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Gastrointestinal Gastrointestinal Bleeding Bleeding Jarrett Lefberg Jarrett Lefberg South Pointe Hospital South Pointe Hospital

Gastrointestinal Bleeding

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Page 1: Gastrointestinal Bleeding

Gastrointestinal Gastrointestinal BleedingBleeding

Jarrett LefbergJarrett Lefberg

South Pointe HospitalSouth Pointe Hospital

Page 2: Gastrointestinal Bleeding

IncidenceIncidence

Upper GI bleed 100/100,000Upper GI bleed 100/100,000

Above the ligament of TreitzAbove the ligament of TreitzLower GI Bleed 20/100,000Lower GI Bleed 20/100,000

Below the ligament of TreitzBelow the ligament of TreitzBoth are more common in males and Both are more common in males and

elderly.elderly.

Page 3: Gastrointestinal Bleeding

Causes of Upper GI BleedCauses of Upper GI Bleed

1) 1) Peptic ulcer diseasePeptic ulcer disease - most - most common common

cause cause A) duodenal ulcers 29%A) duodenal ulcers 29% will rebleed in 10% of cases withinwill rebleed in 10% of cases within 24-48h 24-48h B) gastric ulcers 16%B) gastric ulcers 16% more likely to rebleedmore likely to rebleed C) stomal ulcers <5%C) stomal ulcers <5%

Page 4: Gastrointestinal Bleeding

Causes of Upper GI BleedCauses of Upper GI Bleed

2) 2) Erosive gastritis, esophagitis, Erosive gastritis, esophagitis, duodenitisduodenitis

some causes are ETOH, ASA, NSAID’ssome causes are ETOH, ASA, NSAID’s 3) 3) Esophageal and gastric varicesEsophageal and gastric varices

causes by portal hypertensioncauses by portal hypertension 4) 4) Mallory-Weiss syndromeMallory-Weiss syndrome – longitudinal – longitudinal

mucosal tear in the cardioesophagealmucosal tear in the cardioesophageal

regionregion

caused by repeated retchingcaused by repeated retching

Page 5: Gastrointestinal Bleeding

Causes of Upper GI BleedCauses of Upper GI Bleed

5) 5) stress ulcersstress ulcers6) 6) arteriovenous arteriovenous

malformationmalformation7) 7) malignancymalignancy8) 8) aortoenteric fistulaaortoenteric fistula

Page 6: Gastrointestinal Bleeding

Causes of Lower GI BleedingCauses of Lower GI Bleeding

1) 1) HemorrhoidsHemorrhoids - most common cause - most common cause 2) 2) DiverticulosisDiverticulosis – common, painless, – common, painless, and can be massive and can be massive Caused from an erosion into aCaused from an erosion into a penetrating artery from the penetrating artery from the diverticulum.diverticulum. 3) 3) Arteriovenous malformationsArteriovenous malformations – –

commoncommon and seen in people with hypertension andand seen in people with hypertension and aortic stenosisaortic stenosis

Page 7: Gastrointestinal Bleeding

Causes of Lower GI BleedingCauses of Lower GI Bleeding

4) 4) CA/polypsCA/polyps5) 5) inflammatory bowel inflammatory bowel

diseasedisease 6) 6) infectious gastroenteritisinfectious gastroenteritis7) 7) Meckel diverticulumMeckel diverticulum

Page 8: Gastrointestinal Bleeding

DiagnosisDiagnosis

Questions to ask in historyQuestions to ask in history Any hematemesis, coffee-ground emesis, melena, Any hematemesis, coffee-ground emesis, melena,

or hematochezia.or hematochezia. Any weight loss or changes in bowel habits.Any weight loss or changes in bowel habits. Any vomiting and retching.Any vomiting and retching. Any history aortic graft.Any history aortic graft. Any history of ASA, NSAID’s, steroids.Any history of ASA, NSAID’s, steroids. Any ETOH abuse.Any ETOH abuse. Any history of iron or bismuth which can simulate Any history of iron or bismuth which can simulate

melena and beets which can simulate melena and beets which can simulate hematochezia. hematochezia. Note stool guaiac testing will Note stool guaiac testing will be negative.be negative.

