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GI Hemorrhage October 11, 2014 David Hughes. Incidence 1-2% of all hospital admissions Most common diagnosis of new ICU admits 5-12% mortality 40% for.

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Presentation on theme: "GI Hemorrhage October 11, 2014 David Hughes. Incidence 1-2% of all hospital admissions Most common diagnosis of new ICU admits 5-12% mortality 40% for."— Presentation transcript:

1 GI Hemorrhage October 11, 2014 David Hughes

2 Incidence 1-2% of all hospital admissions Most common diagnosis of new ICU admits 5-12% mortality 40% for recurrent bleeders 85% stop sponateously Those with massive bleeding need urgent intervention Only 5-10% need operative intervention after endoscopic interventions

3 Site Upper Esophageal Stomach Doudenum Hepatic Pancreatic Lower Small bowel Colon Anus

4 Etiology 85% are due to: Peptic ulcer disease Variceal hemorrhage Colonic diverticulosis Angiodysplasia

5 Chain of events 1. Recognize severity 2. Establish access for resusitation 3. Resusitate 4. Identify source 5. Intervention

6 Question #1 JB a 30 y/o with hematemesis presents with orthostatic hypotension, clammy hands, but without tachycardia. How much blood has he lost? a) >40% b) 20-40% c) 10-20% d) <10%

7 Question #1 JB a 30 y/o with hematemesis presents with orthostatic hypotension, clammy hands, but without tachycardia. How much blood has he lost? b) 20-40%

8 Upper GI hemorrhage How do you know its upper? – 85% of all GI hemorrhage is upper – Hematemesis diagnostic Don’t forget about nasal bleeding as possible source – Melena Degradation of hemoglobin to hematin by acid Bowel bacteria and digestive enzymes also contribute – Hematochezia 10% of patients with very rapid UGI source

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10 Gastric varices

11 Esophageal Varices

12 Gastric varices Bleeding ulcers Esophageal Varices

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14 Gastritis

15 Dieulafoy’s lesion

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17 Mallory-weiss

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21 Watermelon stomach

22 Upper GI hemorrhage Etiology Peptic ulcer disease - 50% Varices – 10-20% Gastritis – 10-25% Mallory-weiss – 8-10% Esophagitis – 3-5% Malignancy – 3% Dieulafoy’s lesion – 1-3% Watermelon stomach – 1-2%

23 Upper GI hemorrhage Crampy abdominal pain common Large caliber NGT Coffee grounds or gross blood No blood Can be used for lavage prior to endoscopy Upper endoscopy indications Melena or hematochezia with hypotension Hematemesis NGT with guiac positive fluid Should be completed in 24hrs for stable patients

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25 Peptic ulcer hemorrhage Peptic ulcer disease 20% of patients bleed at least once Most lethal complication Vessel is usually <1mm diameter Causes H. pylori 40-50% NSAID’s 40-50% Other (Z-E syndrome)

26 Peptic ulcer hemorrhage Predictors of mortality Renal disease 29% – Acute renal failure 63% Liver disease 25% – Jaundice 42% Pulmonary disease 23% – Respiratory failure 57% Cardiac disease 13% – Congestive heart failure 28%

27 Peptic ulcer hemorrhage Medical management Anti-ulcer medication H. pylori treatment Stop NSAIDs Follow up EGD for gastric ulcer in 6 weeks

28 Peptic ulcer hemorrhage Endoscopic interventions Thermal coagulation Injected agents Success rate – 95% initailly – 80% will not rebleed – Repeat treatment after 1 st rebleed salvages 50% Increased risk of mortality

29 Peptic ulcer hemorrhage Surgical intervention – Only 10% of patients – Indications – Failure of endoscopy – Significant rebleeding after 1 st endoscopy – Ongoing transfusion requirement – Need for >6 units over 24 hours – Earlier for elderly, multiple co-morbidities

30 Peptic ulcer hemorrhage Anti-secretory surgery?? Indicated for NSAID pts who need to continued meds H. pylori ulcer disease controversial – Only 0.2% of pts every require surgery for bleeding ulcer – Surgery pts had lower than average H. pylori positivity – Oversewing and antibiotics still leave 50% at high risk for rebleeding Bottom line: still recommended but without definitive evidence

31 Peptic ulcer hemorrhage Doudenal ulcer – Expose ulcer with duodenotomy or duodenopyloromyotomy – Direct suture ligation, four quadrent ligation, ligation of gastroduodenal artery – Anti-secretory procedure Truncal, parietal cell vagotomy If unstable can use meds

