (NSAIDs, infection, gastrinoma)
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medications stopping
infections treatment
surgery (excision of gastrinoma, resection of bleeding segment of the
jejunum)
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Lower GI Bleeding
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Distal to the ligament of Treitz
Causes:
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Diverticulosis 60%
Angiodysplasia 20%
Neoplasia
IBD
Ischaemic colitis
Infective colitis
Ano-rectal disease
Small intestine
coagulopathy
Upper GI cause in 10-15%
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Management Principles
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Treatment & evaluation should be
instigated concurrently
Haemodynamic assessment +
directed history and examination
PR / proctoscopy essential to
evaluate ano-rectum
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Initial Management
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Large bore IV access + crystaloid
resucitation
NGT
X-match, coagulation profile, Blood
film & count, routine biochemistry
85% cease spontaneously
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Localisation
 99mTc
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labelled RBC scan
Selective mesenteric angiography
Colonoscopy
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Selective Mesenteric Angiography
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Once localised can treat bleeding with
super selective embolisation
Vasopressin infusion superseeded due to
cardiac and ischaemic complications
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Management of LGI Bleeding
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Endoscopy
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thermal contact probes
laser photocoagulation
electrocauterization
injection of vasoconstrictors
application of metallic clips
injection sclerotherapy
Angiographic therapy
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Selective Mesenteric Angiography
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Super selective embolisation into
bleeding vessel (beyond marginal artery)
Excellent control if technically feasible.
Time consuming, risk of colonic
infarction (0-20%), rebleeding (10-20%)
?Role of check colonoscopy at 2-3days
Bandi R, Shetty P, Sharma R, Burke T, Burke M, Kastan D. Superselective
arterial emboilization for the treatment of lower gastrointestinal hemorrhage. J
Vasc Interv Radiol 2001; 12: 1399-1405
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Colonoscopy 1
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Procedure of choice if bleeding has
stopped or slowed significantly
Reports of the use of colonoscopy in
acute bleeds (+/- cleansing purge)
Only consider in stable patient, abort
if severe colitis
Localisation in 70-80%
Jensen D, Machicado G. Diagnosis and treatment of severe
hematochezia: the role of urgent colonoscopy after purge.
Gastroenterology 1988; 95: 1569-1574
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Colonoscopy 2
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Heater probe or Argon / Nd:YAG laser can be
used to treat angiodysplasia.
Diverticular bleeding can also be treated with
endoscopic therapy
Rebleed 10-50%, Perforation <2%
Procedure of choice for post polypectomy
bleeding
Jensen D, Machicado G, Jutabha R, Kovacs T. Urgent Colonoscopy for the
Diagnosis and Treatment of Severe Diverticular Hemorrhage. New Eng J Med;
342(2):78-82
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Indications for Surgery
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HD unstable despite resuscitation
More than 6-8 units PRBC required
Ongoing bleeding beyond 72 hours
Significant early (<1 week) re-bleed
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Surgery
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Operative localisation (endoscopy,
colotomies, transverse loop colostomy)
are notoriously poor
Gastroscopy is essential
Treatment of choice is subtotal
colectomy + IRA
If localised pre-operatively then
segmental resection.
Primary anastomosis is generally safe
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References
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