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Upper GI bleeding. UGI bleding ONE syndrome: a group of diseases.

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Presentation on theme: "Upper GI bleeding. UGI bleding ONE syndrome: a group of diseases."— Presentation transcript:

1 Upper GI bleeding

2 UGI bleding ONE syndrome: a group of diseases

3 Definitions l Intraluminal, exteriorised bleeding l Hematemesis – above the angle of Treitz l Melena – above the ileo-cecal valve l Hematochezia – bellow the spelnic flexure

4 A major health problem  / admission/year in US  Mortality is high ~10% even if: í fiberoptic endoscopy - general í better understanding of pathology í high performance medication  POPULATION IS GROWING OLDER  Great variety of pathologies risk of rebleeding very difficult to evaluate

5 Major cause l Duodenal ulcer 24% l Gastritis 23% l Gastric ulcer21% l Esophageal varices10% l Esofagitis8% l Sdr. M-W7% l Duodenitis6% l Tumors3% Large variations according to region

6 DIAGNOSTIC VS TRATAMENT l Major emergency l Urgent treatment before ethiological diagnostic l Sequence: »Diagnostic of UGI bleeding »Resuscitation »Empiric treatment »Ethiologic treatment »Specific treatment


8 Anamnesis l Describe bleeding »Quantification of blood loss is ridiculous l Other symptoms on onset: ex cough l Past medical history – associated with bleeding: hepatitis, chirrhosis… l Family problems l Alchool intake l Previous bleedings l Medication intake in the last week

9 FIRST AID l Decubitus l One or two large vein access l Insure vital function l Safe transportation l A sample for blood typing l No macromolecules before sample l Nill per mouth l +/- nasogastric tube + drainage

10 Haemodynamic evaluation l Hypovolemic shock if: Systolic blood pressure <90 mmHg = 50% circulating volume l NO shock – check for changes in blood pressure and puls in orthostatism »BP< % loss »BP-10 or puls rate >120/min %

11 EVALUATION BEFORE ETHIOLOGY IS ESTABLISHED l 1. Hemoglobine l 2. Platelets l 3. Hematocrit l 4. Screening test for coagulation l 5. BUN l 6. Screening for live function tests l 7. Abdominal and/or thorax X-Ray for associated pathology that could change protocol

12 EVALUATION BEFORE ETHIOLOGY IS ESTABLISHED l Patient in ICU under gastroenterology care l Supress HCl secretion (i.v. H2 bloxkers, PPI) l Treat coagulation disfunctions l Blood products »Balance for risks – viral infections »Risks vs benefits in continuous bleeding

13 SURVEILANCE - MODELES FOR REBLEEDING - l CONTINUOUS BLEEDING –No response –42% do not present a major episode of rebleeding –Aggressive monitoring = ESSENTIAL l MAJOR EPISODE OF REBLEEDING –15,2% rebleeding in ICU »61% sudden onset –ONLY shock is very unusual but possible

14 REBLEEDING MAJOR RISK FACTOR l Definition: new bleeding episode after an initial stop and haemodynamic stability l High mortality: 20% (3x more then average for UGU bleeding) l 3 major risk factors for in hospital morbidity and mortality:  Major rebleeding during hospital stay  Old age  Total quantity of transfused blood



17 Clinical Evaluation l Haemodyanmic evaluation and stabilisation l Confirm the dg of UGI bleeding –HEMATEMESIS, MELENA + rectal exam –Ex oral cavity + ENT for swallowed blood –Medicaton l Clinical signs suggestive for liver chirrhosis l Palpable tumors l Other medical problems that can cause UGI bleeding

18 IMAGISTICS l Can point to a possibel diagnostic l Rx thorax –Pleural efusions –TBC –Primary or secondarty tumors l Abdominal US –Liver chirrhosis + portal hypertension –Abdominal tumors l Rx g-d –Unusual alternative to explore UGI after the remission of signs or when endoscopic examination is incomplete.