32 Peptic ulcer hemorrhage Gastric ulcer – 10% are maliganant – 30% will rebleed with simple ligation Need Resection Distal gastrectomy with Bilroth I or II Subtotal gastrectomy for 10% high on lesser curve

33 Variceal hemorrhage Cirrhotics usually 25% mortality for each bleeding episode 75% will rebleed 50% mortality with surgery Based on Child’s class

34 Somatostatin or vasopressin w/wo NTG

35 Shunt procedures Sugiura procedure TIPS

36 Other sources of UGI hemorrhage – Mucosal lesions – Gastritis, ischemia, stress ulceration – Key is prevention with acid supression – Surgery often requires resection and Roux-en-Y due to multiple bleeding sites – >50% mortality with surgery – Mallory-Weiss – 10% will have significant bleeding – 90% stop spontaneously – Surgery rare, but gastrotomy with oversewing effective – Dieulafoy’s – Wedge rxn after endoscopic marking – Aortoenteric fistula – 1% of AAA repair patients – Herald bleed preceeds exsangunation by hours to days – Endoscopy and if negative CT scan and if negative angiography – Surgery – graft removal and extraanatomic bypass

37 LGI hemorrhage Sites Colon – 95-97% Small bowel – 3-5% Only 15% of massive GI bleeding Finding the site Intermittent bleeding common Up to 42% have multiple sites

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39 Bleeding diverticulosis

40 Colonic angiodysplasia

41 LGI hemorrhage Etiology – Diverticulosis – 40-55% – Right sided lesions > left – 90% stop spontaneously – 10% rebleed in 1 st year and 25% at 4 years – Angiodysplasia – 3-20% – Most common cause of SB bleeding in >50 y/o – >50% are in right colon – Neoplasia – Typically bleed slowly – Inflammatory conditions – 15% of UC patients, 1% of chron’s patients – Radiation, infectious, AIDS rarely – Vascular – Hemorrhoids – >50% have hemorrhoids, but only 2% of bleeding attributed to them – Others

42 LGI hemorrhage Evaluation Same for UGI bleed If unstable with hematochezia need EGD 1st After stable Rectal Anoscopy for hemorrhoids

43 LGI hemorrhage diagnostics Colonoscopy Within 12 hours in stable patients without large amounts of bleeding Selective viseral angiography Need >0.5 ml/min bleeding 40-75% sensitive if bleeding at time of exam Tagged RBC scan Can detect bleeding at 0.1 ml/min 85% sensitive if bleeding at time of exam Not accurate in defining left vs right colon

44 Meckel’s Diverticulum Cecal angiodysplasia with extravasation Small bowel ulceration due to NSAIDS

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46 LGI hemorrhage treatment Endoscopy – Great for angiodysplasia and polypectomy sites Angiographic – Selective embolization for poor surgical candidates – Can lead to ischemic sites requiring later resection Surgery – Ongoing hemorrhage, >6 units or ongoing transfusion requirement – Site selection Blind segmental will rebleed in 75% Based on TRBC scan will rebleed in 35%

47 GI hemorrhage from unknown source Only 2-5% are not upper or lower Average patient – 26 month duration of intermittent bleeding – 1-20 diagnostic tests – Average of 20 units transfused

48 Localization of GIHOUS CT scan – Tumors, inflammation, diverticuli Enteroclysis – Ulcerations, inflammation – Only 10-20% yeild (SBFT is 0-6%) Meckel’s scan – Initial test for patients <30 years old Endoscopy – Push or pull endoscopy – Video capsule endoscopy – Intraoperative endoscopy – 70% successful

49 Etiology of GIHOUS Arteriovenous malformation 40 Small bowel leiomyoma 11 Small bowel adenocarcinoma 7 Small bowel lymphoma 6 Crohn’s disease 6 “Watermelon” stomach 4 Meckel’s diverticulum 4 Small bowel leiomyosarcoma 3 Metastatic colon carcinoma to small bowel 3 Small bowel varices 3 Small bowel melanoma 3 Others 10 Szold A, Katz L, Lewis B: Surgical approach to occult gastrointestinal bleeding. Am J Surg 163:90–93, 1992.

50 Treatment Surgery Without localization only for acute exsanguinating hemorrhage Intraoperative endoscopy Segmental resection


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