UPPER AND LOWER GASTROINTESTINAL BLEEDINGBLEEDING.ppt

Introduction

GASTROINTESTINAL
BLEEDING
Dr. Haitham Al-Amir
Lecturer of Internal Medicine

Introduction
 Gastrointestinal bleeding (GIB) common clinical
problem
 GIB traditionally divided into either upper, lower
Or acute and chronic
Upper gastrointestinal bleeding (UGIB):
 bleeding from any source proximal to ligament of
Treitz
Lower gastrointestinal bleeding (LGIB):
 bleeding from any source distal to ligament of Treitz

UGIB is more common than LGIB;
UGIB approx. 67/100,000 population
LGIB approx. 36/100,000 population
LGIB:
 More common with increasing age
 More common in men
 mortality rate 2 - 4%
Epidemiology

GIB- Presentation
Haematemesis: Vomiting of blood whether fresh
and red or digested and black.
Melaena: Passage of loose, black tarry stools
with a characteristic foul smell.
Coffee ground vomiting: Blood clot in the
vomitus.
Hematochezia: Passage of bright red blood per
rectum, usually indicates bleeding from the
lower GI tract, but can occasionally be the
presentation for a briskly bleeding upper GI
source

GIB- Presentation
 The presence of frank bloody emesis suggests more
active and severe bleeding in comparison to coffee-
ground emesis.
 Lower GI bleeding classically presents with
hematochezia, however bleeding from the right colon
or the small intestine can present with melena.
 Bleeding from the left side of the colon tends to
present bright red in color, whereas bleeding from the
right side of the colon often appears dark or maroon-
colored and may be mixed with stool.

GIB- Presentation
Other presentations which can accompany GIB
include hemodynamic instability, abdominal
pain and symptoms of anemia such as lethargy,
fatigue, syncope and angina.
Patients with acute bleeding usually have
normocytic red blood cells. Microcytic red
blood cells or iron deficiency anemia suggests
chronic bleeding.

 Occasionally, hemoptysis may be
confused for hematemesis or vice versa.
 Ingestion of bismuth containing products
or iron supplements may cause stools to
appear melanic.
Certain foods/dyes may turn emesis or
stool red, purple, or maroon (such as
beets).
Differential Diagnosis

 Majority of patients with UGIB will spontaneously
cease.
 70-80% will stop within first 48 hrs of onset; of those
10-20% will have recurrence of UGIB. At initial
presentation ~20% will continue to bleed.
 Mortality greatest in these patients and also patients
that have recurrent bleeding
UGIB

Can divide causes into; variceal and non-
variceal
Despite advances in diagnosis and treatment,
mortality of UGIB remains from 5 – 14%
Mortality higher in patients > 60 yrs old and in
patients with multiple comorbid conditions
Introduction
Etiology- UGIB

Etiology %
Peptic ulcer disease 50
Esophageal varices 10
Mallory-Weiss tear 5-10
Esophagitis 8-10
Neoplasm 2-5
Angiodysplasia 2-5
Miscellaneous 10

 Dieulafoy’s lesion (bleeding dilated vessel that erodes
through the gastrointestinal epithelium but has no primary
ulceration; can any location along the GI tract).
 Gastric Antral Vascular Ectasia (GAVE; also known as
watermelon stomach).
 Cameron lesions (bleeding ulcers occurring at the site of a
hiatal hernia).
 Post-surgical bleeds (post-anastomotic bleeding, post-
polypectomy bleeding, post-sphincterotomy bleeding).
 Hemobilia (bleeding from the biliary tract).
Miscellaneou
s

20-30% of patients will have two or more
diagnoses of UGIB.
No disease is found in 10-15% of patients
(prognosis is excellent).
bleeding peptic ulcer disease most common
etiology and is also the most widely studied
UGIB

LGIB
Diverticulosis (colonic wall protrusion at the site of
penetrating vessels; over time mucosa overlying the vessel
can be injured and rupture leading to bleeding).
Angiodysplasia
Infectious Colitis
Ischemic Colitis
Inflammatory Bowel Disease
Colon cancer

LGIB
Hemorrhoids
Anal fissures
Rectal varices
Dieulafoy’s lesion
Radiation colitis
Post-surgical (post-poly pectomy bleeding,
post-biopsy bleeding)

Monitor hemodynamic status; Look for signs of
hemodynamic instability:
 Resting tachycardia: associated with the loss of less than 15%
total blood volume
 Orthostatic Hypotension: carries an association with the loss of
approximately 15% total blood volume
 Supine Hypotension: associated with the loss of approximately
40% total blood volume
UGIB- Initial
Evaluation

