Gastrointestinal Bleeding Dr.Mirzaei

Bleeding: oropharynx => Anus Acute: rapid loss of blood even shock Chronic: anemia, fatigue Maybe the first symptom of GI disease Self limited or need for intervention

Hematemesis , coffee-ground Melena (50 – 60 cc) Hemato chezia Occult blood in stool (10 cc)

Upper G I Bleeding Lower G I Bleeding Obscure G I Bleeding

UPPER GI BLEEDING

Causes of Upper GI Bleeding PUD 40% Oesophagitis 10% Varices 5% Mallory – Weiss Syndrome (longitudinal tear in the mucosa of the GE junction) 5% Erosive Disease 6% Neoplasm 4% Other 6% No Obvious Cause 24%

Massive Upper GI Bleeding Acute Bleeding Proximal to the ligament of treitz Requires blood transfusion

Massive Upper GI Bleeding PUD Gastritis Mallory weiss Syndrome Esophagogastric Varices

Massive Upper GI Bleeding ( Less Common Causes) Neoplasm (malignant – benign) Angiodysplasia Dieulafoy’s Lesion (Congenital arteriovenous malformation) Arterioenteric Fistula (Aortic Graft-Repair of visceral artery aneurysm)

History P. U. D-Heart burn – reflux Drugs (NSAID- stroid- anticoagulant) Alcohol Cirrhosis

Peptic ulcer disease Bleeding may be the first symptom DU: GU = 4 : 1

Upper GI Bleeding Most common complication of PUD Most peptic ulcer related death Typically Present with melena and/or hematemesis

Management Resuscitation Continuous IV PPI Large-bore IV access (2 IV line) Foley catheterization NGT + irrigation with normal saline (room temperature) Continuous IV PPI

Managment Lab test CBC, Hb, HCT, Platelet BUN - Cr – Na – K PT, PTT L.F.T ABG + E.C.G

Upper GI Bleeding due to peptic ulcer Acid suppression + NPO ¾ will stop ¼ will continue to bleed or will rebleed All mortalities & operations occur in this group

Risk Stratification Magnitude of the Hemorrhage - Shock - Hematemesis - Transfusion > 4 units in 24 h - Hypotension - Tachycardia - Oliguria - Low Hct - Pallor - Altered Mentation

Risk Stratification Comorbidities - Lung - Liver - Kidney - Heart Age Anticoagulated or immunosuppressed

Risk Stratification Endoscopic Findings Bleeding from varices Active bleeding or Visible vessel

High Risk Patients (25%) Type & Crossmatch Admit to ICU Consult Surgeon Consult gastroenterologist Start continuous infusion of PPI

High Risk Group (25%) Endoscopy within 12 hours after correction of coagulopathy (Diagnosis the cause – Assess the need for hemostatic therapy) Endoscpic hemostasis Arteriography (occasionally) Operation

Endoscopic Therapy Injection with epinephrine Electrocautery Clip (exposed vessel)

Indications of Operation Massive Bleeding unresponsive to Endoscopic Therapy Transfusion requirement of > 4-6 Unit Persistent bleeding or rebleeding after one or more endoscopic therapy Lack of availability of a therapeutic endoscopist Lack of availability of blood for transfusion Repeat hospitalization for bleeding ulcer Concurrent indication: Perforation – Obstruction

Indications of Early Elective Operation After initially successful endoscopic treatment Elderly Patients Multiple comorbidity (don’t tolerate another episode of Hemorrhage) Deep ulcer overlying a large vessel :posterior duodenal bulb(Gastroduodenal Artery) or lesser gastric curve (left gastric artery)

LOWER GI BLEEDING

Symptoms Unexplained Iron – Deficiency Anemia (Occult Blood) Hematochezia Dark or Clot Rectal Bleeding Massive Shock

Causes Hemorrhoids Fissure SRU IBD Malignancy Polyps

Causes - Angiodysplasia Usually in cecum & R.T Side colon Non congenital or Neoplastic but Degenerative No relation with other skin & visceral vascular lesions with age Usually small < 5 mm

Causes - Angiodysplasia Colonoscopy or Angiography for diagnosis 80 % self limited 50 % Recurrence during 3 years Treatment options: laser, electrocoagulation ,surgery

Causes - Diverticulosis Left sided colon Cause of > 50% massive lower GI Bleeding

Causes Meckel’s Diverticulum Infectious Colitis A-V malformation Ischemic colitis Mesenteric Thrombosis

History Weight loss Abdominal Pain / Cramp Recent Bowel Habit Change + Ve Family hx of colorectal CA Drug History

Management Resuscitation (2 IV Line) Correction of coagulopathy, thrombocytopenia Lab test CBC, Hb, HCT, Platelet BUN - Cr – Na – K PT, PTT L.F.T ABG + E.C.G

Identify the Source NGT: - Return of Bile => Source of Bleeding is distal to the ligament of treitz - Blood => Upper GI Bleeding

Proctoscopy + DRE Rectal Tumors Hemorrhoids SRU Proctitis Rectal Polyps Varices

Colonoscopy Stable Patients Rapid Bowel Prep 4-6 h Therapeutic - Cautery - Injection of Epinephrine

99 mTC RBC Scintigraphy Massive Bleeding Responsive to conservative treatment (Stable Patients) Extremely Sensitive Detection of 0.1 ml/min bleeding Localization is imprecise Intermittent bleeding (can repeat till 30 h)

Positive TC => Angiogaphy To localize bleeding (the most definite for localization) Detection of 0.5 cc/min Infusion of vasopressin or angioembolization (Therapeutic) Catheter can left for laparotomy

Barium Enema Double contrast Difficult, poor prep, unsuccessful colonoscopy

Obscure GI Bleeding

90% lesions for GI Bleeding are within the reach EGD and colon <10 % GI Bleeding, No source by endoscopic studies Overt 80 % : Hematemesis, Melena, Hematochezia Occult 20% : Iron-Deficiency Anemia, Positive Guaiac Most lesions in small intestine Angiodysplasia 75 % Neoplasms 10 % Meckel’s diverticulum: most common in children

Crohn’s Infectious enteritis NSAID induced ulcers & erosions Vasculitis Ischemia Varices Diverticula Intussusception

Enteroscopy Push => 60 cm Jejunum (+ therapeutic) Sonde => 50-75 % of the small intestinal mucosa can be examined (No Biopsy or therapy) Wireless Capsule => Success rate 90% Radiotelemetry, portable, detectors attached to the patient’s body, stable patient but continues to bleed, success rate 90 %

Enteroscopy Intraoperative Enteroscopy Oral Cecum Enterotomy Exam during insertion rather than withdrawal

Enteroclysis Small Bowel follow – through MR Enterography Angiography (angiodysplasia, vascular tumors) 99 mTC – labeled RBC Scan (Meckel’s Diverticulum)