Gastrointestinal Bleeding

Dr. Mohammad Shaikhani.

MBChB –CABM - FRCP.

Introduction:• GIB is classified in several ways:

• 1) Upper or lower

• 2) Variceal or nonvariceal

• 3) Acute or chronic; determined by the clinical presentation.

• UGIB: bleeding proximal to the ligament of Treitz ,eiher variceal(portal hypertension & bleeding varices) or nonvariceal.

• LGIB: bleeding into GIT lumen distal to the ligament of Treitz.

• UGIB requiring hospitalization is *5 more common than LGIB& has a mortality rate of up to 10%.

Introduction: causes• Variceal & nonvariceal causes. • Variceal bleeding, associated with portal hypertension,often

chronic liver disease. • The most common cause of NVGIB is PUD, including both GU

/DU accounting for 35-50% of all cases of UGIB.• Most PU occur secondary to H pylori infection or use of NSAIDs. • Esophagitis / gastritis, which account for up to 25% of UGIB& a

Mallory-Weiss tear of GEJ secondary to retching,accounts for up to 15%, are other common causes.

• Malignancy of UGIT is a rare cause.• Gastric antral vascular ectasia (GAVE syndrome, also called

watermelon stomach) &arteriovenous malformations can cause both chronic &acute GIB.

• Rarer causes include Dieulafoy lesion (an exposed arteriole), hemobilia (bleeding from the biliary tree)& hemosuccus pancreaticus (blood loss from the pancreatic duct).

• A rare cause but one with high morbidity in a patient with recent vascular surgery is an aortoenteric fistula.

Evaluation: Presentation• Melena (black, tarry stools), as little as100 mL of blood loss.• Hematemesis (vomiting of blood or coffee-ground material).or• Occasionally Hematochezia (red or maroon-colored stools)when

massive, usually at least 1000 mL.• Hematochezia generally indicates LGIB,but a more proximal UGI

source should be considered if:• The patient has hematemesis• Hemodynamic instability • A NGT aspirate reveals fresh blood. • UGIB with hematochesia have significant bleeding &a mortality

rate of 30%> if melena alone.

Evaluation: History /Physical exam• History:

• Prior episodes of UGIB

• PUD

• Cirrhosis with portal hypertension

• Medication use (aspirin, other NSAID, anticoagulants)

• A bleeding diathesis

Evaluation: History /Physical exam• Significant comorbid conditions as HF.

• Abdominal pain,but a bleeding PUD can occur without pain.

• Signs of volume loss (orthostatic hypotension)& ischemia (chest pain, dyspnea, or stroke-like features).

• Resting tachycardia (heart rate >100/min) suggests a 15-30% loss of blood volume, while a blood pressure that is below normal is consistent with a loss of > 30% of blood volume.

• A significant postural pulse change (≥30 beats/min) or severe postural hypotension/dizziness suggest hypovolemia from significant blood loss, often absent with more moderate blood loss.

• The exam should focus on vital signs, CV assessment& airway evaluation.

Management:• Treatment often involves a multidisciplinary approach, including

a gastroenterologist, radiologist& surgeon. • Include 3 steps:• 1) Hemodynamic stabilization• 2) Finding & controlling the source of bleeding• 3) Preventing recurrence of bleeding. • Adequate IV access either 2 large-bore IV access or central vein. • Resuscitation with IVF/ blood products is the initial step in

stabilizing patients prior to upper endoscopy.• Plasma expanders used until blood is available • Endotracheal intubation should be performed prior to endoscopy

to prevent aspiration if there are:• Ongoing bleeding• Continuing hematemesis• Altered level of consciousness• Loss of the gag reflex.

Management:Lab• A CBC with blood type & cross-match • Coagulation profile • S. electrolytes• BUN, S.creatinine, BUN:creatinine ratio does not reliably

discriminate between U & LGIB& although it is higher with UGIB.

Management:• The Hct initially appear normal because of the loss of whole

blood; but following hemodilution, it will fall & will continue to fall for up to 72 hours.