19 ENDOSCOPY l Establishes SOURCE OR SOURCES of bleeding l Evaluation of risk of rebleeding l THERAPEUTIC acces directly to the lesion ENDOSCOPY - in emergency - not after 24 hourse SHORT LIVED LESIONS

20 PREPARE FOR ENDOSCOPY l Patient should be stable / in OR l Empty stomach if possible l +/- sedation – risk of aspiration l Patient in left lateral position – prevent aspiration

21 ENDOSCOPIC DIAGNOSTIC l Portal hypertension: varices YES/NO –Significant in massive bleeding l Diagnostic for all lesions with potential of bleeding l Evaluation of RISK of rebleeding l Type of ACTIVE bleeding l Complete vs incomplete examination: which areas not evaluated

22 MIRAGE – the first lesion ? the most significant lesion?

23 TREATMENT l Stabilise and monitor patient l STOP THE BLEEDING l Prevent recurrent bleeding l Treat the disease CAUSE l Treat complications and associated diseases

24 TRATAMENT according to cause l ENDOSCOPY: Oclude the vessel  the least aggressive for patient  immediate after diagnosis  very efficient  required in all cases with major risk of rebleeding l Medication l Surgical l Interventional radiology

25 ESOPHAGIAN CAUSES - 4% a. Congenital  Weber-Rendu-Osler  Blue rubber bleb nevus  Bullous epidermolisis  Esophageal duplication b. Inflamatory  GERD  Barrett disease  Infectious esophagitis  Caustic lesions  RT induced lesions  CHT induced lesions  Crohn disease  Behcet disease  pemfigoid

26 b. Traumatic or mechanic  Hiatus hernia  Mallory-Weiss syndrome  Boerhaave syndrome  Foreign body  Iatrogenic c. Neoplasia  malignant  benign d. Vascular  Varices  Aortic aneurism  After cardiac surgery e. Hematological  anticoagulants  coagulation disorders

27 ESOPHAGIAN CAUSES l Esophagus varices l Mallory-Weiss sundrome l Hiatus hernia and GERD l Tumors

28 l Varices  10% of cases  Associated with alcohol abuse and hepatitis: clinical signs of chirrhosis  ESSENTIAL to exclude variceal haemorrhage  Endoscopy may be difficult but very important

29 VARICELE ESOFAGIENE l Endoscopic difficulties –Important bleeding –Stomach full of cloths –Gastric varices –Encephalopathy l BUT ONLY 60% of patients with chirrhosis bleed from varices


31 TRATAMENT l MEDICATION - OCTREOCTIDE: decreases portal flux and pressure in varices l TAMPONDE – Segstaken Blackmore tube –Not a first choice l SURGICAL SHUNT –~70% mortality in emergency cases l TIPS –~50% mortality on emergency

32 M-W SYNDROM l Diagnostic only with endoscopy in emergency –Short lived lesions »Usually with small quantity of blood but may produce shock »Short monitoring »~0% risk of rebleeding »Conservative treatment ~ 100%

33 Mallory Weiss

34 HIATUS HERNIA AND GERD l dg+ EDS – stigmata of recent bleeding l HH very frequent encounter l Treatment: H2 blockers, PPI

35 TUMORS of ESOPHAGUS l Very unusual cause of clinical manifest bleeding: occult l Endoscopic hemostasis »Laser YAG »Argon plasma

36 GASTRIC ORIGINE l Hemorrhagic gastritis l Gastric ulcer l Benign tumors l Malignant tumors

37 HEMORRHAGIC GASTRITIS l Morfologic criteria l EDS aspect may vary l Radiology useless and pointless l EDS: if late may not show anything

38 HEMORRHAGIC GASTRITIS l H2 blockers and PPI – routine but doubtful benefit l Rebleeding extremely rare l Endoscopic treatment: not recommended (numerous lesions with small risk of rebleeding) l SURGICAL(unusual: doubtfull diagnostic + hemodynamic instability) »In situ hemostasissutura in situ »Vagotomy + gastrectomy

