1. GI Hemorrhage
April 6, 2017
David Hughes

2. Incidence 1-2% of all hospital admissions 5-12% mortality
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 Lower Esophageal Stomach Doudenum Hepatic Pancreatic
Small bowel
Colon
Anus

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

5. Chain of events Recognize severity Establish access for resusitation
Resusitate
Identify source
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?
>40%
20-40%
10-20%
<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) %

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

10. Gastric varices

11. Gastric varices
Esophageal
Varices

12. Gastric varices
Bleeding ulcers
Esophageal
Varices

14. Gastritis

15. Gastritis
Dieulafoy’s lesion

17. Mallory-weiss

21. Watermelon stomach
Watermelon stomach = Gastric antral vascular ectasia

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

24. AGML = Acute Gastric Mucosal Lesions

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 1st rebleed salvages 50%
Increased risk of mortality

29. Peptic ulcer hemorrhage
Surgical intervention
Only 10% of patients
Indications
Failure of endoscopy
Significant rebleeding after 1st 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. TIPS
Shunt procedures
Sugiura procedure

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 Only 15% of massive GI bleeding Finding the site
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

39. Bleeding diverticulosis

40. Colonic angiodysplasia
Bleeding diverticulosis

41. LGI hemorrhage Etiology Diverticulosis – 40-55% Angiodysplasia – 3-20%
Right sided lesions > left
90% stop spontaneously
10% rebleed in 1st 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
Others = meckel’s, juvinial polyps, solitary rectal ulcer, Dieulafoy’s lesion of the colon, portal colopathy, NSAIDs, intussusception, or bleeding following colonoscopic biopsy or polypectomy.

42. LGI hemorrhage Evaluation Same for UGI bleed After stable
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

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