• During early UGIB resuscitation is based upon orthostatic changes in vital signs rather than Hb level.

• ECG is needed for:• > 50 years of age & older • Younger patients with underlying cardiac disease or features of

ischemia.

Management:NGT• A NGT can be passed if the source of bleeding is not clinically

obvious.

• A bloody NGT aspirate proves UGIB & is significantly associated with high-risk lesions (spurting, oozing, or a visible vessel) on upper endoscopy

• A clear aspirate reduces the likelihood of such lesions by 50%, but does not exclude a more distal UGIB.

Management: OGD• Upper endoscopy should be performed (within 12 hours) to find

the source of bleeding & estimate the risk of re-bleeding.

• Patient should be stabilized prior to endoscopy but unstable patients require emergent endoscopy to control ongoing bleeding.

• Directed endoscopic therapy is initiated once the bleeding source is established.

Management: PPI• PPIs is used to decrease gastric acidity & stabilize clots.

• Use of IV PPIs with endoscopic therapy reduces the risk of recurrent bleeding in patients with bleeding PUD & is a cost-effective.

• After stabilization, triple therapy for H pylori–related disease should be considered for patients found to be infected.

Management: VGIB• Targeted medical therapy for bleeding varices in patients with

cirrhosis includes the use of :• Vasoactive drugs as vasopresin/ octreotide plus• Endoscopic therapeutic hemostasis usually by endoscopic band

ligation being better than endoscopic scleotherapy.

Management:Endoscopic treatment• Endoscopic therapy to control bleeding:

• Injection (NS + epinephrine, sclerosing agents), thermal techniques( heat probes, argon plasma coagulation), mechanical modalities (clips).

• The type of lesion & the presence or absence of ongoing bleeding determine which technique is used.

• Endoscopic therapy usually include combination of inj plus one of the other modalities, can control bleeding , decrease the rebleeding rate & the need for surgery& indicated in high risk lesions.

• Independent endoscopic predictors of high-risk lesions that require endoscopic interventions&rebleeding, include:

• Arterial spurting (55-90% recurrence rate)

• A visible vessel (40-50%)

• Adherent clot that does not wash off (10-35%).

Management:Endoscopic treatment• Endoclips, which are metallic mechanical devices that function

like a suture, can be used in endoscopy to provide sufficient hemostasis for most UGIB sources.

Management: Surgery/IR• When endoscopic therapy is ineffective (usually because of active

hemorrhage, ulcer size >2 cm, shock, or low Hb), a surgical or interventional radiology consultation should be obtained usually after a second endoscopic intervention trial.

• Surgical or radiology consultation is also indicated for patients with suspected aortoenteric fistulas, large vascular abnormalities, or ulcers located on the lesser curvature of the stomach (left gastric artery) or the posterior wall of the duodenum (gastroduodenal artery).

Management of patients at risk of recurrent bleeding:

• Clinical features indicating a higher likelihood of rebleeding or death in a patient with UGIB:

• Older patients (>60 years of age)• Hematochezia• Bleeding during hospitalization• Bloody nasogastric aspirate or hematemesis.• Large transfusion requirement (>5 units)• Ongoing or recurrent bleeding• Varices• Cancer& other comorbid illnesses.

Management of patients at risk of recurrent bleeding:

• Lower rates of rebleeding occur in patients with:• Flat pigmented spots (7- 10%)• Ulcers with clean bases (3-5%)• These lesions do not require endoscopic therapy. • Patients with both low-risk clinical criteria for rebleeding & low-

risk endoscopic lesions (clean-based ulcers, Mallory-Weiss tears) without stigmata of recent hemorrhage can be fed& discharged home after volume resuscitation&upper endoscopy,but require directed OP therapy& close follow-up.

Management of patients at risk of recurrent bleeding:

• Continued or recurrent bleeding is associated with significant mortality as a consequence of either the bleeding itself or the presence of a comorbid condition.

