GI Bleeding- Nurses

Gastrointestinal BleedingDr Christopher KhorSenior Consultant GastroenterologistDivision of Gastroenterology & HepatologyNational University Hospital

Introduction

Causes of GI Bleeding

Management Principles

Assessment

Management

GI Bleeding

Common: UGIB 30-100/100,000 vs. LGIB 20/100,000 (5x less common)

Risk increased in aspirin (dose-related) & NSAID

Decreased hosp stays due to endoscopy, 25% therapeutic endoscopy

Reductions in surgery, rebleed, mortality

Introduction

Introduction

Upper GI Bleeding (UGIB)Non-Variceal Bleeding

Variceal Bleeding

Lower GI Bleeding (LGIB)

‘Obscure’ cause 5%Small bowel

Non-variceal Bleeding

Mortality 3.5-14%

Variceal Bleeding

Mortality 30-50%

2/3 die within 1 year

Introduction

80% stop spontaneously

Mortality correlated with comorbidity

Diagnosis facilitates endotherapy, lowers mortality

Introduction

Causes of GI Bleeding

Upper GI Bleeding- Etiology

3 major causes:Peptic Ulcer

Gastric Erosions

Varices

No diagnosis in 10-15%, >1 in 20-30%

Silverstein FE et al, GI Endosc 1981; 21:73

Duod ulcer 24.30%Gastric erosions 23.40%Gastric ulcer 21.30%Varices 10.30%Mallory-Weiss tear 7.20%Esophagitis 6.30%Erosive duodenitis 5.80%Neoplasm 2.90%Stomal ulcer 1.80%Esophageal ulcer 1.70%Misc 6.80%

Diagnosis of UGIB in 2225 patients

Peptic Ulcer Bleeding

Variceal Bleeding

Angiodysplasia

Aortoenteric fistula

Dieulafoy disease

Hemobilia

Hemosuccus pancreaticus

Factitious bleeding or non-GI source

Rarer causes of UGIB

Diverticulosis

Angiodysplasia

Undetermined

Neoplasia

Colitis

Other

Boley SJ et al Am J Surg 1979

43%20%12%9%9%7%

Lower GI Bleeding- Causes

Diverticular Bleeding

Evaluation & Management of GI Bleeding

Rapid, accurate assessmentSeverity

Site

? Variceal

NSAID use

Resuscitation

Stabilize before diagnosis, therapy & rebleeding prevention

Endoscopic therapyGold standard

Management Principles

Suspect Variceal Bleeding if:

Prior history

Ethanol abuse

Jaundice or stigmata of liver disease

Severity of initial bleedTransfusion, BRB in NG aspirate, hypotension, tachycardia

Age >60

Comorbid disease

Onset of bleeding in hospitalMortality 25% vs. 4%, Hb drop >1g/day

Emergency surgeryMortality up to 30%

Poor Prognostic Features

NG tubeSignificance of negative aspirate

Stool colorMelena

Rectal bleed: massive UGI vs LGI

Mild elevation in Urea

Bleeding Site (Upper vs. Lower)

IV accessLarge-bore x 2, CVP, +-S-G catheter

Replete volume with NS

PCT ASAPWhen to transfuse?

Age, comorbidity, ongoing bleed

Resuscitation

Correct coagulopathy>6 Units bld consider FFP, plt, Ca

Close monitoring (+-in ICU)

Protect airwayIf massive hematemesis

OtherIV OmeprazoleIV Somatostatin / Octreotide

• Suspicion of variceal bleeding

Resuscitation

IV OmeprazoleEvidence for benefit

No benefitIV H2RA

Iced saline lavage

Non-endoscopic Treatment: Nonvariceal Bleeding

IV Somatostatin / OctreotideSuspicion of variceal bleeding

Sengstaken-Blakemore tube

IV AntibioticsGram neg coverage

Ceftriaxone, Ciprofloxacin

Non-endoscopic Treatment: Variceal Bleeding

Within 24 hrs

Diagnostic & therapeutic benefitReduction in rebleed, surgery, mortality

• Cook et al Gastroenterol 1992

Early endoscopyOngoing bleed after resuscitation

Suspicion of variceal bleeding

Poor prognostic factors

OGD, colonoscopy

Small bowel evaluation

Endoscopy

Radionuclide scan

Angiography

Enteroclysis

Capsule Endoscopy

Non-endoscopic evaluation

Tagged Red Cell Scan

Mesenteric Angiography & Embolization

Enteroclysis

Enteroscopy

Capsule Endoscopy

Now the gold standard for small bowel evaluation

Double-Balloon Enteroscopy

Double-Balloon Enteroscopy

Endo stigmata & rebleeding

3% 7%

30%

50%

90%

Clean Base Flat Spot AdherentClot

VisibleVessel

ArterialBleed

18%Post-Tx

Thermal methodsheater probe

electrocoagulation

Nd: YAG laser

Argon Plasma Coagulation (APC)

Endoscopic Therapy

Electrocoagulation

Electrocoagulation

Heater Probe

Argon Plasma Coagulator (APC)

APC

Non-thermalInjection therapy

Sclerosants: ulcer and variceal bleed

Vasoconstrictors: ulcer eg. Adrenaline

Histoacryl: variceal bleed

Endoscopic variceal ligation for bleeding esophageal varices

Endoscopic Therapy

Endoscopic Accessories

Bleeding Duodenal Ulcer

Double-Balloon Enteroscopy

Different pathophysiology

Portal Venous HPT >12mmHg due to cirrhosis

Varices most commonly in esophagus, gastric fundus/cardia

Bleeding risk related to varix size

Variceal Bleeding

Variceal Bleeding

IV antibiotics

IV Octreotide / Somatostatin

Esophageal

Ligation vs. sclerotherapy vs. histoacryl injection

Sengstaken tube

TIPS

Gastric

Histoacryl injection

TIPS

Treatment of Variceal Bleeding

Esophageal Varices

Band Ligation of Varices

Multi-band Ligator

Variceal Ligation

Portal Hypertensive Gastropathy

Gastric Varices

Histoacryl injection

Sengstaken Tube

Transjugular Intrahepatic Porto-Systemic Shunt (TIPS)

Bleeding in Cirrhosis

Diverticulosis

Angiodysplasia

Undetermined

Neoplasia

Colitis

Other

Boley SJ et al Am J Surg 1979

Lower GI Bleeding- Causes

43%

20%

12%

9%

9%

7%

Diverticular Bleeding

Lower GI Bleed

Vital signs

Urine output

Continued/recurrent bleed

Repeat FBC- when?

? Repeat endoscopy

Post-endoscopy care

Summary

GI bleeding is common

Variceal bleeding has different pathophysiology, a/w increased mortality

Evaluation & management are key

Endoscopic Mx is definitive for most

Only with Registrar/GI approval, prompt decision

First approach with endotherapy

Continued bleed > 24 hrs

> 6 unit transfusion

Recurrent bleed despite endotherapy

When to call the surgeon

Gastric Angiodysplasia

Dieulafoy Lesion- Prepyloric

Bleeding Duodenal Diverticulum

Bleeding Duodenal Diverticulum

Hemosuccus Pancreaticus

Aorto-Enteric Fistula

Gastric Cancer

Gastric Cancer