39 GASTRIC ULCER l Some localisations are difficult to see l EDS needs to evaluate »Stigmata of bleeding »Risk of rebleeding

40 Treatment l H2, IPP +/- l i.v route l Endoscopic direct treatment Sclerosis Thermocoagulation Clips

41 Surgical treatment l If so, resection of lesion is better l Frozen section pathology: malignnancy always in doubt l Limited resections for bening disease

42 Benign gastric tumors l Bleding is RARE  Polipoid lesions can be resected endoscopically  Surgical excision

43 Malignant gastric tumors 6% Special characteristics High mortality 9% Frequently non- resectable Large costs little benefit in survival

44 ENDOSCOPY l Examination: advanced lesion è Hemostasis (laser or argon plasma) Ex. Echografic è Ultrasound: MTS and large LN: inoperable

45 Surgical treatment l Laparotomy or laparoscopy: confirm advanced disease vs operability l Massive bleeding: most often advanced lesions l Paliation ~25% î bypass î gastrostomy î jejunostomy

46 Vascular malformations Dielafoy ( exulceratio simplex) l ~5% l Congenital anomaly l Abnormal artery protruding in submucoasa

47 Echoendoscopy

48 Treatment l Mechanic destruction of the vascular anomaly »Surgery: in situ hemostasis »Endoscopy – GOLD STANDARD –Correct diagnostic –Banding –Hemoclips –Laser thermocoagulation

49 Bading

50 DUODENAL ORIGIN l Very frequent l Justifies the empiric treatment with PPI

51 EROSIVE DUODENITIS l BIG BAG with different pathologies: erosions  Confusion in term with ulcer/superficial ulcer  Frequent association with Helicobacter Pylori  Treatment conservative: H2 blockers, PPI and antiobiotics

52 DUODENAL ULCER l Incidence is constant l 53% known ulcer in PMH l HDS iterative: 17% High gravity and high risk 25% in difficult localizations Requires a new approach

53 ASSOCIATED LESIONS l Multiple ulcers l Association with varices!!!!! l Duodenal stenosis: may be associated with postbulbar ulcer l Association of bleeding and perforation


55 ENDOSCOPIC TREATAMENT l Standard l Very good results l Little requirement of surgical procedures

56 Heater probe l Very good on visible vessels

57 Clips l Visible vessels l Difficult and expensive

58 SURGICAL l Emergency operation l Major indication:  Massive bleeding  More then 6 units of blood/24 hours = continuous bleeding

59 SURGICAL PROCEDURES l In situ hemostasis: the most used technique l Resections (limited in number and extent)

60 CONCLUSIONS l UGI bleeding is still a significant problem l Endoscopy is mandatory for diagnostic and treatment l Surgery is limited in emergency situations



63 CLINICAL PRESENTATION l History taking-type of bleeding »Careful interpretation of data »Blood on paper »Red blood vs feaces mixed with blood »Quantity »etc

64 Paraclinical l Wbc l Hct l Plt l Coagulation profile l LFT l + numerous other according to associated pathology

65 Risk stratification

66 Seven independent predictors of severity in acute LGIB »hypotension »tachycardia, »syncope, »nontender abdominal exam, »bleeding within 4 hours of presentation, »aspirin use, and »more than two comorbid diseases

67 LOCALIZATION The duration, frequency, and color of blood passed per rectum. l Characteristically, melena or black, tarry stool, indicates bleeding from an upper gastrointestinal or small bowel source l Maroon color suggests rt. Sided lesion l whereas bright red blood per rectum signifies bleeding from the left colon or rectum. However, patient and physician reports of stool color are often inaccurate and inconsistent l In addition, even with objectively defined bright red bleeding, significant proximal lesions can be found on colonoscopy

68 LOCALIZATION l past medical history. l antecedent constipation or diarrhea (hemorrhoids, colitis), l the presence of diverticulosis (diverticular bleeding), l receipt of radiation therapy (radiation enteritis), l recent polypectomy (postpolypectomy bleeding), and l vascular disease/hypotension (ischemic colitis). l A family history of colon cancer l Nonetheless, even after a detailed history, physicians cannot reliably predict which patients with hematochezia will have significant pathology and a history of bleeding from one source does not eliminate the possibility of bleeding from a different source.