• 98% of all re-bleeding episodes occur within 3-4 days after the initial episode.

• Patients who have the highest risk of rebleeding (active bleeding, visible vessel,adherent clot) or a significant co-morbid condition should be observed initially in ICU, after 1st endoscopic therapeutic intervention.

Lower Gastrointestinal Bleeding • LGIB GIB distal to the ligament of Treitz.• Acute LGIB is defined as bleeding for less than 3 days, whereas

chronic bleeding consists of an intermittent & slow loss of blood over several days or longer.

• The colon is the most common site of bleeding.• Similar to UGIB, LGIB can be either acute or chronic.• The incidence of LGIB increases with age, with mean age at

presentation 63-77 years. • LGIB accounts for 20% of all episodes of GIB. • The most common causes of acute LGIB are diverticulosis,

angiectasia, ischemic colitis, perianal disease.• The most frequent causes of chronic LGIB are neoplasms,

angiectasia, IBD.• Most episodes of LGIB will stop without intervention.

Lower Gastrointestinal Bleeding • Diverticular bleeding: often painless, from the right or left side of

the colon,usually stops spontaneously. • Patients with previous episode have a 14-38% chance recurrence

Lower Gastrointestinal Bleeding • Other causes include:• IBD• Neoplasms• Infectious colitis• Radiation colitis or proctitis• Postpolypectomy ulcer• Stercoral ulcer• Meckel's diverticulum• Colonic varices • Dieulafoy's lesions.

Lower Gastrointestinal Bleeding • Angiectasia:• Painless ectatic dilated submucosal vessels • Most commonly occur in the cecum& proximal colon in patients

who are typically 60 years of age or older.

Lower Gastrointestinal Bleeding • Ischemic colitis:• Caused by a decline in mesenteric blood flow• Often involves the watershed areas of the colon, as the splenic

flexure&sigmoid colon where perfusion is relatively decreased, although any segment of the colon may be affected.

• Patients typically report relative hypotension followed by mild abdominal pain &passage of bright red blood from the rectum 24 hours later.

Lower Gastrointestinal Bleeding • Hemorrhoids/ fissures• May have pain with defecation & bleeding after using toilet paper • Careful perianal exam with anoscopy may assist in the diagnosis.

LGIB Evaluation: • Present with hematochezia, melena, or passing of clots & may also

have chest pain, shortness of breath, lightheadedness, syncope, or other ischemic features.

• Those with chronic LGIB may have symptoms of fatigue/dyspnea on exertion due to IDA, or the bleeding may be detected incidentally after a positive fecal occult blood test.

LGIB Evaluation:History/PE • History of:

• Diarrhea, fever, abdominal or rectal pain.

• Previous episodes of LGIB

• Use of aspirin or other NSAIDs

• A history of pelvic radiation therapy,

• Episodes of relative hypotension

• Recent polypectomy

• Severe constipation.

• The physical exam should focus on the cardiopulmonary system, abdomen, rectum.

Evaluation: Lab • The same as those for the diagnosis of UGUB• Independent risk factors for severe LGIB are an initial

hematocrit ≤35%, tachycardia, hypotension, gross blood on initial rectal exam.

Management:• Patients usually require hospitalization because of the generally

advanced age, the presence of comorbid conditions& the need for transfusions.

• Admission to an ICU should be considered for those with:• Ongoing bleeding• Large transfusion requirements• Ischemic complications• Significant comorbid disorders. • Mortality from LGIB is <5%& is highest in those who are

hospitalized for other reasons when the bleeding episode occurs.

Management:• Hemodynamic stabilization.• Most episodes of LGIB stop without intervention. • The cause of the bleeding should be determined once the patient is

hemodynamically stable. • The initial step is to rule out brisk bleeding from UGIB because

10-15% of patients with presumptive LGIB may actually have a more proximal source.

• If features such as hematemesis, bloody NGT aspirate, or hemodynamic instability suggest a proximal lesion, upper endoscopy is performed first.

