1. GI bleeding Mackay Memorial Hospital Department of Internal Medicine
Division of Gastroenterology
R4 陳泓達
97/6/22

2. GI Bleeding
UGI bleeding
Peptic ulcer disease
Variceal bleeding
LGI bleeding

3. UGI bleeding: 5 times more common than LGI bleeding.
Men > Women
Elderly persons.
Despite ongoing advances, fundamental principles are the same !!!!
 immediate assessment and stabilization of
hemodynamic status

4. Determine the source of bleeding
Stop active bleeding
Treat underlying abnormality
Prevent recurrent bleeding

5. hemodynamics Severity of bleeding normal < 10 minor 10-20 moderate
Blood loss(% of intravascular volume)
Severity of bleeding
normal
< 10
minor
Orthostatic hypotension or tachycardia
10-20
moderate
shock
20-25
massive

7. Resuscitation In hemodynamically unstable…
Set up two large-bore IV catheter
Colloid solution (NS or lactated Ringer’s)
To restore vital sign !!
ICU monitor is indicated
Central venous monitoring
F/U vital sign and urine output

8. History taking and physical examination
UGI or LGI ?
UGI  peptic ulcer disease or portal hypertension related (EV or GV)?

9. Differentiate LGI and UGI
Melena – upper GI cause in 90%
Hematochezia – upper GI cause in 10%

10. The intermediate patient
Take more time….
Re-examine,
Monitor vital signs,
Re-check CBC, BUN

11. Transfusion ?
In hemodynamic unstable, any sign of poor tissue oxygenation, continued bleeding, persistent low Ht level(20-25%)
Maintain adequate perfusion
Target ?

12. Other Blood tests on the bleeding patient…
INR, PTT
– coagulopathy anyone?

13. “There is no single value of hemoglobin concentration that justifies or requires transfusion; an evaluation of the patient’s clinical situation should also be a factor in the decision.” Capital Health Guide to Blood Transfusion

14. You’ve decided to give blood…
Options?

15. O neg Type Specific Full Cross Match
– immediately available – 10 – 15 min – 30 – 60 min.
O neg Type Specific Full Cross Match

16. What is in a unit of packed cells?
250 mL volume
Contains citrate (anticoagulant), and preservative.
1 unit packed cells will increase the Hb concentration by approx. --?
0.5mg/dL

17. Massive Transfusion
Greater than 1 blood volume( or 10 units ) transfused within 24 hours
May dilute platelets and clotting factors

18. Dilution coagulopathy
Monitor the patient for coagulopathy
Follow the resuscitation (CBC, INR, PTT)

19. Treatment of dilution coagulopathy
Plasma /FFP 10 – 15 mL / kg
Usual adult dose 2 units.
5 –8 mL / kg dose for warfarin reversal

20. Treatment of dilution coagulopathy
Platelets
Keep the count greater than 50 ,000 in the bleeding patient
1 unit should increase platelet count by 5 ,000– 10, 000 / L
Dose: 6 pack

21. Massive Transfusion What else can go wrong?
Hypothermia
Potassium
Citrate toxicity (hypocalcemia)

22. Vomiting Blood Hematemesis
Upper GI Bleeding

23. Etiology Peptic Ulcer 50 % Gastritis 20% Esophageal varices 10%
The rest: Tears, AVM, CA,etc 20%

24. More about bleeds….
80 % of Non – variceal upper GI bleeds will stop spontaneously
60 % of variceal bleeds will stop spontaneously

25. What else can I do for GI bleeding, before endoscopy
NG lavage
Drug
ABC
Patient and family Agree
( Sign permit first)

26. Urgent Endoscopy ?
Initial evaluation: 初始出血量是否大量 ?
出血量大者,rebleeding 機會也大
觀察重點: vital sign (tachycardia, orthostatic
hypotension resting hypotension, shock), 吐血或
血便黑便的頻次與量, NG lavage的結果

27. NG lavage 15 – 20 % of upper GI bleeds have a negative aspirate
Sensitivity 79%, Specificity 55%
Cuellar et al, Arch of Int Med Jul 1990
For endoscopic preparation
( not contraindicated in patients with varices)