Page 9: Gastrointestinal Bleeding

DiagnosisDiagnosis

Physical examPhysical exam Vital signs may show hypotension and Vital signs may show hypotension and

tachycardia.tachycardia. Cool, clammy skin then in shock.Cool, clammy skin then in shock. Spider angiomata, palmer erythema, Spider angiomata, palmer erythema,

jaundice, and gynecomastia seen in liver jaundice, and gynecomastia seen in liver disease.disease.

Petechiae and purpura seen in coagulopathy.Petechiae and purpura seen in coagulopathy. Careful ENT exam to rule out causes Careful ENT exam to rule out causes

that can mimic upper GI bleeds.that can mimic upper GI bleeds. Proper abdominal exam and rectal exam.Proper abdominal exam and rectal exam.

Page 10: Gastrointestinal Bleeding

DiagnosisDiagnosis

LabLab CBCCBC ElectrolytesElectrolytes GlucoseGlucose BUN/Creatine –BUN will be elevated in BUN/Creatine –BUN will be elevated in

upper GI bleedsupper GI bleeds Coagulation studiesCoagulation studies Liver function studiesLiver function studies Type and cross-matchType and cross-match

Page 11: Gastrointestinal Bleeding

DiagnosisDiagnosis

DiagnosticDiagnostic ECGECG Abdominal seriesAbdominal series - not beneficial unless specific - not beneficial unless specific

indicationsindications AngiographyAngiography - can be diagnostic and therapeutic - can be diagnostic and therapeutic

but requires a brisk bleed at .5-2ml/minbut requires a brisk bleed at .5-2ml/min Bleeding scansBleeding scans - can only be diagnostic but are - can only be diagnostic but are

more sensitive then angiography and require a more sensitive then angiography and require a bleeding rate of only .1ml/minbleeding rate of only .1ml/min

ColonoscopyColonoscopy - is diagnostic and therapeutic and - is diagnostic and therapeutic and more accurate than bleeding scans and more accurate than bleeding scans and angiography angiography

Page 12: Gastrointestinal Bleeding

TreatmentTreatment

Large-bore intravenous lines with fluid Large-bore intravenous lines with fluid replacement. replacement.

Class I + II hemorrhage replace with Class I + II hemorrhage replace with crystalloid.crystalloid.

Class III + IV hemorrhage replace with Class III + IV hemorrhage replace with crystalloid and blood.crystalloid and blood.

NG tube should be placed and can determine NG tube should be placed and can determine upper GI from lower GI but not 100%. Also upper GI from lower GI but not 100%. Also NG tubes will not worsen varice bleeds.NG tubes will not worsen varice bleeds.

Foley catheter for hypotension patients to Foley catheter for hypotension patients to monitor output. monitor output.

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TreatmentTreatment

Proton-pump inhibitorProton-pump inhibitorEndoscopyEndoscopySomatostatin, octretide for varicesSomatostatin, octretide for varicesBalloon tamponadeBalloon tamponadeSurgerySurgeryMust get early consultation with Must get early consultation with

gastroenterologist and general gastroenterologist and general surgeon for significant GI bleeds. surgeon for significant GI bleeds.

Page 14: Gastrointestinal Bleeding

Peptic Ulcer DiseasePeptic Ulcer Disease

Jarrett LefbergJarrett Lefberg

South Pointe HospitalSouth Pointe Hospital

Page 15: Gastrointestinal Bleeding

EpidemiologyEpidemiology

10% US population >17 years of age 10% US population >17 years of age have peptic ulcer disease at some have peptic ulcer disease at some time.time.

White Americans have a 10% White Americans have a 10% prevalence of H. pylori by age 35 and prevalence of H. pylori by age 35 and 80% by age 75.80% by age 75.

Black Americans have a 45% Black Americans have a 45% prevalence of H. pylori by age 25.prevalence of H. pylori by age 25.

Page 16: Gastrointestinal Bleeding

PathophysiologyPathophysiology

Prostaglandins produce mucous and Prostaglandins produce mucous and bicarbonate ions which protect the tissue bicarbonate ions which protect the tissue in the stomach by being destroyed with in the stomach by being destroyed with hydrochloric acid and pepsin.hydrochloric acid and pepsin.

Dyspepsia is the imbalance between the Dyspepsia is the imbalance between the protective mucosa and acid/pepsin.protective mucosa and acid/pepsin.

Peptic ulcer which is a defect beyond Peptic ulcer which is a defect beyond muscularis mucosa will develop if there is muscularis mucosa will develop if there is an imbalance. an imbalance.