• NGT is not recommended to exclude an UGIB, because a duodenal ulcer may yield a false-negative result.

• Patients with chronic bleeding can be scheduled for elective colonoscopy with complete colonic purging prior to the procedure.

Management:• If no features of UGIB are present, colonoscopy is the initial test

of choice usually within the first 48 hours of admission• Early colonoscopy has been correlated with decreased length of

hospital stay& improved outcome. • The procedure should be performed after first purging the colon

with polyethylene glycol, which improves endoscopic visualization / diagnostic yield.

• The yield of colonoscopy ranges from 48-90%. • Patients with acute bleeding can safely undergo colonoscopy as

the first-line test. • Colonic purging should be attempted(sometime through NGT) in

order to provide better visualization, decrease the risk of perforation, permit therapeutic techniques that require adequate bowel preparation in order to be used safely.

Management:Endo trt• The injection, thermal, mechanical therapeutic modalities used to

control UGIB can also be used during colonoscopy&the type of lesion found directs the therapeutic modality used.

Management:• If colonoscopy can not find or control bleeding, additional

diagnostic studies; angiography or a radionuclide imaging, are required.

Management: Angio• Requires a bleeding rate of at least 1 mL/min to find the site so

not so sensitive.• Should be done in place of colonoscopy in patients with:• Massive bleeding.• Persistent bleeding despite endoscopic evaluation & treatment• The source of bleeding is still unknown after colonoscopy. • Angiography can also be used therapeutically to provide selective

microcoil embolization or vasopressin infusion. • Side effects: contrast-induced complications, localized ischemia

due to embolization &generalized ischemia due to vasopressin.

Management: Radionuclide imaging • Can detect bleeding occurring at a rate of 0.1–0.5 mL/min.• It is more sensitive than angiography• Can be done prior to angiography to detect ongoing bleeding• RBC scanning is positive in 45% with an active bleed• Has an overall accuracy for localizing the bleeding of 78%.• It can detect ongoing bleeding occurring at a rate of 0.1- 0.5

mL/min. • This scan is more sensitive than angiography & often the first

radiologic test performed.• A technetium-99m (99mTc) pertechnetate scan should also be

considered in younger patients with undiagnosed overt LGIB. • Disdvantages:• The images produced are not as specific as angiographic images

for localizing the source of bleeding• Therapeutic intervention is not possible

Management:• If angiography & radionuclide imaging studies fail to locate the

bleeding source, a small bowel evaluation using either push enteroscopy or capsule endoscopy should be performed.

• The yield of detecting the source of occult GIB by capsule endoscopy is highest in a patient with active bleeding.

Management: Meckel scan • Should also be considered in younger patients with LGIB.

Management:Chronic LGIB• With normal results on upper endoscopy & colonoscopy require

small bowel evaluation by DBE or VCE because the slow bleeding rate precludes use of angiography & radionuclide imaging.

Management:surgery• Surgical consultation should be requested for patients who have: • Unidentified source of bleeding after initial endoscopic evaluation.• Who continue to have massive bleeding or become unstable. • Preoperative localization of the region of bleeding is imperative to

avoid an extensive subtotal colectomy.

Key points:• The most common cause of NVUGIB is PUD secondary to H

pylori infection or use of NSAIDs. • The most important part of treating UGIB is establishment of IV

access & correction of volume loss with fluid resuscitation &transfusion of blood products when needed.

• Upper endoscopy provides diagnosis of the cause, treatment of the bleeding source& prognosis for the risk of re-bleeding.

• Surgery or interventional radiology for UGIB should be reserved for patients who fail to respond to medical &endoscopic therapy.

• Up to 20% of episodes of acute GIB result from a LGI. • Colonoscopy is effective in the early diagnosis & trt of LGIB. • The most common causes of acute LGIB are diverticulosis,

vascular ectasias& ischemic colitis. • Most LGIB resolve spontaneously& require supportive care.