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Gastrointestinal Bleeding

Dr Christopher Khor
Senior Consultant Gastroenterologist
Division of Gastroenterology & Hepatology
National University Hospital
GI Bleeding

Introduction
Causes of GI Bleeding
Management Principles
Assessment
Management
Introduction

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
Upper GI Bleeding (UGIB)
Non-Variceal Bleeding
Variceal Bleeding

Lower GI Bleeding (LGIB)


‘Obscure’ cause 5%
Small bowel
Introduction
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
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%
Diagnosis of UGIB in 2225 patients

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%

Silverstein FE et al, GI Endosc 1981; 21:73


Peptic Ulcer Bleeding
Variceal Bleeding
Rarer causes of UGIB
Angiodysplasia
Aortoenteric fistula
Dieulafoy disease
Hemobilia
Hemosuccus pancreaticus
Factitious bleeding or non-GI source
Lower GI Bleeding- Causes

Diverticulosis 43%
Angiodysplasia 20%
Undetermined 12%
Neoplasia 9%
Colitis 9%
Other 7%

Boley SJ et al Am J Surg 1979


Diverticular Bleeding
Evaluation & Management
of GI Bleeding
Management Principles
Rapid, accurate assessment
Severity
Site
? Variceal
NSAID use

Resuscitation
Stabilize before diagnosis, therapy & rebleeding
prevention
Endoscopic therapy
Gold standard
Suspect Variceal Bleeding if:
Prior history
Ethanol abuse
Jaundice or stigmata of liver disease
Poor Prognostic Features
Severity of initial bleed
Transfusion, BRB in NG aspirate, hypotension, tachycardia

Age >60
Comorbid disease
Onset of bleeding in hospital
Mortality 25% vs. 4%, Hb drop >1g/day

Emergency surgery
Mortality up to 30%
Bleeding Site (Upper vs. Lower)

NG tube
Significance of negative aspirate

Stool color
Melena
Rectal bleed: massive UGI vs LGI

Mild elevation in Urea


Resuscitation
IV access
Large-bore x 2, CVP, +-S-G catheter

Replete volume with NS


PCT ASAP
When to transfuse?
Age, comorbidity, ongoing bleed
Resuscitation
Correct coagulopathy
>6 Units bld consider FFP, plt, Ca

Close monitoring (+-in ICU)


Protect airway
If massive hematemesis

Other
IV Omeprazole
IV Somatostatin / Octreotide
• Suspicion of variceal bleeding
Non-endoscopic Treatment:
Nonvariceal Bleeding

IV Omeprazole
Evidence for benefit

No benefit
IV H2RA
Iced saline lavage
Non-endoscopic Treatment:
Variceal Bleeding

IV Somatostatin / Octreotide
Suspicion of variceal bleeding

Sengstaken-Blakemore tube
IV Antibiotics
Gram neg coverage
Ceftriaxone, Ciprofloxacin
Endoscopy
Within 24 hrs
Diagnostic & therapeutic benefit
Reduction in rebleed, surgery, mortality
• Cook et al Gastroenterol 1992

Early endoscopy
Ongoing bleed after resuscitation
Suspicion of variceal bleeding
Poor prognostic factors

OGD, colonoscopy
Small bowel evaluation
Non-endoscopic evaluation

Radionuclide scan
Angiography
Enteroclysis
Capsule Endoscopy
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
90%

50%

30%

18%
7% Post-Tx
3%

Clean Base Flat Spot Adherent Visible Arterial


Clot Vessel Bleed
Endoscopic Therapy

Thermal methods
heater probe
electrocoagulation
Nd:YAG laser
Argon Plasma Coagulation (APC)
Electrocoagulation
Electrocoagulation
Heater Probe
Argon Plasma Coagulator (APC)
APC
Endoscopic Therapy
Non-thermal
Injection therapy
Sclerosants: ulcer and variceal bleed
Vasoconstrictors: ulcer eg. Adrenaline
Histoacryl: variceal bleed
Endoscopic variceal ligation for bleeding
esophageal varices
Endoscopic Accessories
Bleeding Duodenal Ulcer
Double-Balloon Enteroscopy
Variceal Bleeding
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
Treatment of Variceal Bleeding
IV antibiotics
IV Octreotide / Somatostatin
Esophageal
Ligation vs. sclerotherapy vs. histoacryl injection

Sengstaken tube

TIPS

Gastric
Histoacryl injection

TIPS
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
Lower GI Bleeding-
Causes
43%
Diverticulosis
20%
Angiodysplasia
12%
Undetermined
9%
Neoplasia
9%
Colitis
7%
Other

Boley SJ et al Am J Surg 1979


Diverticular Bleeding
Lower GI
Bleed
Post-endoscopy care

Vital signs
Urine output
Continued/recurrent bleed
Repeat FBC- when?
? Repeat endoscopy
Summary
GI bleeding is common
Variceal bleeding has different
pathophysiology, a/w increased
mortality
Evaluation & management are key
Endoscopic Mx is definitive for most
When to call the surgeon
Only with Registrar/GI approval, prompt
decision
First approach with endotherapy
Continued bleed > 24 hrs
> 6 unit transfusion
Recurrent bleed despite endotherapy
Gastric Angiodysplasia
Dieulafoy Lesion- Prepyloric
Bleeding Duodenal Diverticulum
Bleeding Duodenal Diverticulum
Hemosuccus Pancreaticus
Aorto-Enteric Fistula
Gastric Cancer
Gastric Cancer

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