1. Gastrointestinal Bleeding Dr.Mirzaei

2. 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

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

4. Upper G I Bleeding
Lower G I Bleeding
Obscure G I Bleeding

5. UPPER GI BLEEDING

6. 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%

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

8. Massive Upper GI Bleeding
PUD
Gastritis
Mallory weiss Syndrome
Esophagogastric Varices

9. 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)

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

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

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

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

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

15. 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

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

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

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

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

22. 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

23. Endoscopic Therapy Injection with epinephrine Electrocautery
Clip (exposed vessel)

26. 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

27. 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)

28. LOWER GI BLEEDING

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

30. Causes
Hemorrhoids
Fissure
SRU
IBD
Malignancy
Polyps

31. 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

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

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

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

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

36. 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

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

38. Proctoscopy + DRE Rectal Tumors Hemorrhoids SRU Proctitis
Rectal Polyps
Varices

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

40. 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)

41. 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

42. Barium Enema Double contrast
Difficult, poor prep, unsuccessful colonoscopy

44. Obscure GI Bleeding

45. 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

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

47. Enteroscopy Push => 60 cm Jejunum (+ therapeutic)
Sonde => % 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 %

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

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