Transcript gastrointestinal bleeding

GASTROINTESTINAL
BLEEDING
Part 1
Stephanie Faith C. Bautista
DEFINITION of
Gastrointestinal (GI) Bleeding
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refers to any bleeding that starts in the gastrointestinal tract, which
extends from the mouth to the anus.
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can occur from abnormal blood clotting
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can be caused by vitamin K deficiencies and thrombocytopenia — a
drop in platelets (the blood cells that normally initiate the clotting
process).
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The amount of bleeding can range from nearly undetectable to acute,
massive, and life threatening.
SITE
Divided into:
 Upper GI bleeding: The upper GI tract is located between the
mouth and the upper part of the small intestine.
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Lower GI bleeding: The lower GI tract is located between the
upper part of the small intestine and the anus. The lower GI
tract includes the small and large bowels.
CONSIDERATIONS
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can range from microscopic bleeding and massive bleeding
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important to be aware, because it may point to many significant diseases and
conditions.
• Prolonged microscopic bleeding can lead to loss of iron, causing anemia.
• Acute, massive bleeding can lead to hypovolemic shock, and even death.
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can occur at any age from birth on.
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the degree and suspected location of the bleeding determines what tests should be
performed to find the cause.
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once a bleeding site is identified, many therapies are available to stop the bleeding.
COMMON CAUSES
Some of the possible causes of GI bleeding include:
Anal Fissure
Gastric (stomach) ulcer
Aorto-enteric fistula
Hemorrhoids
Arterio-venous malformations (angiodysplasias)
Bleeding diverticulum
Ischemic bowel
Intestinal polyps
Cancer of the small intestine
Intestinal obstruction (twisted bowel)
Celiac sprue
Intestinal vasculitis
Colon cancer
Intussusception
Cow's milk allergy
Mallory-Weiss tear
Crohn’s disease
Meckel’s diverticulum
Dieulafoy's lesion
Nosebleed
Duodenal ulcer
Portal hypertensive gastropathy
Dysentery
Radiation injury to the bowel
(infectious diarrhea that causes bleeding)
Ruptured appendicitis
Esophageal varices
Stomach cancer
Esophagitis
Ulcerative colitis
Upper Gastrointestinal Bleeding
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Upper GI bleeding originates in the first part of the GI tract - the
esophagus, stomach, or duodenum (first part of the intestine).
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Upper GI bleeding is caused by one of the following:
– Peptic ulcers
– Gastritis
– Esophageal varices
– Mallory-Weiss tears
Lower Gastrointestinal Bleeding
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Lower GI bleeding originates in the portions of the GI tract farther down the
digestive system-the segment of the small intestine farther from the stomach,
large intestine, rectum, and anus.
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Lower GI bleeding is caused by one of the following:
– Diverticular disease
– Angiodysplasia
– Polyps
– Hemorrhoids
– Anal fissures
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Blood in the stool can result from cancers, inflammatory bowel disease, and
infectious diarrhea.
SYMPTOMS
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Acute gastrointestinal bleeding first will appear as vomiting of blood, bloody
bowel movements, or black, tarry stools. Blood may look like "coffee grounds."
Symptoms associated with blood loss can include the following:
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Fatigue
Weakness
Shortness of breath
Abdominal pain
Pale appearance
Vomiting of blood usually originates from an upper GI source.
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Bright red or maroon stool can be from either a lower GI or an upper GI source.
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Long-term GI bleeding may go unnoticed or may cause fatigue, anemia, black
stools, or a positive test for microscopic blood.
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WHEN TO SEEK MEDICAL CARE
Call for an appointment with your doctor if:
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You have black, tarry stools (this may be a sign of upper GI bleeding)
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You have blood in your stool
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You vomit blood or you vomit material that looks like coffee grounds
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Any presence of blood in the stool or the upper gastrointestinal tract is significant
and needs medical investigation. Black or dark stools may represent slow bleeding
into the GI tract and should be investigated by a physician.
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Any significant bleeding into the GI tract, either vomited blood or blood through
the rectum, should be evaluated.
What to expect at your health care provider's
office:
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GI bleeding is diagnosed by a doctor
GI bleeding can be an emergency condition requiring immediate medical
attention.
You will also be asked questions about your symptoms, including:
 When did you first notice symptoms?
 Did you have black, tarry stools or red blood in the stools?
 Have you vomited blood?
 Did you vomit material that looks like coffee grounds?
 Do you have a history of peptic or duodenal ulcers?
 Have you ever had symptoms like this before?
 What other symptoms do you have?
EXAMS AND TESTS
Tests that may be done include:
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Abdominal CT scan
Abdominal MRI scan
Abdominal x-ray
Angiography
Bleeding scan (tagged red blood cell scan)
Capsule endoscopy (camera pill that is swallowed to look at the
small intestine)
Colonoscopy
Complete blood count (CBC)
EGD (Esophagogastroduodenoscopy)
Enteroscopy
Sigmoidoscopy
MEDICAL TREATMENT
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Serious gastrointestinal bleeding can destabilize your vital signs.
The physician may need to resuscitate you with IV fluids and medicine through a
vein
Blood transfusions
In some cases, you may need surgery.
Tube through the mouth into the stomach to drain the stomach contents (gastric
lavage)
Once the condition is stable, a physical examination, including a detailed
abdominal examination, will be performed.
FOLLOW-UP
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Maintain a proper diet and take the medications prescribed to you as your doctor
directs.
Follow up with your physician on a regular basis to monitor progress, so that your
doctor can prevent further progression and complications of your gastrointestinal
bleeding.
TREATMENT
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Early endoscopy is recommended, both as a diagnostic and therapeutic approach,
as endoscopic treatment can be performed through the endoscope.
