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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