69 LOCALIZATION l Multiple factors make the identification of a precise bleeding source in LGIB challenging. l The diversity of potential sources, l The length of bowel involved, l The need for colon cleansing, and l The intermittent nature of bleeding. l In up to 40% of patients with LGIB, more than one potential bleeding source will be noted and l Stigmata of recent bleeding in LGIB are infrequently identified l As a result, no definitive source will be found in a large percentage of patients

70 Clinical scenarios l Pt. continued to bleed with hypotension and tachycardia. Patient requires 2 units of PRBCs l Pt. stopped bleeding. Vitals normalizes

71 Options to diagnose and control the bleeding l RBC scan, requires ml/min bleeding l Mesenteric angiography, requires ml/min bleeding l Colonoscopy l Surgery l Meckels scan

72 l Scenario one- Pt. continues to bleed and is unstable.

73 Rbc scan vs colonoscopy

74 COLONOSCOPY l Colonoscopy is undoubtedly the best test for confirming the source of LGIB and for excluding ominous diagnoses, such as malignancy. l The diagnostic yield of colonoscopy ranges from 45% to 95% l Identifies lesion in 75 % or more l Can provide endoscopic therapy l most patients undergoing radiographic evaluation for LGIB regardless of findings and interventions will subsequently require a colonoscopy to establish the cause of bleeding.

75 CLINICAL SCENARIO l Patient continues to bleed l RBC scan is positive on the left side? How much true this information is?? l What to do next? surgery, ?angio with embolization?

76 RADIONUCLIDE SCAN l radionuclide scanning has variable accuracy, cannot confirm the source of bleeding, Correct localization rate is % l Accuracy appears to be best when the scan becomes positive within a short period of time l In one study, 42% of patients underwent an incorrect surgical procedure based on scintigraphy results.

77 CLINICAL SCENARIO l Patient underwent angiogram with embolization l Vitals improved l What are the chances that pt. will rebleed? l Colonoscopy?

78 MESENTERIC ANGIOGRAM l Selective embolization initially controls hemorrhage in up to 100% of patients, but rebleeding rates are 15% to 40% l Advantages: »Precise localization »Can provide therapy with intra-arterial vasopressin or coil embolization »Procedure of choice in briskly bleeding pts »Minor complication rate of 9% and a 0% major complication rate

79 l Disadvantages: »Invasive »Less sensitive in detecting venous bleeding »Can cause ischemia, contrast reactions, arterial injury

80 DIAGNOSTIC DIFFICULTIES l the diagnostic modalities for lower GI bleeding are not as sensitive or specific in making an accurate diagnosis (versus UGIB) l Diagnostic evaluation is complicated: more than one potential source of hemorrhage is identified. l If more than one source is identified, it is critical to confirm the responsible lesion before initiating aggressive therapy. l This approach may occasionally require a period of observation with several episodes of bleeding before a definitive diagnosis can be made. l In fact, in up to 25% of patients with lower GI hemorrhage, the bleeding source is never accurately identified.

81 SURGERY l Surgery usually is employed for hemorrhage in two settings: massive or recurrent bleeding. l It is required in 15% to 25% of patients who have diverticular l Recurrent bleeding from diverticula occurs in 20% to 40% of patients and generally is considered an indication for surgery l In patients with serious comorbid medical conditions and without exsanguinating hemorrhage, this decision should be made carefully. l Great effort should be made to accurately localize the site of bleeding preoperatively so that segmental rather than subtotal colectomy can be performed Operative mortality is 10% even with accurate localization and up to 57% with blind subtotal colectomy.

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