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Gastrointestinal Bleeding Rajeev Jain, M.D.. GI Bleeding Background Acute Upper GI Bleed Acute Lower GI Bleed.

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Presentation on theme: "Gastrointestinal Bleeding Rajeev Jain, M.D.. GI Bleeding Background Acute Upper GI Bleed Acute Lower GI Bleed."— 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 –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 27% 45%

10 Location of Bleeding Upper –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 Cause of bleeding Severity of initial bleed Age of the patient Comorbid conditions Onset of bleeding during hospitalization Acute UGIB Prognostic Indicators

13 Tedesco et al. ASGE Bleeding Survey. Gastro Endo

14 Acute UGIB Differential Diagnosis

15 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 Acute UGIB Differential Diagnosis

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

22 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) Leontiadis, G. et al. BMJ 2005;330:568

24 Mallory-Weiss Tear

25 Esophageal Varices

26 Variceal Band Ligation

27

28

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

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

31 Aortoduodenal Fistula Aorta Duodenum Graft Fistula

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

33 Acute LGIB Differential Diagnosis

34 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 Acute LGIB Differential Diagnosis

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) 1 st 73 pts: no colonoscopic tx Last 48 pts eligible for colonoscopic tx Colonoscopy w/in 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 Incidence % EtiologyIncomplete obliteration of the vitelline duct. Pathology50% ileal, 50% gastric, pancreatic, colonic mucosa Complications –Painless bleeding (children, currant jelly) –Intussusception Acute LGIB Meckel’s Diverticulum

47 Acute LGIB Evaluation Zuccaro. ASGE Clinical Update

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


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