Download Gastrointestinal Bleeding of Obscure Origin

Gastrointestinal Bleeding
Amr Mohsen, M.D., FRCS(Ed)
Professor of Surgery, Cairo University
Gastrointestinal Bleeding
Spectrum 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 Bleeding
Definition 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 Bleeding
Definition of Terms



Manifest bleeding
Occult bleeding
Bleeding of obscure origin
I Chronic Gastrointestinal Bleeding
Occult Bleeding – Manifestations






Weakness
Fatigue
Shortness of breath
Faintness
Accidentally discovered anemia
Routine screening
I Chronic Gastrointestinal Bleeding
Occult Bleeding – Causes - Diagnosis





GIT malignancy
GERD & esophagitis
Peptic ulcer
NSAIDs
GIT polyps
Detection depends on peroxidase activity of hemoglobin
Guaiac test
Hemoccult test
II Acute Gastrointestinal Bleeding
Initial Evaluation




Estimate severity of bleeding
Institute resuscitation
Localize site of bleeding (UGI vs LGI)
Diagnose and treat specific lesion
II Acute Gastrointestinal Bleeding
Estimation 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 Bleeding
Localization


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 Bleeding
Management

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 Bleeding
Resuscitation




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 Bleeding
Etiology (Egypt)
Esophageal varices
 Acute gastric erosions








Chronic DU
Chronic GU
Esphagitis & erosions
Mallory Weiss tears
Duodenitis
Gastric cancer
Coagulopathies
55%
15%
IIa Acute UGI Bleeding
Diagnosis

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 Bleeding
Diagnostic Procedures

Endoscopy
–
–

Barium radiography
–
–


90-95% accurate
Diagnosis and treatment
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 Bleeding
Contrast radiography
IIa Acute UGI Bleeding
Contrast radiography
IIa Acute UGI Bleeding
Endoscopy
Varices
Normal
IIa Acute UGI Bleeding
Endoscopy
Acute gastric erosions
Signs of recent
bleeding
IIa Acute UGI Bleeding
Endoscopy
DU – signs of recent
bleeding
IIa Acute UGI Bleeding
Endoscopy
GU
Blood clot
Visible vessel
IIa Acute UGI Bleeding
Endoscopy
Mallory Weiss tear
IIa Acute UGI Bleeding
Treatment of Specific Lesions
Esophageal varices
URGENT
1.
2.
3.
Endoscopic sclerotherapy or banding
Vasopressin infusion
Surgery
IIa Acute UGI Bleeding
Treatment of Specific Lesions
Esophageal varices
Sengstaken tube
Temporary measure
IIa Acute UGI Bleeding
Treatment of Specific Lesions
Esophageal varices
1.
Endoscopic sclerotherapy or banding
IIa Acute UGI Bleeding
Treatment of Specific Lesions
Esophageal varices
1.
Endoscopic sclerotherapy or banding
–
Highly successful
Failure
Repeat injection
Followed by chronic sclerotherapy
Failure rate ~15%
From esophageal varices
Missing fundal varices
Difficulty injecting fundal varices
–
–
–
IIa Acute UGI Bleeding
Treatment of Specific Lesions
Esophageal varices
2. Vasopressin (1 unit/min) IV infusion
Beware of coronary heart disease
IIa Acute UGI Bleeding
Treatment of Specific Lesions
Esophageal varices
3. Urgent surgery
Emergency shunt surgery is losing favor
IIa Acute UGI Bleeding
Treatment of Specific Lesions
Esophageal varices
3. Urgent surgery
Most popular
procedure
IIa Acute UGI Bleeding
Treatment 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 Bleeding
Treatment of Specific Lesions
Peptic Ulcers
Surgery
IIb Acute LGI Bleeding
General 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 Bleeding
Common causes

Hemorrhoidal bleeding
•
•
Fresh bright red
Jet or drops separate from stools
With straining at end of defecation

Massive bleeding in adults
•
1. Diverticula
4. Angiodysplasia

2. UC
3. Ischemic colitis
5. Massive bleeding from upper GIT
Massive bleeding in children
Meckel’s diverticulum
IIb Acute LGI Bleeding
General 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
IIb Acute LGI Bleeding
Management

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 Bleeding
Diagnosis

History
–
–
–
–
–

Physical Exam
–
–

Previous bleeding episodes
Rectal pain/hemorrhoids
IBD
Change in stool caliber
Weight loss
Rectal examination: hemorrhoids, tears, fissures, fistulas
Anoscopy: hemorroids, fissures
Sigmoidoscopy
IIb Acute LGI Bleeding
Evaluation

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 Bleeding
Evaluation
Angiodysplasia (usually Rt colon)
IIb Acute LGI Bleeding
Evaluation
Diverticula (usually Lt colon)
IIb Acute LGI Bleeding
Evaluation
Normal colon
UC
IIb Acute LGI Bleeding
Evaluation
Ischemic colitis (usually splenic flexure)
IIb Acute LGI Bleeding
Evaluation
Diverticula (usually Lt colon)
IIb Acute LGI Bleeding
Management
1. 80% of bleeding cases stop spontaneously
2. Arteriography & embolization
Angiodyaplasia
Argon beam coagulation
3. Urgent surgery
Preoperative localization
No localization + I.O. colonoscopy
After treatment and follow-up
Resection
High failure
III Bleeding of obscure origin
Definition
the cause of the bleeding has not been
determined after an initial gastrointestinal
evaluation
May be occult or manifest
III Bleeding of obscure origin
Sources
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 origin
Management steps
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 origin
Management 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
Application



Case variation
Surgeon’s experience
Hospital facilities
Individualize management
Don’t hesitate to TRANSFER