Note -stress ulcers do not extent Note -stress ulcers do not extent through the muscularis mucosa.through the muscularis mucosa.

Page 17: Gastrointestinal Bleeding

PathophysiologyPathophysiology

Two types of peptic ulcersTwo types of peptic ulcers

1) 1) Duodenal ulcersDuodenal ulcers which which occur in the first portion of the occur in the first portion of the duodenum.duodenum.

2) 2) Gastric ulcersGastric ulcers which which usually occur in the lesser usually occur in the lesser curvature of the stomach.curvature of the stomach.

Page 18: Gastrointestinal Bleeding

CausesCauses

H. pyloriH. pylori - a spiral, urease producing - a spiral, urease producing flagellated bacterium which lives between flagellated bacterium which lives between the mucus gel and mucosa. Its production the mucus gel and mucosa. Its production of urease, cytotoxins, proteases and other of urease, cytotoxins, proteases and other compounds disturb the gel and increase compounds disturb the gel and increase tissue exposure to acid and pepsin.tissue exposure to acid and pepsin.

H. pylori is seen in 95% of patients with H. pylori is seen in 95% of patients with duodenal ulcers and 80% of gastric ulcers.duodenal ulcers and 80% of gastric ulcers.

Note only 10-20% of patients who are Note only 10-20% of patients who are infected with H. pylori will develop infected with H. pylori will develop ulcers.ulcers.

Page 19: Gastrointestinal Bleeding

CausesCauses

NSAID’sNSAID’s - inhibit prostaglandins which in turn - inhibit prostaglandins which in turn increases tissue exposure to acid and pepsin.increases tissue exposure to acid and pepsin.

Zollinger-Ellison syndrome Zollinger-Ellison syndrome - is a gastrin - is a gastrin secreting tumor which creates such a high secreting tumor which creates such a high acid level it over rides the protective gel.acid level it over rides the protective gel.

Cigarette smoking -Cigarette smoking - inhibits bicarbonate ion inhibits bicarbonate ion production and increases gastric emptying.production and increases gastric emptying.

Page 20: Gastrointestinal Bleeding

CausesCauses

Bile saltsBile saltsEmotional stressEmotional stressType O bloodType O bloodProlonged use of corticosteriodsProlonged use of corticosteriodsCaffeinated beveragesCaffeinated beveragesNote diet and alcohol are not Note diet and alcohol are not

predisposing factors to the predisposing factors to the development of peptic ulcers.development of peptic ulcers.

Page 21: Gastrointestinal Bleeding

Clinical FeaturesClinical Features

Epigastric painEpigastric pain - (gnawing, aching or - (gnawing, aching or burning) is the main complaint.burning) is the main complaint.

Gastric ulcers usually develop pain shortly Gastric ulcers usually develop pain shortly after eating.after eating.

Duodenal ulcers usually develop pain 2-3 Duodenal ulcers usually develop pain 2-3 hours after eating and awaken patients at hours after eating and awaken patients at night. Pain can be relieved by food.night. Pain can be relieved by food.

Physical exam of uncomplicated PUD, Physical exam of uncomplicated PUD, there may be a finding of there may be a finding of epigastric epigastric tenderness.tenderness.

Page 22: Gastrointestinal Bleeding

Diagnosis Diagnosis

Definite diagnosis can only be made Definite diagnosis can only be made by visualization with an upper GI or by visualization with an upper GI or endoscopy.endoscopy.

Endoscopy has the advantage of Endoscopy has the advantage of being able to take a biopsy which is being able to take a biopsy which is definitely needed for gastric ulcers definitely needed for gastric ulcers to rule out malignancy.to rule out malignancy.

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DiagnosisDiagnosis Several ways to determine H. pylori infectionSeveral ways to determine H. pylori infection 1) invasive1) invasive a) during endoscopy a rapid urease test, a) during endoscopy a rapid urease test,

histologichistologic study, or culture can be done.study, or culture can be done. 2) noninvasive2) noninvasive a) serologic studies which can not be done as aa) serologic studies which can not be done as a follow up for cure due to antibodies beingfollow up for cure due to antibodies being positive for several years after eradication ofpositive for several years after eradication of infection.infection. b) urea breath test can be used to confirm cure.b) urea breath test can be used to confirm cure. c) stool antigens test can also be used to confirmc) stool antigens test can also be used to confirm cure. cure.

