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Gastrointestinal Bleeding

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Presentation on theme: "Gastrointestinal Bleeding"— Presentation transcript:

1 Gastrointestinal Bleeding
Rajeev Jain, M.D.

2 GI Bleeding Background Acute Upper GI Bleed Acute Lower GI Bleed

3 Clinical Presentation Definitions
Hematemesis: bloody vomitus (bright red or coffee-grounds) Melena: black, tarry, foul-smelling stool Hematochezia: bright red or maroon blood per rectum Occult: positive guaiac test Symptoms of anemia: angina, dyspnea, or lightheadedness

4 Clinical Presentation
Reflection of bleeding: Site Etiology Rate

5 Initial Patient Assessment Hemodynamic Status

6 Resuscitation 2 large bore peripheral IV’s
Colloid (normal saline or lactated Ringer’s) Transfuse packed RBCs In elderly, goal Hct 30% In young, goal Hct 20-25% In cirrhotics, goal Hct 25-28% Correct coagulopathy Reassess hemodynamics

7 History Prior history of bleeding Previous gastrointestinal illnesses
Previous surgery Other medical conditions (ie, cirrhosis) Medications Aspirin, NSAIDs, & anti-platelet agents Anticoagulants ? SSRIs Abdominal pain, weight loss

8 Physical Exam & Labs Focused but thorough Laboratory studies
Look for markers of liver disease Laboratory studies CBC INR Electrolytes Type and crossmatch RBCs

9 Acute Bleeding Changes Before and After 2 Liter Bleed
45% 45% 27%

10 Location of Bleeding Upper Lower Proximal to Ligament of Treitz
Melena ( cc of blood) Azotemia Nasogastric aspirate Lower Distal to Ligament of Treitz Hematochezia

11 Acute UGIB Demographics
Annual incidence of hospitalization: 100/100,000 persons 80% self-limited Mortality stable at 10% Continued or recurrent bleeding - mortality 30-40%

12 Acute UGIB Prognostic Indicators
Cause of bleeding Severity of initial bleed Age of the patient Comorbid conditions Onset of bleeding during hospitalization

13 Acute UGIB Prognostic Indicators
Tedesco et al. ASGE Bleeding Survey. Gastro Endo

14 Acute UGIB Differential Diagnosis

15 Acute UGIB Differential Diagnosis
Peptic ulcer disease Gastric ulcer Duodenal ulcer Mallory-Weiss tear Portal hypertension Esophagogastric varices Gastropathy Esophagitis Dieulafoy’s lesion Vascular anomalies Hemobilia Hemorrhagic gastropathy Aortoenteric fistula Neoplasms Gastric cancer Kaposi’s sarcoma

16 Acute UGIB Final Diagnoses of the Cause in 2225 Patients
Tedesco et al. ASGE Bleeding Survey. Gastro Endo

17 Acute UGIB Causes in CURE Hemostasis Studies (n=948)
Savides et al. Endoscopy 1996;28:244-8.

18 Acute UGIB CORI Database: 7822 EGDs b/n 1999-2001
73 practices in 24 states: private, academic & VA; wide-range of practices; more reflective of real care; less selection bias Boonpongmanee S. et al. Gastrointest Endosc 2004;59:

19 Peptic Ulcers Stigmata of Recent Hemorrhage (SRH)

20 Acute Peptic Ulcer Bleeding Prognosis by SRH
Laine and Peterson. New Eng J Med 1994;331:

21 Endoscopic Therapy of PUD
Thermal Bipolar probe Monopolar probe Argon plasma coagulator Heater probe Mechanical Hemoclips Band ligation Injection Epinephrine Alcohol Ethanolamine Polidocal

22 Endoscopic Therapy of PUD
Laine and Peterson New Eng J Med 1994;331:

23 Peptic Ulcer Bleeding Adjuvant Medical Therapy
Erythromycin 250 mg IV 30 minutes before endoscopy decreases blood in stomach Proton pump inhibitor therapy 80 mg IV bolus followed by 8 mg/hr continuous infusion for 72 hrs Reduced risk: Rebleeding (NNT 12) Surgery (NNT 20) 3 European studies have shown that IV Emycin prior to EGD increases view and ability to localize bleeding site Leontiadis, G. et al. BMJ 2005;330:568

24 Mallory-Weiss Tear

25 Esophageal Varices

26 Variceal Band Ligation

27 Variceal Band Ligation

28 Variceal Band Ligation

29 MEDICAL THERAPY Acute Variceal Bleeding
Octreotide Cyclic octapeptide analog of somatostatin Longer acting than somatostatin Equivalent to sclerotherapy and improves endoscopic results

30 Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Coronary Vein IVC Splenic Vein Portal Vein

31 Aortoduodenal Fistula
Aorta Duodenum Fistula Graft

32 Acute UGIB Surgery Recurrent bleeding despite endoscopic therapy
> 6-8 units pRBCs

33 Acute LGIB Differential Diagnosis

34 Acute LGIB Differential Diagnosis
Diverticulosis Colitis IBD (UC>>CD) Ischemia Infection Vascular anomalies Neoplasia Anorectal Hemorrhoids Fissure Dieulafoy’s lesion Varices Small bowel Rectal Aortoenteric fistula Kaposi’s sarcoma UPPER GI BLEED

35 Acute LGIB Diagnoses in pts with hemodynamic compromise.
Zuccaro. ASGE Clinical Update

36 Etiology of Acute LGIB Strate LL. Gastroenterol Clin North Am Dec;34(4):

37 Outcomes of Acute LGIB Strate LL. Gastroenterol Clin North Am Dec;34(4):

38 Diverticulosis

39 Diverticular Bleeding

40 Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage
121 pts with severe bleeding (>4 hrs after hospitalization) 1st 73 pts: no colonoscopic tx Last 48 pts eligible for colonoscopic tx Colonoscopy w/in 6-12 hrs

41 Urgent Colonoscopy for the Diagnosis and Treatment of Severe Diverticular Hemorrhage
Jensen DM, et al. New Eng J Med 2000:342:78-82.

42 Ischemic Colitis Most common form of intestinal ischemia
Transient and reversible Abdominal pain Watershed areas Splenic flexure Rectosigmoid junction

43 Hemorrhoids

44 Bleeding AVM

45 Radiation Proctitis

46 Acute LGIB Meckel’s Diverticulum
Incidence % Etiology Incomplete obliteration of the vitelline duct. Pathology 50% ileal, 50% gastric, pancreatic, colonic mucosa Complications Painless bleeding (children, currant jelly) Intussusception

47 Acute LGIB Evaluation Zuccaro. ASGE Clinical Update

48 Acute LGIB Key Points Annual incidence of hospitalization:
20-30/100,000 persons Resuscitation Exclude an UGI source Most bleeding ceases Colonoscopy No role for barium studies

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