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Gastrointestinal Bleeding
Amr Mohsen, M.D., FRCS(Ed)
Professor of Surgery, Cairo University
Gastrointestinal BleedingSpectrum of Disease
NOT one disease but various pathological processes Common problem Mortality rate still 10% Massive acute hemorrhage to occult, trivial Timely evaluation is critical to proper management
Gastrointestinal BleedingDefinition of Terms
Upper Gastrointestinal Bleeding: proximal to Ligament of Treitz
Lower Gastrointestinal Bleeding: distal to the ligament of Treitz
Hematemesis: vomiting of blood Melena: Passage of black tarry stools Hematochezia: Passage of fresh blood per rectum
Gastrointestinal BleedingDefinition of Terms
Manifest bleeding Occult bleeding Bleeding of obscure origin
I Chronic Gastrointestinal BleedingOccult Bleeding – Manifestations
Weakness Fatigue Shortness of breath Faintness Accidentally discovered anemia Routine screening
I Chronic Gastrointestinal BleedingOccult Bleeding – Causes - Diagnosis
GIT malignancy GERD & esophagitis Peptic ulcer NSAIDs GIT polyps
Detection depends on peroxidase activity of hemoglobin
Guaiac testHemoccult test
II Acute Gastrointestinal BleedingInitial Evaluation
Estimate severity of bleeding Institute resuscitation Localize site of bleeding (UGI vs LGI) Diagnose and treat specific lesion
II Acute Gastrointestinal BleedingEstimation of Severity
BEST METHOD: vital signs
Massive hemorrhage: shock (supine hypotension) 20-25% loss of vascular volume
Submassive hemorrhage: orthostatic hypotension
15-20% loss of vascular volume
Trivial hemorrhage: No change in vital signs < 15% loss of vascular volume
II Acute Gastrointestinal BleedingLocalization
Distinguishing LGI and UGI Clincal Signs
– Hematemesis: UGI bleeding – Melena: Usually UGI – Hematochezia: Usually LGI
Nasogastric aspirate (ALL PATIENTS) – Lavage +: UGI bleeding – 15% miss rate
IIa Acute UGI BleedingManagement
Hematemesis, or melena is an emergency.
Admission to an ICU for all patients with severe GI bleeding.
The team approach includes a gastroenterologist, a surgeon with expertise in GI surgery, and skilled nurses.
A major cause of morbidity and mortality is aspiration of blood. To prevent this complication in patients with altered mental
status, endotracheal intubation should be considered.
IIa Acute Gastrointestinal BleedingResuscitation
All patients need 2 large-bore IVs Crystalloid solutions until blood available Send blood for Hct, coagulation studies (PT, PTT,
platelet), crossmatch Transfuse blood for:
– Obvious massive blood loss – Hematocrit < 25% with active bleeding – Symtpoms due to low Hct
Correct coagulopathies – Fresh frozen plasma – Platelet transfusion
IIa Acute UGI BleedingEtiology (Egypt)
Esophageal varices 55%Acute gastric erosions 15% Chronic DU Chronic GU Esphagitis & erosions Mallory Weiss tears Duodenitis Gastric cancer Coagulopathies
IIa Acute UGI BleedingDiagnosis
History – of previous bleeding – of peptic ulcer symptoms – of previous surgery – of medications: NSAID
Physical Exam – Stigmata of cirrhosis: spider angiomata, jaundice,
gynecomastia, palmar erythema, testicular atropy, splenomegaly, ascites, noular liver.
– Surgical scars – Tenderness
IIa Acute UGI BleedingDiagnostic Procedures
Endoscopy – 90-95% accurate – Diagnosis and treatment
Barium radiography– 80% accurate – Barium makes further studies difficult
Arteriography (failure of localization / active bleeding) Nuclear Scanning (Technetium-99m) ??
