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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