28. Diagnostic Therapeutic Prognostic
Endoscopy
Diagnostic
Therapeutic
Prognostic

29. Endoscopic features and risk of re-bleeding
Active bleeding
55 – 90%

30. Endoscopic features and risk of re-bleeding
Non bleeding visible vessel
40 – 50 %

31. Endoscopic features and risk of re-bleeding
Adherent clot
10 – 33%

32. Endoscopic features and risk of re-bleeding
Flat spot
7 – 10 %

33. Endoscopic features and risk of re-bleeding
Clean base
3 – 5%

34. Variceal bleeding
Non-variceal bleeding

35. Drugs: Peptic ulcer bleeding
Manipulation of gastric pH

36. Use of PPI’s Theory : raise gastric pH Better platelet activity
Pepsinogen requires acid to become activated to pepsin
Clots will form, clots not digested

37. More severe bleeding (hemo-dynamically unstable, ongoing bleeding
High Risk Patients
Elderly
Co – Morbidity
More severe bleeding (hemo-dynamically unstable, ongoing bleeding

38. Other helpful medication
somatostatin / octreotide 
associated with a reduced risk of continued bleeding and rebleeding in PUD

39. When endoscopic / pharmacological treatment
fail…
◎ angiography  to localize bleeder and
hemostasis
generally reserved for patient:
poor surgical candidates
control of bleeding in an unstable patient
awaiting surgery

40. Surgery
Hemodynamic instability despite vigorous resuscitation (more than a three unit transfusion)
Recurrent hemorrhage after initial stabilization (attempts at obtaining endoscopic hemostasis)
Shock associated with recurrent hemorrhage
Continued slow bleeding with a transfusion requirement exceeding three units per day.

41. Variceal Bleeding
EGD finding:
F1-4
Ls-m-i
Cb / Cw
Red color sign

42. Pharmacological treatment:
Drug of choice:
control bleeding and reduce mortality rate
Glypressin (Terlipressin)
1 amp iv stat and q6h.
Sandostatin  no evidence
2 amp iv drip stat and 12 amp in 500 c.c. D5W run 24 hours
Pitressin: -- Seldom used in recently years

44. After endoscopic treatment…
Fail to achieve hemostasis or rebleeding
Balloon tamponade
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Surgery for shunt

45. Balloon Tamponade -Buy time
Available in MMH
S-B tube

46. McCormick. British Journal of Hospital Medicine. 43, Apr. 1990
Esophageal ballon
Gastric ballon
SB tube
McCormick. British Journal of Hospital Medicine. 43, Apr. 1990

54. McCormick. British Journal of Hospital Medicine. 43, Apr 1990
never exceed 45mmHg.
Volume 200ml
McCormick. British Journal of Hospital Medicine. 43, Apr 1990

56. Tamponade Tube Sengstaken-Blakemore (S-B) tube
Radiographic confirmation of the gastric balloon’s position -- 30cc air inflate the gastric balloon
Insufflation of the esophageal balloon to 35mmHg

57. Compression of varices for not excess 48 hours
Deflate the esophageal balloon for about 30 mins every 12 hours
Major complications -- aspiration and esophageal perforation
Control hemorrhage >90%, but it is temporary

58. Bridging procedure buy time
Definite therapeutic management must be performed.

59. Hematochezia 90% Melena 10%
Lower GI Bleeding
Hematochezia 90%
Melena 10%

60. Etiology Most blood passed per rectum is from the upper GI tract.
Lower GI Bleeds
Diverticulosis, angiodysplasia, CA, colitis, ischemia, hemorrhoids

61. More about Lower GI Bleeds
80% resolve spontaneously
25 % will re–bleed
Usually painless
If painful, r/o mesenteric ischemia

62. Investigation of the lower GI bleed
The usual suspects: CBC, BUN, Creatinine, INR, PTT, T/S

63. Investigation of the lower GI bleed
Plain X-rays and abd. CT – not much help unless you clinically suspect perforation, obstruction, ischemia (PAIN)

64. Endoscopy : 80% accuracy Poor visibility with heavy bleeding
Diagnostic procedure
Endoscopy : 80% accuracy
Poor visibility with heavy bleeding
Angiography : 40–80% accuracy Requires heavy bleeding Able to perform embolization or vasopressin infusion

65. RBC scans 25–90% accurate Able to do with lower bleeding rates
Diagnostic procedure
RBC scans
25–90% accurate
Able to do with lower bleeding rates

66. What if the patient is really bleeding?
Involve your consultants early.
Radiologist for angiography
Procto. If tumor or ischemic bowel