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TreatmentTreatment

Stop any offending agents such Stop any offending agents such as NSAID’s.as NSAID’s.

Bland diets with frequent Bland diets with frequent feedings has not been shown to feedings has not been shown to be effective.be effective.

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TreatmentTreatment

AntacidsAntacids – neutralize gastric acids. – neutralize gastric acids. a) good for acute pain relief and healing ulcers.a) good for acute pain relief and healing ulcers. b) poor compliance due frequency of doses.b) poor compliance due frequency of doses. c) inhibit absorption of some drugs such as c) inhibit absorption of some drugs such as

warfarin,warfarin, digoxin, some anticonvulsants and antibiotics.digoxin, some anticonvulsants and antibiotics. d) aluminum causes constipation and should not bed) aluminum causes constipation and should not be given with renal failure patients due togiven with renal failure patients due to accumulation which can cause osteoporosis andaccumulation which can cause osteoporosis and encephalopathy.encephalopathy. e) magnesium causes diarrhea.e) magnesium causes diarrhea.

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TreatmentTreatment H2- AntagonistsH2- Antagonists – inhibit gastric acid secretion – inhibit gastric acid secretion a) equally as effective as antacids with bettera) equally as effective as antacids with better compliance due to decreased frequency ofcompliance due to decreased frequency of doses.doses. b) cimetidine inhibits cytochrome p450 systemb) cimetidine inhibits cytochrome p450 system greater than other H2-antagonists whichgreater than other H2-antagonists which will cause an increase in drugs such as will cause an increase in drugs such as warfarin, phenytoin, diazepam, TCA’s, warfarin, phenytoin, diazepam, TCA’s,

propranolol,propranolol, etc.etc. c) renal excretion and therefore must adjust doses c) renal excretion and therefore must adjust doses

inin patients with renal disease. patients with renal disease.

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TreatmentTreatment Proton Pump InhibitorsProton Pump Inhibitors - inhibit gastric acid - inhibit gastric acid

secretion secretion a) heal ulcers faster then H2-antagonists anda) heal ulcers faster then H2-antagonists and antacids.antacids. b) omeprazole has also been shown to affectb) omeprazole has also been shown to affect the cytochrome p450 system. the cytochrome p450 system. c) lansoprazole does not affect other drugc) lansoprazole does not affect other drug metabolism.metabolism. d) pantoprazole has been shown to decreased) pantoprazole has been shown to decrease bleeding from peptic ulcers.bleeding from peptic ulcers.

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TreatmentTreatment

SulcralfateSulcralfate – locally binds to the base of the – locally binds to the base of the ulcer and therefore protects it from acidulcer and therefore protects it from acid

a) Also has been shown to absorb bile acids,a) Also has been shown to absorb bile acids, inhibit pepsin activity, and increaseinhibit pepsin activity, and increase prostaglandin production.prostaglandin production. b) Needs an acidic environment to workb) Needs an acidic environment to work therefore not beneficial to give antacidstherefore not beneficial to give antacids c) Causes constipation, dry mouth and inhibitsc) Causes constipation, dry mouth and inhibits the absorption of many medications.the absorption of many medications.

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TreatmentTreatment

MisoprostolMisoprostol – prostaglandin E1 analogue which – prostaglandin E1 analogue which acts as natural prostaglandin in the bodyacts as natural prostaglandin in the body

a) Only indicated for prevention of NSAIDa) Only indicated for prevention of NSAID -induced gastric ulcers in high risk patients.-induced gastric ulcers in high risk patients. b) contraindicated in pregnant women andb) contraindicated in pregnant women and women in childbearing age because itwomen in childbearing age because it causes spontaneous abortion.causes spontaneous abortion. c) can cause diarrhea and crampy abdominalc) can cause diarrhea and crampy abdominal pain. pain.

Page 30: Gastrointestinal Bleeding

TreatmentTreatment

Bismuth compoundsBismuth compounds – decrease – decrease pepsin activity, increase mucus pepsin activity, increase mucus secretion, form a barrier protection on secretion, form a barrier protection on ulcers, augment prostaglandin ulcers, augment prostaglandin synthesis, slow hydrogen ion diffusion synthesis, slow hydrogen ion diffusion across mucosal barrier, and H. pylori across mucosal barrier, and H. pylori bactericidal effect.bactericidal effect.

a) Used in triple drug combinations fora) Used in triple drug combinations for

the treatment of H. pylori.the treatment of H. pylori.