Endoscopy is routinely used first, particularly in patients with significant hemorrhage
IIa Acute UGI BleedingContrast radiography
IIa Acute UGI BleedingContrast radiography
IIa Acute UGI BleedingEndoscopy
NormalVarices
IIa Acute UGI BleedingEndoscopy
Acute gastric erosions
Signs of recent bleeding
IIa Acute UGI BleedingEndoscopy
DU – signs of recent bleeding
IIa Acute UGI BleedingEndoscopy
GU
Blood clot Visible vessel
IIa Acute UGI BleedingEndoscopy
Mallory Weiss tear
IIa Acute UGI BleedingTreatment of Specific Lesions
Esophageal varices
URGENT
1. Endoscopic sclerotherapy or banding
2. Vasopressin infusion
3. Surgery
IIa Acute UGI BleedingTreatment of Specific Lesions
Esophageal varices
Sengstaken tube Temporary measure
IIa Acute UGI BleedingTreatment of Specific Lesions
Esophageal varices1. Endoscopic sclerotherapy or banding
IIa Acute UGI BleedingTreatment of Specific Lesions
Esophageal varices1. Endoscopic sclerotherapy or banding
– Highly successful– Failure Repeat injection– Followed by chronic sclerotherapy– Failure rate ~15%
From esophageal varicesMissing fundal varicesDifficulty injecting fundal varices
IIa Acute UGI BleedingTreatment of Specific Lesions
Esophageal varices
2. Vasopressin (1 unit/min) IV infusion
Beware of coronary heart disease
IIa Acute UGI BleedingTreatment of Specific Lesions
Esophageal varices3. Urgent surgery
Emergency shunt surgery is losing favor
IIa Acute UGI BleedingTreatment of Specific Lesions
Esophageal varices3. Urgent surgery
Most popular procedure
IIa Acute UGI BleedingTreatment of Specific Lesions
Peptic Ulcers– Antacids or H2 blockers and proton
pump antagonists promote healing but DON’T stop acute bleeding
URGENT
– Endoscopic coagulation– Angiographic embolization– Surgery
IIa Acute UGI BleedingTreatment of Specific Lesions
Peptic UlcersSurgery
IIb Acute LGI BleedingGeneral Considerations
Spontaneous remission rate is 80%
Bleeding has usually ceased by the time the patient presents to hospital
No source of bleeding can be identified in 12%
Bleeding is recurrent in 25%
IIb Acute LGI BleedingCommon causes
Hemorrhoidal bleeding• Fresh bright red• Jet or drops separate from stools• With straining at end of defecation
Massive bleeding in adults1. Diverticula 2. UC 3. Ischemic colitis
4. Angiodysplasia 5. Massive bleeding from upper GIT
Massive bleeding in childrenMeckel’s diverticulum
IIb Acute LGI BleedingGeneral Considerations
Initial evaluation is the same – Judge severity – Resuscitate – Localize site (usually difficult)
Patient usually notes hematochezia (bright red rectal bleeding)
Most of LGI bleeding is from anus or rectum especially trivial bleeding
Hematochezia should be considered an emergency.
Admission to an ICU is recommended for all patients with severe GI bleeding.
The team approach includes a gastroenterologist, a surgeon with expertise in GI surgery, and skilled nurses.
IIb Acute LGI BleedingManagement
IIb Acute LGI BleedingDiagnosis
History – Previous bleeding episodes – Rectal pain/hemorrhoids – IBD – Change in stool caliber – Weight loss
Physical Exam – Rectal examination: hemorrhoids, tears, fissures, fistulas – Anoscopy: hemorroids, fissures
Sigmoidoscopy
IIb Acute LGI BleedingEvaluation
Nasogastric tube if massive bleeding
Sigmoidoscopy Colonoscopy
Angiography require blood loss > 0.5 ml/min Isotope scanning
Barium enema not for initial diagnosis
IIb Acute LGI BleedingEvaluation
Angiodysplasia (usually Rt colon)
IIb Acute LGI BleedingEvaluation
Diverticula (usually Lt colon)
IIb Acute LGI BleedingEvaluation
UCNormal colon
IIb Acute LGI BleedingEvaluation
Ischemic colitis (usually splenic flexure)
IIb Acute LGI BleedingEvaluation
Diverticula (usually Lt colon)
1. 80% of bleeding cases stop spontaneously
2. Arteriography & embolizationAngiodyaplasia Argon beam coagulation
3. Urgent surgeryPreoperative localization ResectionNo localization + I.O. colonoscopy High failure
After treatment and follow-up
IIb Acute LGI BleedingManagement
the cause of the bleeding has not been determined after an initial gastrointestinal evaluation
May be occult or manifest
III Bleeding of obscure originDefinition
In 38% of patients the source of bleeding is located in the distal duodenum and proximal jejunum
Duodeno-jejunal arteriovenous malformations (AVMs) are the most common cause for bleeding
III Bleeding of obscure originSources
1. Repeat upper and/or lower GI endoscopy
2. Enteroscopy– Push enteroscopy. can be advanced as much as
100 cm past the ligament of Treitz– Sonde enteroscopy, a tube is advanced by peristalsis
into the small intestine. Lengthy and uncomfortable– Swallowed capsule endoscopy
III Bleeding of obscure originManagement steps
3. Isotope-labelled RBCs scan (0.1-0.4ml/min)
4. Mesenteric angiography (>0.5ml/min)
5. Meckel’s scan
6. Barium meal for chronic cases (limited value in AVM)
7. intraoperative enteroscopy
III Bleeding of obscure originManagement steps
Application
Case variation Surgeon’s experience Hospital facilities
Individualize management
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