Confirm UGI source of bleeding by
history (hematemesis – fresh blood or coffee
ground emesis, melena)
Nasogastric aspiration is 80% sensitive for
actively bleeding UGI source
 False negative aspirates occur when the
tube is improperly positioned or when
reflux of blood from a duodenal source
prevented by pylorospasm or obstruction
UGIB- Initial
Evaluation

 Complete blood count
Hemoglobin/Hematocrit
INR, PT, PTT
Liver and renal function tests
UGIB- Lab
Evaluation

UGIB- Treatment /
Management
Risk Stratification
Specific risk calculators attempt to help identify
patients who would benefit from ICU level of care;
most stratify based on mortality risk.
The Rockall Score calculate the mortality rate of upper
GI bleeds. There are two separate Rockall scores; One
is calculated before endoscopy and identifies pre-
endoscopy mortality, whereas the second score is
calculated post-endoscopy and calculates overall
mortality and re-bleeding risks.

UGIB- Treatment /
Management
 Acute management of UGIB typically involves;
1. Assessment of the appropriate setting
2. Resuscitation
3. Supportive therapy
4. Investigating the underlying cause and
attempting to correct it.

UGIB- Treatment /
Management
Setting
 ICU; Patients with hemodynamic instability,
continuous bleeding, or those with a significant risk of
morbidity/mortality should undergo monitoring in an
intensive care unit to facilitate more frequent
observation of vital signs and more emergent
therapeutic intervention.

UGIB- Treatment /
Management
Setting
Most patients with GI bleeding will require
hospitalization. However, some young, healthy
patients with self-limited and asymptomatic
bleeding may be safely discharged and
evaluated on an outpatient basis.

UGIB- Resuscitation
Nothing by mouth
Adequate IV access - at least two large-bore
peripheral IVs or a centrally placed.
Provide supplemental oxygen if patient hypoxic
(typically via nasal cannula, but patients with
ongoing hematemesis or altered mental status
may require intubation).

UGIB- Resuscitation
IV fluid resuscitation (with Normal Saline or
Lactated Ringer’s solution)
Type and Cross matching.
Transfusions:
RBC transfusion; typically started if hemoglobin is
< 7g/dL, including cardiac patients.
Platelet transfusion; started if platelet count <
50,000.
Prothrombin complex concentrate; if INR > 2

UGIB- Resuscitation
Medications;
PPIs: Bolus (80 mg), followed by
maintainence (8 mg/kg/hr)- 3-5 days-
significant benefit in decreasing recurrent
bleeding.
Vasoactive medications: Somatostatin and its
analog octreotide can be used to treat
variceal bleeding by inhibiting vasodilatory
hormone release.
Erythromycin: Given to improve visualization

UGIB- Resuscitation
Antibiotics; Considered prophylactically in
patients with cirrhosis to prevent SBP,
especially from endoscopy
Anticoagulant/antiplatelet agents; Should be
stopped if possible in acute bleeds. Consider
the reversal of agents on a case-by-case basis
dependent on the severity of bleeding and
risks of reversal.

UGIB- Resuscitation
Placement of a sengestaken tube should be
considered in patients with hemodynamic
instability/massive GI bleeds in the setting of
known varices, which should be done only
once the airway is secured.
This procedure carries a significant
complication risk (including arrhythmias,
gastric or esophageal perforation) and should
only be done by an experienced provider as a
temporizing measure.

UGIB- Endoscopy
Can be diagnostic and therapeutic. It is the
test of choice for identifying and treating the
bleeding lesion
Allows visualization of the upper GI tract
(typically including from the oral cavity up to
the duodenum) and treatment with injection
therapy, thermal coagulation, hemostatic
clips/bands or band ligation.
No role for barium studies in acute UGIB

UGIB- Endoscopy
Greatest benefit in the ~20% of patients with
continued or recurrent bleeding
Improve morbidity and mortality: mortality
decreased by nearly 30%.
Active bleeding can be controlled in 85-90%
of patients, with less than 3% complication
rate.
Should be done within 12-24 hrs.

UGIB- Endoscopy
 Endoscopic Management
 Several endoscopic therapeutic techniques available
to attempt hemostasis in patients with UGIB
 Thermal
 Multipolar electrocautery /bipolar
electrocautery
 Argon plasma coagulation
 Injection
 Epinephrine
 Mechanical
 Band Ligation
 Hemoclips (Endoclip)

Endoscopy- Thermal
Small ulcer with a
prominent visible
vessel
Site after eradication of
the vessel using heater
probe

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