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Patients with esophageal varices typically have coagulopathy, plasma products
may have to be administered. Vitals signs are continuously monitored.
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Endoscopic Therapy depends on the lesion identifies, and can include:
• Injection of adrenaline or other sclerotherapy
• Electrocautery
• Endoscopic clipping or
• Banding of varices
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Bleeding lesion are usually removed in order to determine the underlying
pathology, and to determine the risk for rebleeding.
PHARMACOTHERAPY
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Includes the following:
• Proton pump inhibitors (PPIs) - reduce gastric acid production and accelerate healing of
certain gastric, duodenal and esophageal sources of hemorrhage. Administered orally /
intravenously
• Octreotide is a somatostatin - shunt blood away from the splanchnic circulation.
Found to be a useful in management of both variceal and non-variceal upper GI
hemorrhage.
• Terlipressin is a vasopressin - most commonly used for variceal upper GI hemorrhage.
• Antibiotics are prescribed in upper GI bleeds - associated with portal hypertension
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If Helicobacter pylori is identified as a contributant to the source of hemorrhage, then therapy
with antibiotics and a PPI is suggested.
PREVENTION
 You can prevent some causes of gastrointestinal
bleeding.
 Avoid foods and factors, such as alcohol and
smoking, that increase gastric secretions.
 Eat a high-fiber diet to increase the bulk of the stool,
which helps prevent diverticulosis and hemorrhoids.
Ligament of Treitz
Upper gastrointestinal bleeding.
Ulcer with a clean base.
Upper gastrointestinal bleeding
Ulcer with a black spot
Ulcer with an overlying clot
Upper gastrointestinal bleeding.
Ulcer with a visible vessel.
Upper gastrointestinal bleeding.
Ulcer with active bleeding
Intussusception - x-ray:
Abdominal x-ray showing an
intestinal condition in which a loop of
bowel has slipped into another
section of bowel called
INTUSSUSCEPTION.
causing swelling, reduced blood
flow, obstruction, and tissue damage.
Intussusception requires
emergency treatment (barium enema
or surgery) to prevent intestinal tissue
death (necrosis), intestinal
perforation, peritonitis, and death.
Volvulus - x-ray:
Patient with a
twisted bowel
(volvulus).
Normal anatomy:
The Gastrointestinal
Tract starts at the
mouth, which leads
to the esophagus,
stomach, small
intestine, colon, &
finally, the rectum
and anus.
The GI tract is a
long, hollow,
muscular tube
through which food
passes & nutrients
are absorbed.
Bleeding from the
GI tract is a
common medical
problem.
Indication:
Patients usually
notice either dark
red blood or bright
red blood in their
stool.
Ulcers of the
stomach and
duodenum are
common causes of
bleeding from the
upper GI tract.
Bleeding can also occur in the lower GI tract (colon).
Diverticular bleeding is a common cause of lower GI bleeding.
ENDOSCOPY
Procedure, part 1
The first step in the
treatment of GI bleeding is
to locate the source of the
bleeding. Patients who
have lost significant
amounts of blood are
transfused with blood.
Next, an endoscopy is used
to locate the source of the
bleeding. Upper
endoscopy is generally
performed first, and if no
bleeding source is located,
then lower endoscopy is
performed. During an
endoscopy, the patient is
usually sedated but awake.
Procedure, part 2
In many cases, GI
bleeding will stop on
its own, with no
treatment.
In other cases,
treatment can be
provided with the
endoscope, most often
in the form of cautery
(electrocoagulation)
of the site of bleeding.
Procedure, part 3:
If the bleeding cannot be stopped using the endoscope, surgery may be
required. The bleeding segment of intestine or stomach is removed. However,
most cases of GI bleeding are managed succesfully with endsocopy.
Endoscopic
Therapy
Endoscopic Therapy
UPPER GASTROINTESTINAL BLEEDING
Endoscopic image of a posterior wall duodenal ulcer with a clean base,
which is a common cause of upper GI hemorrhage.
Gastric ulcer in antrum of stomach with overlying clot.
Pathology was consistent with gastric lymphoma.
Endoscopic image of
small gastric ulcer with
visible vessel
Same ulcer seen after
endoscopic clipping
Mallory-Weiss Syndrome
34-year-old male
physician who had
been ingesting
alcoholic beverages,
presented with
bleeding of the g.i.
tract.
43-year-old male who presented with
vomiting after ingestion of alcoholic
beverages. Also note the signs of
reflux esophagitis as well as a blood
clot from a gastro esophageal tear.
Peptic ulcer
Peptic ulcer caused
by excess acid in the
stomach...
Acute Gastritis
Chronic Gastritis
Esophageal Varices
Hematemesis and Melena
Hypovolemic Shock
Types of LOWER GASTROINTESTINAL (GI) BLEEDING
Algorithm
for
Massive
Lower
Gastrointestinal
(GI)
Bleeding
Basic Algorithm for the Management of
Lower GI Bleed
Diverticular disease - a cause of LGIBs
Acute Variceal Bleed
Exact site of the bleeding of
acute variceal bleeding
Endoscopy is an essential
step in the diagnosis and
treatment of acute
variceal bleeding
Endoscopic Variceal Ligation (Banding)
ENDOSCOPIC VARICEAL LIGATION is like rubber-band ligation of hemorrhoids
Esophageal mucosa and submucosa containing varices are ensnared, causing
subsequent strangulation, sloughing, and eventual fibrosis, resulting in
obliteration of the varices.
Endoscopic ligation requires placement of an opaque cylinder over the end of the
endoscope. This decreases the endoscopic field of view and may allow pooling of
blood. Thus, in patients with active bleeding, visualization may be impaired more
with ligation than with sclerotherapy.
Local complications are less common with ligation compared to sclerotherapy.