Page 31: Gastrointestinal Bleeding

TreatmentTreatment

If H. pylori positive then must be If H. pylori positive then must be given antibiotics to prevent given antibiotics to prevent recurrence of ulcer.recurrence of ulcer.

Usually done with triple or quadruple Usually done with triple or quadruple treatment regimens.treatment regimens.

Some antibiotics in regimens are Some antibiotics in regimens are metronidazole, tetracycline, metronidazole, tetracycline, amoxicillin, clarithromycin.amoxicillin, clarithromycin.

Page 32: Gastrointestinal Bleeding

Complications of PUDComplications of PUD

GI bleeding is the most common GI bleeding is the most common complication of PUD and the most complication of PUD and the most common cause of upper GI bleeding.common cause of upper GI bleeding.

Please see previous lecture Please see previous lecture on management of GI on management of GI Bleeding.Bleeding.

Page 33: Gastrointestinal Bleeding

Complications of PUDComplications of PUD

PerforationPerforation Initially a chemical peritonitis develops which then Initially a chemical peritonitis develops which then

progresses to a bacterial peritonitis. progresses to a bacterial peritonitis. Anterior perforationAnterior perforation - patients will have sudden - patients will have sudden

abdominal pain with guarding and rebound. 60-70% abdominal pain with guarding and rebound. 60-70% will demonstrate free air of x-rays.will demonstrate free air of x-rays.

Posterior perforationPosterior perforation - patients will develop back - patients will develop back pain with no free air on x-ray and may mimic pain with no free air on x-ray and may mimic pancreatitis but lipase will be normal or only slightly pancreatitis but lipase will be normal or only slightly elevated.elevated.

No free air on x-rays cannot rule our perforation.No free air on x-rays cannot rule our perforation. IV fluids, electrolyte corrections, NG tube, broad IV fluids, electrolyte corrections, NG tube, broad

spectrum antibiotics and surgery.spectrum antibiotics and surgery.

Page 34: Gastrointestinal Bleeding

Complications of PUDComplications of PUD

Gastric outlet obstructionGastric outlet obstruction Scaring from healed ulcers or edema from active Scaring from healed ulcers or edema from active

ulcer with development of obstruction.ulcer with development of obstruction. Obstruction will cause gastric dilation, vomiting, Obstruction will cause gastric dilation, vomiting,

dehydration, metabolic alkalosis.dehydration, metabolic alkalosis. Patients will develop upper abdominal pain with Patients will develop upper abdominal pain with

vomiting, early satiety, weight loss, succussion vomiting, early satiety, weight loss, succussion splash.splash.

Abdominal x-ray will show dilated stomach Abdominal x-ray will show dilated stomach shadow with large air-fluid level. shadow with large air-fluid level.

IV fluids, electrolyte corrections, NG tube, and IV fluids, electrolyte corrections, NG tube, and surgery if needed.surgery if needed.

Page 35: Gastrointestinal Bleeding

QuestionsQuestions

The most common cause of a lower The most common cause of a lower GI bleed is?GI bleed is?

A) DiverticulosisA) Diverticulosis

B) CancerB) Cancer

C) HemorrhoidsC) Hemorrhoids

D) AV malformationsD) AV malformations

Page 36: Gastrointestinal Bleeding

QuestionsQuestions

2) Colonoscopy is diagnostic and 2) Colonoscopy is diagnostic and therapeutic and is more accurate than therapeutic and is more accurate than bleeding scans and angiography for GI bleeding scans and angiography for GI bleeds.bleeds.

T/FT/F3) Only 40% of patients who are 3) Only 40% of patients who are

infected with H. pylori will develop infected with H. pylori will develop ulcers.ulcers.

T/FT/F

Page 37: Gastrointestinal Bleeding

QuestionsQuestions

4) Treatment of ulcers which are 4) Treatment of ulcers which are positive for H. pylori need?positive for H. pylori need?

A) only a longer coarse of PPIA) only a longer coarse of PPI B) addition of antibioticsB) addition of antibiotics C) need an inpatient coarse ofC) need an inpatient coarse of treatmenttreatment D) can be treated the same as D) can be treated the same as

ulcersulcers that are negative for H. pylori that are negative for H. pylori

Page 38: Gastrointestinal Bleeding

AnswersAnswers

1) C1) C2) T2) T3) F3) F4) B4) B